note_id
stringlengths 13
15
| subject_id
int64 10M
20M
| hadm_id
int64 20M
30M
| note_type
stringclasses 1
value | note_seq
int64 2
133
| charttime
stringlengths 19
19
| storetime
stringlengths 19
19
| text
stringlengths 1.56k
52.7k
|
|---|---|---|---|---|---|---|---|
19735459-DS-26
| 19,735,459 | 29,341,860 |
DS
| 26 |
2133-09-19 00:00:00
|
2133-09-21 20:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine / Ultram / Plavix
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Capsule endoscopy
History of Present Illness:
___ with PMHx of ___ syndrome with multiple GI bleeds
requiring hospitalization and transfusions, E antigen positive),
also squamous cell lung cancer s/p radiofrequency ablation of
LUL, COPD (on 2L O2 at home), HFpEF, severe AS s/p TAVR, Stage
III CKD (baseline Cr 1.5) who presents with acute on chronic
dyspnea. Of note, pt has had numerous prior admissions for GI
bleed, scopes mostly unrevealing, one prior with AVM in stomach,
recent d/c home on ___ with home O2 use PRN. Now presents with
non-exertional dyspnea, weakness, and malaise for ___ days.
States his stools have been black, but formed and have been that
way since starting iron on last admission. Denies BRBPR,
hematemesis.
Also having non-productive cough for last week. Denies fevers,
chills, sputum production, chest pain.
In the ED,
Initial vitals were: 98.3, 80, 153/68, 18, 100% RA
Exam notable for: Diffuse coarse breath sounds, Abd benign,
rectal with guiaic positive
Labs notable for: H&H: 7.5/24.4 down from 4.___.1 on ___
Imaging notable for CXR with stable LUL opacity
Patient was given 1 uPRBCs with repeat Hct 18.0
Patient was discussed GI who recommended capsule endoscopy.
Decision was made to admit for upper GI bleed
On the floor,
Pt is going well. Denies shortness of breath, currently on 2L NC
O2.
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 ___
# 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
=======================
VS: 98.5, 149/42, 97, 18, 90% on 2L
Gen: NAD, A&O x3, lying in bed
Eyes: PERRLA EOMI, sclerae anicteric
Neck: elevated JVP 10cm
ENT: MMM, OP clear
Cardiovasc: RRR, mechanical S2, no MRG
Resp: normal effort, bibasilar rales, no wheezing, no accessory
muscle use
GI: soft, NT, ND, BS+, No HSM
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
DISCHARGE PHYSICAL EXAM
=========================
Gen: Patient sitting comfortably in bed with breakfast tray.
NAD, conversational.
Eyes: pupils 2-3 mm, sluggish (prior cataract surgery), EOMI
grossly, sclerae anicteric
Neck: JVP does not appear elevated this AM
ENT: MMM, OP clear
Cardiovasc: RRR, mechanical S2, no M/R/G
Resp: normal effort. Mild crackles to bases bilaterally. No
wheezing, no accessory
muscle use
GI: soft, NT, ND, BS+, No HSM
Extremities: Warm, well-perfused. Trace edema to shins
Skin: No visible rash. No jaundice.
Neuro: Strength ___ in UE and ___ bilaterally. CN II-XII intact.
Tongue midline. Following all commands.
Psych: Full range of affect
Pertinent Results:
LABS ON ADMISSION
==================
___ 01:00PM BLOOD WBC-2.6* RBC-1.43*# Hgb-4.8*# Hct-16.1*#
MCV-113* MCH-33.6* MCHC-29.8* RDW-20.4* RDWSD-82.3* Plt ___
___ 11:54PM BLOOD WBC-4.5# RBC-1.99*# Hgb-6.6*# Hct-20.9*
MCV-105*# MCH-33.2* MCHC-31.6* RDW-21.2* RDWSD-76.6* Plt ___
___ 01:00PM BLOOD Glucose-120* UreaN-69* Creat-1.8* Na-139
K-5.3* Cl-101 HCO3-25 AnGap-18
___ 08:20AM BLOOD Calcium-8.8 Phos-5.3* Mg-2.2
___ 01:00PM BLOOD Hapto-305*
PERTINENT LABS DURING HOSPITALIZATION
=====================================
___ 01:00PM BLOOD WBC-2.6* RBC-1.43*# Hgb-4.8*# Hct-16.1*#
MCV-113* MCH-33.6* MCHC-29.8* RDW-20.4* RDWSD-82.3* Plt ___
___ 11:54PM BLOOD WBC-4.5# RBC-1.99*# Hgb-6.6*# Hct-20.9*
MCV-105*# MCH-33.2* MCHC-31.6* RDW-21.2* RDWSD-76.6* Plt ___
___ 08:20AM BLOOD WBC-4.1 RBC-2.29* Hgb-7.6* Hct-23.6*
MCV-103* MCH-33.2* MCHC-32.2 RDW-21.6* RDWSD-74.5* Plt ___
___ 07:05AM BLOOD WBC-4.6 RBC-2.05* Hgb-6.7* Hct-22.0*
MCV-107* MCH-32.7* MCHC-30.5* RDW-22.3* RDWSD-81.0* Plt ___
___ 08:30PM BLOOD WBC-4.0 RBC-2.18* Hgb-6.9* Hct-22.6*
MCV-104* MCH-31.7 MCHC-30.5* RDW-22.2* RDWSD-80.2* Plt ___
___ 07:30AM BLOOD WBC-4.1 RBC-2.47* Hgb-7.8* Hct-25.0*
MCV-101* MCH-31.6 MCHC-31.2* RDW-21.8* RDWSD-74.1* Plt ___
___ 03:10PM BLOOD WBC-3.8* RBC-2.51* Hgb-8.0* Hct-25.6*
MCV-102* MCH-31.9 MCHC-31.3* RDW-21.8* RDWSD-73.3* Plt ___
___ 08:10AM BLOOD WBC-3.6* RBC-2.56* Hgb-8.2* Hct-26.0*
MCV-102* MCH-32.0 MCHC-31.5* RDW-21.4* RDWSD-72.8* Plt ___
___ 04:45PM BLOOD WBC-3.4* RBC-2.40* Hgb-7.6* Hct-24.7*
MCV-103* MCH-31.7 MCHC-30.8* RDW-21.0* RDWSD-72.5* Plt ___
___ 08:29AM BLOOD WBC-3.0* RBC-2.56* Hgb-8.2* Hct-26.3*
MCV-103* MCH-32.0 MCHC-31.2* RDW-20.5* RDWSD-71.5* Plt ___
___ 01:00PM BLOOD Neuts-75* Bands-0 Lymphs-13* Monos-9
Eos-2 Baso-1 ___ Myelos-0 AbsNeut-1.95 AbsLymp-0.34*
AbsMono-0.23 AbsEos-0.05 AbsBaso-0.03
___ 01:00PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-2+
Macrocy-1+ Microcy-1+ Polychr-NORMAL Ovalocy-1+ Tear Dr-1+
___ 01:00PM BLOOD Plt Smr-NORMAL Plt ___
___ 08:29AM BLOOD Plt ___
___ 01:20PM BLOOD ___
___ 01:00PM BLOOD Hapto-305*
LABS AT DISCHARGE
===================
___ 08:29AM BLOOD WBC-3.0* RBC-2.56* Hgb-8.2* Hct-26.3*
MCV-103* MCH-32.0 MCHC-31.2* RDW-20.5* RDWSD-71.5* Plt ___
___ 08:29AM BLOOD Plt ___
___ 08:29AM BLOOD Glucose-98 UreaN-33* Creat-1.4* Na-139
K-4.1 Cl-100 HCO3-31 AnGap-12
___ 08:29AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.7
MICROBIOLOGY
=============
Blood Culture, Routine (Final ___: NO GROWTH x 2
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
IMAGING & PROCEDURES
================
CXR ___
IMPRESSION:
Unchanged left upper lobe opacity, previously assessed on prior
CT. Patchy left basilar atelectasis.
KUB (___)
Indication: Assess for retained capsule. Obstruction?
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Multilevel degenerative changes in the lumbar spine are
extensive with loss of
vertebral body height, overall similar to the prior exam. The
patient has had
right total hip replacement, unchanged in appearance with
extensive
heterotopic bone formation and osteopenia in the right hip
including greater
trochanter.
No unexplained soft tissue calcifications or radiopaque foreign
bodies.
Surgical clips project over the left upper medial abdomen,
unchanged. A
replaced cardiac/aortic valve is partially imaged.
IMPRESSION:
1. No unexplained radiopaque foreign body to suggest a retained
capsule.
2. No bowel obstruction.
Brief Hospital Course:
___ with PMHx of ___ syndrome with multiple GI bleeds
requiring hospitalization and transfusions, E antigen positive),
squamous cell lung cancer s/p XRT, COPD (on 2L O2 at home),
HFpEF, severe AS s/p TAVR, and Stage III CKD (baseline Cr 1.5)
presented with acute on chronic dyspnea. In the ED he was found
to have a hemoglobin of 4.8 and a hematocrit of 16.1. During the
course of his hospital stay the following issues were addressed:
# Acute blood loss anemia: Patient has a history of Heydes
syndrome with multiple episodes of GI bleeds s/p 40 transfusions
since ___. This admission his hemoglobin was 4.8 on
admission. He was transfused a total of 3 units in the ED on
___ and required another 2 units between ___ and ___. GI was
consulted and capsule endoscopy was performed on ___. Official
report pending, but capsule showed no source of active bleed up
to the cecum. Patient reported ___ stools for 2 days before
discharge and hemoglobin remained stable until discharge.
Hemoglobin was 8.2 and hematocrit was 26.3 on discharge.
# Retained capsule: There was some concern after the procedure
that the capsule was retained. An abdominal supine radiograph
was performed and showed no foreign body. Nursing staff later
reported that capsule was recovered in patient's stool.
# Chronic diastolic CHF: Patient's lasix was initially held in
setting of acute bleed but was restarted without issue on ___.
Patient's metoprolol was continued on discharge.
CHRONIC ISSUES:
==========================
# COPD chronic: Patient reported that he uses his O2
"occasionally" at home. O2 satswere 92-100 during hospital
stay. Home duonebs and albuterol were also continued.
# Severe AS s/p TAVR: Patient underwent TAVR in ___.
# OSA with pulm HTN: Non-compliant with CPAP.
# Chronic anemia: patient with history of multiple transfusions
and episodes of acute GI bleed. Initially held Darbepoetin INJ
1x /week at this time, Cyanocobalamin 1000 daily, folate and
multivitamins but these were resumed on discharge. His ferrous
sulfate was discontinued as patient had received a good amount
of iron in frequent blood transfusions (>50 since ___ and
dark stool won't allow him to monitor for bleeding. Can consider
repeat iron studies as outpatient.
# Hypertension: BPs in 130-140s/40-50s this admission; low to
___ systolic AM of ___. Home amlodipine and metoprolol were
initially held but reintroduced.
# Hyperlipidemia: continue atorvastatin 40 mg
# CKD (Stage III, baseline Cr 1.4-1.6): Cr stable, 1.7 on ___.
Down to 1.4 on discharge.
# Carotid disease: 50-69% LICA, <50% ___. S/p CEA
# Gout: Continued home allopurinol ___ mg
# Benign prostatic hyperplasia: Continued home tamsulosin 0.4 mg
# Bowel regimen: Continued home colace and senna.
TRANSITIONAL ISSUES:
- weight on discharge: 91.36kg (201.4lb)
- H/H 8.2/___.3 on discharge
- Please recheck CBC on ___ in follow up
- Please monitor CBC twice weekly moving forward in order to
transfuse for hgb<7 and consider repeat work up if rapidly
bleeding
- PO iron held as patient has received a good amount of iron in
frequent blood transfusions (>50 since ___ and dark stool
won't allow him to monitor for bleeding. Can consider repeat
iron studies as outpatient
- Patient with chronic leukopenia and macrocytic anemia please
consider referral to hematology oncology as patient may have a
component of MDS contributing to anemia. Consider checking
reticulocyte count
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. Cyanocobalamin 1000 mcg PO DAILY
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. Metoprolol Succinate XL 50 mg PO NOON
11. Multivitamins W/minerals 1 TAB PO DAILY
12. polyvinyl alcohol 1.4 % ophthalmic Q4H:PRN
13. Tamsulosin 0.4 mg PO QHS
14. Vitamin D 1000 UNIT PO DAILY
15. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheeze
16. darbepoetin alfa in polysorbat 60 mcg/mL injection 1X/WEEK
17. Docusate Sodium 100 mg PO BID
18. Ferrous Sulfate 325 mg PO DAILY
19. Furosemide 60 mg PO DAILY
20. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
21. Polyethylene Glycol 17 g PO DAILY constipation
22. Senna 8.6 mg PO DAILY
23. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Furosemide 60 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheeze
4. Allopurinol ___ mg PO DAILY
5. Amlodipine 2.5 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Cyanocobalamin 1000 mcg PO DAILY
8. darbepoetin alfa in polysorbat 60 mcg/mL injection 1X/WEEK
9. Docusate Sodium 100 mg PO BID
10. Famotidine 20 mg PO DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Ipratropium-Albuterol Neb 1 NEB NEB TID SOB, wheeze
14. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
15. Loratadine 10 mg PO DAILY
16. Metoprolol Succinate XL 50 mg PO NOON
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Polyethylene Glycol 17 g PO DAILY constipation
19. polyvinyl alcohol 1.4 % ophthalmic Q4H:PRN
20. Senna 8.6 mg PO DAILY
21. Tamsulosin 0.4 mg PO QHS
22. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnosis:
Acute blood loss anemia
Secondary:
chronic diastolic congestive heart failure
Chronic obstructive pulmonary disease on home oxygen
Hypertension
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 to take care of you at ___. You were
admitted with severe anemia likely from ongoing bleeding in your
GI tract. You had a capsule endoscopy which is a pill camera to
look for a source of bleeding. Unfortunately, the capsule did
not show any source of bleeding in the GI tract. You received 5
units of blood while in the hospital. Your blood counts were
stable for 3 days prior to discharge. You will need to have
frequent blood count checks twice weekly for the next couple of
weeks and follow up closely with your PCP and
gastroenterologist. As always remember to weigh yourself every
morning, call MD if weight goes up more than 3 lbs. Your weight
on day of discharge on our scales was 201.4lb.
If you have any signs of bleeding in the GI tract such as black
or maroon colored stool, fatigue, shortness of breath, or
lightheadedness, call your PCP immediately or proceed to the ED.
Please stop taking your iron so you can monitor your stool for
any signs of bleeding.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
19735516-DS-11
| 19,735,516 | 27,614,893 |
DS
| 11 |
2143-01-01 00:00:00
|
2143-01-01 10:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right ankle pain
Major Surgical or Invasive Procedure:
ORIF Right Ankle
History of Present Illness:
Patient is a ___ with a hx of ETOH abuse who presents with R
ankle pain and deformity and a mechanical fall several hours
ago.
Patient is intoxicated currently an does remember the specifics
of the fall. Her only complaint at this time ss right ankle
pain.
Denies any numbness/tingling in her right foot. Denies headache,
neck pain, visual changes, right knee pain, right hip pain, LLE
pain, UE pain, back pain, chest pain, shortness of breath,
abdominal pain, flank pain.
Past Medical History:
hyperlipidemia
h/o elevated tranaminases in setting of EtOH abuse
h/o ectopic pregnancy s/p R salpingectomy (___)
h/o ovarian cyst s/p drainage (___)
per husband: "fatty liver"
per husband: ___ medical admissions ___ EtOH use
Social History:
___
Family History:
Mother, brother- EtOH
Mother- psychiatric treatment of some kind
Physical Exam:
A&O, NAD, Pain controlled
AFVSS
RLE: Incision d/c/i, +edema, Bivalve cast, Wiggles toes, SILT,
WWP
Pertinent Results:
xray of right ankle fx and after surgical fixation
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 ankle fx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for orif right ankle which the patient tolerated well
(for full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. 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 nwb in the rgiht lower extremity,
and will be discharged on lovenox for DVT prophylaxis. The
patient will follow up in two weeks per routine. Pateint will be
discharged home with services. A thorough discussion was had
with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge.
Medications on Admission:
simvastatin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*42 Capsule Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: STAT
RX *enoxaparin 40 mg/0.4 mL 1 syringe sq qpm Disp #*14 Syringe
Refills:*0
5. Multivitamins 1 CAP PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO ONCE MR1 pain
Duration: 1 Dose
RX *oxycodone 5 mg ___ tablet(s) by mouth q3h Disp #*100 Tablet
Refills:*0
7. Simvastatin 40 mg PO QPM
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right Trimal Ankle fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent
Discharge Instructions:
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
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.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- Non weight bearing right lower extremity
- Please keep elevated
Followup Instructions:
___
|
19735594-DS-20
| 19,735,594 | 26,478,045 |
DS
| 20 |
2173-01-17 00:00:00
|
2173-01-20 14:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cipro / sertraline
Attending: ___.
Chief Complaint:
Foul smelling urine
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Mr. ___ is a ___ male with a past medical
history
of metastatic bladder cancer and bilateral nephrostomy tubes who
presented with abdominal pain.
He has been having suprapubic abdominal pain over the past two
weeks or so, first thought to be secondary to constipation since
it improved initially with a bowel movement. His ___ then
noticed
foul smelling urine. He has been increasingly fatigued. He is
voiding both through the nephrostomy tubes and his penis.
Sometimes all of his urine is through the nephrostomy tubes but
this varies. He has had no known fevers at home.
He was sent to urgent care where a urine specimen obtained from
his nephrostomy tubes was notable for ___ WBCs and positive
nitrites. Due to cipro allergy, decision was made to admit for
IV
antibiotics to treat for complicated UTI.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
Metastatic bladder cancer - chemotherapy on hold; providers are
at ___
Prostate cancer
Atrial fibrillation
Depression
Social History:
___
Family History:
FAMILY HISTORY: Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation
GU: No suprapubic fullness or tenderness to palpation. Bilateral
nephrostomy tubes in place draining yellow urine. No flank
tenderness.
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:
___ 02:50PM BLOOD WBC-7.5# RBC-2.62* Hgb-8.9* Hct-27.2*
MCV-104*# MCH-34.0* MCHC-32.7 RDW-15.9* RDWSD-60.8* Plt ___
___ 05:44AM BLOOD WBC-8.6 RBC-2.84* Hgb-9.4* Hct-29.2*
MCV-103* MCH-33.1* MCHC-32.2 RDW-15.7* RDWSD-59.7* Plt ___
___ 02:50PM BLOOD Glucose-88 UreaN-20 Creat-1.1 Na-136
K-3.5 Cl-104 HCO3-22 AnGap-10
___ 05:44AM BLOOD Glucose-81 UreaN-17 Creat-1.1 Na-141
K-4.4 Cl-107 HCO3-22 AnGap-12
___ 02:50PM BLOOD Albumin-2.7*
Urine culture
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
SUMMARY/ASSESSMENT: Mr. ___ is a ___ male with a past
medical history of metastatic bladder cancer and bilateral
nephrostomy tubes who presented with abdominal pain and foul
smelling urine
ACUTE/ACTIVE PROBLEMS:
# ? Complicated UTI. Patient without fevers, flank pain,
constitutional symptoms, leukocytosis. His abdominal pain
improved when he was standing. However, given his history of
chemotherapy, malignancy and instrumentation with PCN tubes, it
was decided to complete a week course of treatment (he had
received ceftriaxone while hospitalized) and he was discharged
on cefpodoxime. His foul smelling urine may be due to not
emptying nephrostomy tube frequently enough. He was encouraged
to empty bags more frequently. I discussed his case with ___
staff who noted that there was no indication to change the date
of changing his nephrostomy tubes.
# Abdominal pain: Worse at night, improves when he stands up,
no tenderness to palpation. Very mild, at most a ___. Will
monitor for now.
CHRONIC/STABLE PROBLEMS:
# Metastatic bladder cancer:
- continue fentanyl patch
- continue home megestrol
# pAF:
- continue home metoprolol 25mg BID
- continue home apixaban 2.5mg BID (meets criteria for higher
dose but says this dose was agreed upon by his cardiologist and
oncologist)
# GERD:
- continue home omeprazole
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Fentanyl Patch 25 mcg/h TD Q72H
3. Apixaban 2.5 mg PO BID
4. Megestrol Acetate 400 mg PO DAILY
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. Metoprolol Tartrate 25 mg PO BID
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q12H
Take for five additional days
2. Apixaban 2.5 mg PO BID
3. Fentanyl Patch 25 mcg/h TD Q72H
4. Megestrol Acetate 400 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Urinary tract infection
2. Metastatic bladder cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with foul smelling urine and some abdominal
pain. There is bacteria growing in the urine so these symptoms
may be from a urinary tract infection. Please complete an
additional five days of antibiotics for this. Please drain
your nephrostomy tubes frequently to prevent the foul smell from
recurring. I have faxed a prescription for the antibiotic
cefpodoxime to the ___ in ___ for you. Please take 400 mg twice
a day for 5 days.
Followup Instructions:
___
|
19735757-DS-23
| 19,735,757 | 22,487,025 |
DS
| 23 |
2138-04-23 00:00:00
|
2138-04-23 20:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Benzodiazepines
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of T2DM, Glioblastoma (progressed on Avastin, awaiting
cabozantanib initiation) presented with AMS
Outpatient oncology notes suggest that patient's most recent MRI
on ___ was suspicious for progression, so patient was to
receive
1 last dose of avastin while awaiting initiation of
cabozantanib.
In the interim he presented with AMS.
Patient is non ___ speaking but daughter in law at bedside,
and unable to understand patient speaking in his own language.
Accordingly, patient can not be interviewed. Daughter in law
provided history.
She noted that patient chronically has issues with speech, with
less production, and is overall hypoactive. Has imbalance at
baseline. Has little executive function at baseline, but is able
to toilet himself. Then 2 weeks ago he decided he was going to
stop his medications as he felt that they were making him tired.
In the time since he has become increasingly erratic/impulsive.
In the last week he has gotten up and walked out of the house,
and walked down the block, wouldn't comply with his family
requests to have him come home. Most recently, he was impulsive
and tried to leave again and became physically aggressive when
they confronted him and tried to talk him down. Accordingly,
they
felt that they could no longer safely care for him, as there are
times that he is alone with his wife and ___ young grandchildren,
and family is concerned that his new aggressiveness may put them
at risk.
In the ED, initial vitals: 97.4 85 122/65 16 99% RA. WBC 7.5,
Hgb
9.4, plt 203, Lactate 1.3, CHEM wnl, LFT wnl, TSH 8.4.
CXR:
1. No evidence of an acute cardiopulmonary abnormality.
2. Possible mild dilation of the ascending thoracic aorta.
3. Nonspecific distension loops of colon projecting over the
upper abdomen.
CTH without contrast:
1. Acute, approximately 1.1 cm, probably intraparenchymal,
possibly
subarachnoid hematoma in the posterior left frontal lobe. No
significant mass effect.
2. Posttreatment changes adjacent to the acute hematoma are
otherwise stable.
3. Paranasal sinus disease including aerosolized secretions
raising the possibility of acute sinusitis.
Patient was given keppra and insulin. NSGY was consulted and
recd
against surgical intervention. Dr ___ was notified and agreed
with admission to oncology.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Per last outpatient clinic note by Dr ___:
"Treatment History:
1. Partial resection ___ ___
2. IMRT + temozolomide (TMZ) ___ - ___ to 6000 cGy
3. Monthly TMZ ___ - ___ for 6 cycles
4. MRI ___ showing progression left corpus callosum
5. Lumbar puncture ___ - cytology negative, protein 55, OP
17
6. SRT ___ - ___ to 2500 (5 fr)
7. MRI ___ showed increased enhancement left posterior
frontal brain
8. ADM ___ - ___ altered mental status and right upper
extremity weakness
9. Lumbar puncture ___ - ___ protein, negative cytology
10. Bevacizumab started ___
11. Port placed ___
12. MRI brain ___: increase in enhancement at surgical bed
13: MRI brain ___: nearly stable corpus callosum lesion,
progression in left parietal
14. MRI brain ___: MRI brain with stable corpus callosum and
progression in FLAIR and contrast enhancement of left parietal
region.
PAST MEDICAL HISTORY:
Type II diabetes
Hypertension
HLD
Left CVA ___
?Moderate stage glaucoma
Retinopathy
Cataract surgery OS ___
Cataract surgery OD ___
Social History:
___
Family History:
Family Hx: NC
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 24 HR Data (last updated ___ @ 1843)
Temp: 97.5 (Tm 97.5), BP: 199/78, HR: 51, RR: 18, O2 sat:
98%, O2 delivery: RA
GENERAL: laying in bed, appears comfortable, calm
EYES: PERRLA, conjugate gaze
HEENT: OP clear, MMM
NECK: supple, normal ROM
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR, no
increased wOB
CV: RRR normal distal perfusion, no edema
ABD: soft, NT, ND, normoactive BS, no rebound or guarding
GENITOURINARY: no foley or suprapubic tenderness
EXT: warm, dry, no deformity, decreased muscle bulk
SKIN: warm, dry, no rash
NEURO: Alert, not oriented even to himself. Able to follow
simple commands like show me a thumbs up and move his arms and
legs (which appear full strength but full testing not possible
given AMS). Could not do cranial nerve exam given AMS but face
appears symmetric and tongue midline
ACCESS: port in right chest dressing c/d/i
DISCHARGE PHYSICAL EXAM:
VS: ___ 1735 Temp: 97.9 PO BP: 160/78 HR: 67 RR: 18 O2 sat:
99% O2 delivery: RA
GENERAL: Sitting up in bed in NAD
EYES: PERRLA, conjugate gaze
HEENT: OP clear, MMM
NECK: supple, normal ROM
LUNGS: CTA b/l, no wheezes/rales/rhonchi, normal RR, no
increased wOB
CV: RRR normal distal perfusion, no edema
ABD: soft, NT, ND, normoactive BS, no rebound or guarding
EXT: warm, dry, no deformity, decreased muscle bulk
SKIN: Skin type IV. warm, dry, no rash
NEURO: Oriented to self only. Follows some commands (in
___ with aid of pantomiming. PERRL. Face symmetric. No
gross motor deficits, but neuro exam limited by poor
cooperation.
Pertinent Results:
ADMISSION LABS
=====================
___ 05:31AM BLOOD WBC-7.5 RBC-3.04* Hgb-9.4* Hct-27.7*
MCV-91 MCH-30.9 MCHC-33.9 RDW-12.4 RDWSD-40.3 Plt ___
___ 05:31AM BLOOD Neuts-70.6 Lymphs-15.7* Monos-11.3
Eos-1.7 Baso-0.4 Im ___ AbsNeut-5.32 AbsLymp-1.18*
AbsMono-0.85* AbsEos-0.13 AbsBaso-0.03
___ 06:40AM BLOOD ___ PTT-34.0 ___
___ 05:17AM BLOOD Glucose-192* UreaN-14 Creat-1.1 Na-141
K-3.8 Cl-102 HCO3-25 AnGap-14
___ 05:17AM BLOOD Albumin-3.7 Calcium-9.0 Phos-2.8 Mg-1.9
___ 05:17AM BLOOD ALT-5 AST-9 AlkPhos-96 TotBili-0.5
___ 05:17AM BLOOD cTropnT-<0.01
___ 05:17AM BLOOD TSH-8.4*
___ 06:40AM BLOOD T4-8.1
___ 05:21AM BLOOD Lactate-1.3
DISCHARGE LABS
=====================
___ 08:50AM BLOOD WBC-7.6 RBC-3.55* Hgb-10.9* Hct-33.0*
MCV-93 MCH-30.7 MCHC-33.0 RDW-12.5 RDWSD-41.8 Plt ___
___ 08:50AM BLOOD Neuts-69.5 ___ Monos-6.6 Eos-3.4
Baso-0.5 Im ___ AbsNeut-5.30 AbsLymp-1.50 AbsMono-0.50
AbsEos-0.26 AbsBaso-0.04
___ 08:50AM BLOOD Glucose-142* UreaN-24* Creat-1.0 Na-142
K-4.6 Cl-102 HCO3-27 AnGap-13
___ 08:50AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.0
MICROBIOLOGY
=====================
___ 5:20 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:46 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
=====================
___ EEG
IMPRESSION: This continuous EEG monitoring study was abnormal
due to
1. Rare sharp wave epileptiform discharges in the left parietal
region
indicative of cortical hyperexcitability with epileptogenic
potential.
2. Frequent runs of intermittent rhythmic delta activity in the
left temporal and parietal regions, indicative of focal cerebral
dysfunction within these regions.
Higher voltage and faster activity with sharper contour in the
left central and parietal regions is consistent with
neurosurgical breach rhythm was likely related to the skull
defect. There were no electrographic seizures.
___ CXR
IMPRESSION:
1. No evidence of an acute cardiopulmonary abnormality.
2. Possible mild dilation of the ascending thoracic aorta.
3. Nonspecific distension loops of colon projecting over the
upper abdomen.
___ ___
IMPRESSION:
1. Acute, approximately 1.1 cm, probably intraparenchymal,
possibly
subarachnoid hematoma in the posterior left frontal lobe. No
significant mass effect.
2. Posttreatment changes adjacent to the acute hematoma are
otherwise stable.
3. Paranasal sinus disease including aerosolized secretions
raising the
possibility of acute sinusitis.
___ ___
IMPRESSION
1. No significant interval change.
2. Stable left frontal probably intraparenchymal hematoma with
trace adjacent
subarachnoid hemorrhage. No significant mass effect. No new
hemorrhage.
3. Sinus disease as described.
Brief Hospital Course:
PATIENT SUMMARY
=====================
Mr. ___ is a ___ year old man with PMH of T2DM, Glioblastoma
(progressed on Avastin, awaiting cabozantanib initiation)
presented with AMS and found to have new intraparenchymal
hemorrhage.
ACUTE ISSUES
=====================
#Acute encephalopathy
#Acute intraparenchymal bleed vs subarachnoid hematoma
Per family, pt has a history of chronic speech issues,
hypoactivity, and gait imbalance. Recently has had little
executive function at baseline, but is able to toilet himself. 2
weeks prior to admission he decided he was going to stop his
medications as he felt that they were making him tired, and he
subsequently became increasingly erratic/impulsive. Here he was
found to have a small 1cm acute intraparenchymal bleed vs
subarachnoid hematoma on CT without mass effect. NSGY declined
surgical intervention. Also considered alternate concurrent
issues that could be contributing to encephalopathy such as UTI,
seizure, thyroid issue, worsening glioblastoma etc. Infectious
workup negative. TSH elevated at 8.4 but T4 wnl. EEG with left
temporal fast delta and epileptiform discharges making seizure
most likely etiology. He was monitored with q8h neuro checks,
home ASA discontinued, repeat NCHCT stable. HTN medication
management as below to maintain SBP at goal of 140-160. He was
restarted on levetiracetam 750mg q8h for seizure prophylaxis.
Previous home med methylphenidate held due to concern that this
could exacerbate behavioral disturbances and contribute to
hypertension.
#T2DM
Continued home metformin. Increased acarbose from 25mg TID to
50mg with breakfast and lunch plus 25mg at dinner.
#HTN
Patient with HTN, frequently above goal of 160 mmHg. Restarted
home medications including amlodipine, losartan, increased home
HCTZ. In addition he was started on PO hydralazine 25mg q6h prn
to maintain SBP<160.
#Glioblastoma
Outpatient oncology notes suggest that patient's most recent MRI
on ___ was suspicious for progression, so patient was to
receive 1 last dose of avastin while awaiting initiation of
cabozantanib. AMS may be ___ further disease progression, not
necessary to re-image with MRI as has not yet started next line
therapy (cabozantanib).
#Dispo
Family unable to care for patient. He refuses medications at
home and can be physically aggressive though now improved
throughout this admission. Family amenable to attempting trial
at home. ___ and OT evaluated patient and educated family.
TRANSITIONAL ISSUES
=======================
[] F/u BP - home amlodipine, losartan, and HCTZ restarted this
admission for goal SBP < 160.
[] F/u chem 10 in ___ weeks, check electrolytes on uptitrated
dose of HCTZ.
[] F/u blood sugars and ensure diabetic diet. Uptitrated home
acarbose this admission.
[] F/u mental status, seizures on levetiracetam (previous home
medication, restarted this admission).
[] Celecoxib, aspirin, and methylphenidate (concern for bleed,
aggressive behavior) held this admission. Consider restarting
prn.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acarbose 25 mg PO TID
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Celecoxib 200 mg oral Q12H
5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
6. Hydrochlorothiazide 25 mg PO DAILY
7. LevETIRAcetam 1000 mg PO BID
8. Losartan Potassium 100 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. MethylPHENIDATE (Ritalin) 5 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. HydrALAZINE 25 mg PO Q8H
RX *hydralazine 25 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
2. Acarbose 50 mg PO BID W/ MEALS
RX *acarbose 25 mg 2 or 1 tablet(s) by mouth three times a day
Disp #*150 Tablet Refills:*0
3. Acarbose 25 mg PO DINNER
4. Hydrochlorothiazide 25 mg PO BID
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. LevETIRAcetam 750 mg PO Q8H
RX *levetiracetam 750 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
6. amLODIPine 10 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
9. Losartan Potassium 100 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO BID
11. Polyethylene Glycol 17 g PO DAILY
12. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until discussing with Dr. ___
13. HELD- Celecoxib 200 mg oral Q12H This medication was held.
Do not restart Celecoxib until discussing with Dr. ___
14. HELD- MethylPHENIDATE (Ritalin) 5 mg PO DAILY This
medication was held. Do not restart MethylPHENIDATE (Ritalin)
until discussing with Dr. ___
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute encephalopathy
Acute intraparenchymal bleed vs subarachnoid hematoma
Type 2 diabetes mellitus
Hypertension
Glioblastoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted because you had behavioral changes at home.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- A CT scan of your head showed a new small bleed. A repeat CT
scan the next day showed that the bleed had stopped.
- Tests including an electroencephalogram (EEG) showed that you
likely were having seizures. This is probably because you were
not taking levetiracetam (keppra).
- Your home medication aspirin was stopped because it can
increase the risk of bleeding.
- Your blood pressure medications (amlodipine, losartan, and
hydrochlorothiazide) were restarted.
- Your behavior returned to baseline and you were ready to leave
the hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- It is very important that you take all of your medications,
including levetiracetam to prevent seizure recurrence, and your
blood pressure medications to prevent brain bleeds.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19736038-DS-21
| 19,736,038 | 29,947,205 |
DS
| 21 |
2169-01-14 00:00:00
|
2169-01-14 18:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Nsaids / Iodine-Iodine Containing / Sulfa(Sulfonamide
Antibiotics) / aspirin / shellfish derived
Attending: ___.
Chief Complaint:
Left flank pain
Major Surgical or Invasive Procedure:
VATS decortication
placement and removal of 2 chest tubes
History of Present Illness:
___ hx AF s/p recent EP procedures, systolic CHF presents with L
sided flank pain.
She was in her USOH until 3 weeks PTA, when her husband
developed a URI. She later developed these symptoms, which
included nasal congestion, cough productive of clear sputum, and
chills. She did not get a flu shot this year. Cough was
frequent. On that background, in the middle of last week, she
was driving when she noted the onset of a sharp L sided
abdominal wall pain. She was not lifting or straining, and did
not sustain any trauma. This pain was worsened by coughing,
straining, or deep inspiration. Due to persistent pain, she went
to another hospital (in ___ on ___ for cough, and
was diagnosed with PNA. She was also told she had a UTI, and
that antibiotics prescribed for PNA would cover that as well.
She was prescribed levofloxacin and has been taking it, and felt
that her respiratory symptoms are improving.
Unfortunately, she continues to have debilitationg abomdinal
wall pain. She has been unable to function, lie flat, or sit
still because of the pain. Patient has no history of kidney
stones in the past. She denies dysuria.
In the ED, initial vital signs were: 97.9 79 146/64 18 100% RA
- Exam was notable for: relatively benign-appearing, no JVD,
lower extremities without edema.
- Labs were notable for: Na 131, Cr 1.2, WBC 14.9, INR 1.6.
- Imaging: CXR showed . CTAP without contrast showed .
- The patient was given: Morphine. Vanc/cefepime.
- Consults: None
Admitted to Medicine for further dx/tx of LLL PNA.
Vitals prior to transfer were: 98.1 64 110/55 16 96% RA.
Upon arrival to the floor, she recounts the hsitory above. Her
worst symptom is persistent abdominal wall pain, ttp and worse
with movements and deep inspiration.
Past Medical History:
-- Atrial tachyarrhythmias: s/p PVI, L atrial tachycardia
ablation, AFL ablation (___)
-- Systolic heart failure thought to be due to tachyarrhythmia,
now resolved (EF ___ 57%)
-- Hypertension
-- Sleep apnea
Social History:
___
Family History:
No family history of pulmonary disease
Physical Exam:
Admission Physical Exam:
Genl: comfortable, NAD
HEENT: no icterus, PERRLA, MMM, no OP lesions
Neck: no JVP, no LAD
Cor: RRR NMRG
Pulm: no incr WOB, CTAB
Abd: soft, ntnd
Neuro: AOx3, no focal sensory or motor deficits in bilat ___
MSK: ___ without edema, 2+ distal pulses
Skin: no obvious rashes or lesions on torso, UEs, ___
___ PE:
VS: 98.3 97.6 104/52 83 20 96%RA
HEENT: NC AT EOMI
CV: RRR, no MRG
LUNGS: mild bibasilar crackles clear with coughing
ABD: obese soft NT ND no rebound
SKIN: dressing c/d/I over CT sites x2
Pertinent Results:
___ 02:25AM BLOOD WBC-14.9*# RBC-4.26 Hgb-12.9 Hct-39.4
MCV-93 MCH-30.3 MCHC-32.7 RDW-13.1 RDWSD-44.2 Plt ___
___ 02:25AM BLOOD Neuts-80.6* Lymphs-8.7* Monos-9.3
Eos-0.5* Baso-0.2 Im ___ AbsNeut-11.99*# AbsLymp-1.30
AbsMono-1.38* AbsEos-0.07 AbsBaso-0.03
___ 02:25AM BLOOD ___ PTT-33.2 ___
___ 02:25AM BLOOD Glucose-117* UreaN-16 Creat-1.2* Na-131*
K-4.2 Cl-94* HCO3-24 AnGap-17
___ 02:25AM BLOOD ALT-22 AST-27 AlkPhos-100 TotBili-0.9
___ 02:25AM BLOOD Lipase-18
___ 02:25AM BLOOD proBNP-225
___ 02:25AM BLOOD Albumin-3.9
___ 02:25AM BLOOD GreenHd-HOLD
___ 06:17AM BLOOD WBC-10.4* RBC-3.71* Hgb-11.1* Hct-34.4
MCV-93 MCH-29.9 MCHC-32.3 RDW-13.6 RDWSD-46.3 Plt ___
___ 06:04AM BLOOD Neuts-83.9* Lymphs-5.8* Monos-8.4
Eos-0.9* Baso-0.2 Im ___ AbsNeut-13.83* AbsLymp-0.95*
AbsMono-1.39* AbsEos-0.15 AbsBaso-0.04
___ 06:17AM BLOOD Plt ___
___ 06:17AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-137
K-4.7 Cl-101 HCO3-25 AnGap-16
___ 04:06PM BLOOD proBNP-PND
___ 01:29PM BLOOD proBNP-280*
___ 06:17AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.2
___ CXR IMPRESSION:
In comparison with the earlier study of this date, again there
is a small
apical pneumothorax on the left. Otherwise, little change in
the appearance
of the heart and lungs.
___ CXR IMPRESSION:
1. Small left apical pneumothorax, post chest tube removal.
2. Improved pulmonary vascular congestion.
___ CXR IMPRESSION:
1. Unchanged positioning of left chest tube.
2. Stable moderate-sized loculated left pleural effusion.
___ ___ US
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
Brief Hospital Course:
MEDICINE COURSE:
Ms. ___ is a ___ with a history of atrial
fibrillation/atrial, tachycardia s/p PVI in ___, non-ischemic
cardiomyopathy (EF 57%), asthma, and obesity who was admitted to
Medicine on ___ for left upper quadrant pain due to LLL
pneumonia.
She was previously seen at an outside hospital and started on
levofloxacin, which was continued for a 7-day course, ending on
___. During her ___ hospitalization, she was found to have a
small-volume, simple left pleural effusion on CT abdomen on
admission ___. She continued to have LUQ pain and leukocytosis
despite completion of antibiotic course, and Interventional
Pulmonary was consulted on ___. They evaluated her pleural
effusion with ultrasound and did not feel it was large enough to
drain. Her LUQ pain improved with an aggressive bowel regimen
which resolved her constipation.
On ___, a repeat CXR showed her left pleural effusion was
larger, and a subsequent repeat CT chest showed the left pleural
effusion was now loculated. IP was again consulted and placed a
chest tube on ___ with 60cc serosanguinous drainage, which had a
pH of 6.9 and showed large number of PMNs on gram stain,
concerning for empyema. TPA/Dornase was applied on ___ with
>400cc drainage, however on ___ repeat TPA/Dornase treatment was
unsuccessful and Thoracic Surgery was consulted for
decortication. She was transferred to the Thoracic Surgery
service after decortication on ___.
The patient remained clinically well during her time on the
Medicine Service, with ambulatory SPO2>94% on room air and pain
well-controlled on acetaminophen with codeine. Cefepime and
flagyl were started on ___ for empiric empyema coverage and she
remained afebrile with downtrending leukocytosis.
Patient was found to have loculated complex pleural effusion on
CXR, clinically correlated with no further chest tube output
despit tPA x2. Patient met with thoracic surgery and consented
for VATS decortication. Patient tolerated the procedure well.
She was stable post-op with CT x2. Her pain was well controlled
and she was continued on IV abx. Both CT's were removed POD2, no
air leak. Post-pull CXR showed small apical pneumothorax. repeat
CXR was obtained several hours later to evaluated PTX, which was
unchanged compared to prior. Patient was ambulating
independently, voiding well, had BM, pain was well controlled.
Patient was discharged home with close follow up.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Apixaban 5 mg PO BID
2. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 iodine
3. fluticasone propionate (bulk) 220 mcg miscellaneous BID
4. Furosemide 40 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
8. Tobramycin-Dexamethasone Ophth Susp 1 DROP BOTH EARS PRN ear
itch
9. Flecainide Acetate 150 mg PO Q12H
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Levofloxacin Dose is Unknown PO Frequency is Unknown
13. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing sob
14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze SOB
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze SOB
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing sob
3. Flecainide Acetate 150 mg PO Q12H
4. Furosemide 40 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
9. Apixaban 5 mg PO BID
10. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 iodine Duration: 1
Dose
11. fluticasone propionate (bulk) 220 mcg miscellaneous BID
12. Montelukast 10 mg PO DAILY
13. Spironolactone 25 mg PO DAILY
14. Tobramycin-Dexamethasone Ophth Susp 1 DROP BOTH EARS PRN ear
itch
15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
complex pleural effusion
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 for pneumonia and pleural
effusion. You underwent surgery to remove the infected complex
pleural effusion and you've recovered well. You are now ready
for discharge.
* Continue to use your incentive spirometer at home.
* 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 a few days or 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.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry * No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience: -Fevers
> 101 or chills -Increased shortness of breath, chest pain or
any other symptoms that concern you.
Followup Instructions:
___
|
19736541-DS-2
| 19,736,541 | 24,320,242 |
DS
| 2 |
2117-12-21 00:00:00
|
2117-12-24 10:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amlodipine
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
Wound Vac Placed by General Surgery
History of Present Illness:
___ y/o F with hx of hyperkalemia, DM2, CKD (baseline Cr 2.0),
and recent incarcerated transverse colon s/p colectomy and
ileostomy who presents from outside hospital with hyperkalemia.
On ___, patient underwent right colectomy for
incarcerated transverse colon in umbilical herna and given a
temporary ileostomy mucous fistula, with plan to be reversed in
3 months, and umbilical repair. On POD4, her course was c/b GI
bleeding that was found ___ to gastric ulcer-related bleeding.
Hct dropped from 30 to 26 over 5 days. GI performed endoscopy on
___ and a gastric ulcer with a visible vessel was seen,
cauterized completely, and clipped. She was transferred back to
ICU for 4 days on protonix drip, then changed to PO and
transferred back to surgical floor. The patient's diet was
advanced to regular, TPN weaned and discharge plans were
underway. However, once again the hematocrit dropped from 28 to
___. The patient underwent upper endoscopy and was discharged
to a rehabilitation center on ___.
During her ___ rehabilitation, potassium was noted to
be 7.6. She also reports feeling more fatigued and had loss of
appetite during this time. She was initiated with kayexalate and
then transferred to ___ for further evaluation. Potassium was
noted to increase to 8.2. EKG showed peaking T waves. She was
then given 4g calcium gluconate, insulin (blood glucose levels
in 240s), lasix, and was placed on bicarbonate drip. Her
creatinine was at the highest 3.1 during this time period. She
was then transferred to ___ for further evaluation.
In the ED, initial VS were T99.1 (Tmax=99.1) HR 77 (71-96) BP
150 (143-183)/90 (43-90) RR 16 Pox 98%. She reveived calcium
gluconate, insulin + dextrose x2, lasix 90 mg x2, and 500 mL of
fluids. Patient currently denies any fevers, chills, chest pain,
shortness of breath, abdominal pain, or inability to produce
urine.
She had one previous episode of hyperkalemia on ___, when
outpatient labs showed K of 7. She was subsequently admitted and
determined to have acute kidney injury and metabolic acidosis
___ to renal insufficiency.
Received VS were T98.6 BP 190/75 HR 83 RR 20 100 on RA. On
arrival to the floor, patient reports that she continues to have
leg pain.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Insulin-dependent diabetes with diabetic neuropathy
Hypertension
Chronic renal insufficiency
Congestive heart failure
Bilateral hip arthritis of both hips and knees
Hyperlipidemia
Essential Tremor as per patient
Social History:
___
Family History:
Mother had ___ disease and amyloidosis. Father had
mesothelioma. One son passed at age ___ from colon cancer. Other
son committed suicide.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T 98.6 BP 190/75 HR 83 RR 20 100 on RA
General: ___ female, lying in bed in NAD
HEENT: PERRL, oropharynx clear
Neck: Supple. No LAD. Bounding right carotid. No Bruit.
CV: RRR. Grade III/VI pan-systolic murmur heard best in aortic
and tricuspid areas.
Lungs: CTAB. No wheezes, crackles, or rhonchi.
Abdomen: Soft. NT/ND. Ileostomy observed with skin breakdown and
minor leakage noted. Mid-line incision with dermal skin exposure
with a few lower staples missing with mild serous fluid noted on
bandage.
GU: Foley.
Ext: Dark discoloration around ankles bilaterally c/w venous
stasis. 1+ pitting edema. Tenderness to palpation of calves
Neuro: CNII-XII grossly intact.
Skin: No rashes except above aforementioned skin findings on
calf
DISCHARGE EXAM:
VS: 98.0 128/45 p56 rr18 87%RA
I/O: 1440/2350 (1050ML FROM OSTOMY and 350 wound vac)
General: Alert and oriented x 3, lying in bed in NAD
HEENT: PERRL, oropharynx clear
Neck: Supple.
CV: RRR. Grade ___ holosystolic murmur
Lungs: CTAB. No wheezes, crackles, or rhonchi
Abdomen: Soft. NT/ND. Ostomy site intact. Midline incision with
staples in upper segment and wound healed in this portion but
open wound in lower portion with wet to dry gauze dressing.
Ext: Dark chronic discoloration around ankles and lower
extremities c/w venous stasis changes
Pertinent Results:
U/S Soft tissue neck ___
Within the right neck, the internal jugular vein and common
carotid arteries are patent with appropriate direction of flow
and waveforms. No
pseudoaneurysm is present. The right internal jugular is mildly
tortuous.
There is no sonographic evidence for a hematoma or fluid
collection
superficial to the vessels.
IMPRESSION:
Normal sonographic examination of the right neck.
ECHO (___):
Conclusions
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). Doppler parameters are indeterminate for
left ventricular diastolic function. There is a mild resting
left ventricular outflow tract obstruction. A mid-cavitary
gradient is identified. An apical intracavitary gradient is
identified. 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 are mildly
thickened (?#). The study does not suggest aortic stenosis
(leaflets open well visually) but is inadequate to exclude
aortic valve stenosis (elevated velocity may be due to LV
cavitary gradient). No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) 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: Moderate symmetric left ventricular hypertrophy with
a small cavity and hyperdynamic function. Mild resting systolic
gradients in the entire LV cavity. Impaired LV relaxation. Mild
mitral regurgitation.
___ (___):
IMPRESSION:
Limited study as patient was unable tolerate compression
particularly over the superficial femoral veins bilaterally,
however they demonstrate normal color Doppler flow with no
evidence of thrombus. The remainder of the deep venous system
of both lower extremity was unremarkable, with no evidence of
DVT.
Renal Ultrasound (___):
The right kidney measures 10.0 cm and the left kidney measures
10.7 cm. No
evidence of hydronephrosis, renal calculi or focal renal masses.
No perinephric fluid collections are identified. Both kidneys
demonstrate normal corticomedullary differentiation. A Foley
catheter is identified in a nondistended urinary bladder
IMPRESSION:
No renal abnormality identified.
BONE SCAN ___
IMPRESSION: Normal bone scan. No findings to suggest
calciphylaxis.
___ 12:45AM BLOOD WBC-6.6 RBC-3.40* Hgb-10.2* Hct-31.0*
MCV-91 MCH-29.8 MCHC-32.8 RDW-14.6 Plt ___
___ 07:00AM BLOOD WBC-6.4 RBC-3.30* Hgb-9.7* Hct-30.4*
MCV-92 MCH-29.5 MCHC-32.0 RDW-14.6 Plt ___
___ 07:56AM BLOOD WBC-4.9 RBC-3.09* Hgb-9.0* Hct-27.8*
MCV-90 MCH-29.1 MCHC-32.3 RDW-14.7 Plt ___
___ 07:30AM BLOOD WBC-5.9 RBC-2.99* Hgb-8.8* Hct-27.3*
MCV-92 MCH-29.5 MCHC-32.3 RDW-14.3 Plt ___
___ 06:50AM BLOOD WBC-5.5 RBC-2.84* Hgb-8.5* Hct-25.8*
MCV-91 MCH-30.1 MCHC-33.2 RDW-14.3 Plt ___
___ 06:45AM BLOOD WBC-5.2 RBC-2.73* Hgb-7.9* Hct-25.1*
MCV-92 MCH-28.9 MCHC-31.5 RDW-14.5 Plt ___
___ 07:00AM BLOOD WBC-4.5 RBC-2.61* Hgb-7.7* Hct-23.9*
MCV-92 MCH-29.5 MCHC-32.1 RDW-14.2 Plt ___
___ 12:45AM BLOOD Glucose-134* UreaN-65* Creat-2.8* Na-135
K-7.3* Cl-113* HCO3-15* AnGap-14
___ 08:30AM BLOOD Glucose-201* UreaN-59* Creat-2.4* Na-138
K-6.2* Cl-110* HCO3-19* AnGap-15
___ 11:15AM BLOOD Glucose-138* UreaN-56* Creat-2.3* Na-139
K-6.1* Cl-110* HCO3-23 AnGap-12
___ 05:45PM BLOOD Glucose-107* UreaN-53* Creat-2.3* Na-139
K-6.5* Cl-110* HCO3-22 AnGap-14
___ 12:50AM BLOOD Glucose-176* UreaN-53* Creat-2.5* Na-136
K-6.6* Cl-109* HCO3-20* AnGap-14
___ 07:00AM BLOOD Glucose-137* UreaN-53* Creat-2.5* Na-141
K-6.3* Cl-110* HCO3-20* AnGap-17
___ 03:20PM BLOOD Glucose-136* UreaN-52* Creat-2.4* Na-138
K-6.2* Cl-108 HCO3-19* AnGap-17
___ 07:56AM BLOOD Glucose-86 UreaN-50* Creat-2.1* Na-138
K-5.7* Cl-105 HCO3-25 AnGap-14
___ 07:20AM BLOOD Glucose-122* UreaN-54* Creat-2.3* Na-136
K-5.6* Cl-104 HCO3-26 AnGap-12
___ 08:55PM BLOOD Glucose-184* UreaN-49* Creat-2.2* Na-132*
K-5.3* Cl-98 HCO3-28 AnGap-11
___ 06:45AM BLOOD Glucose-151* UreaN-67* Creat-2.7* Na-136
K-5.5* Cl-99 HCO3-29 AnGap-14
___ 03:34PM BLOOD Glucose-99 UreaN-62* Creat-2.7* Na-134
K-5.6* Cl-97 HCO3-29 AnGap-14
___ 07:00AM BLOOD Glucose-166* UreaN-65* Creat-2.7* Na-135
K-4.9 Cl-97 HCO3-31 AnGap-12
___ 12:45AM BLOOD Calcium-10.3 Phos-3.8 Mg-2.1
___ 07:00AM BLOOD Calcium-9.2 Phos-4.7* Mg-2.2
___ 11:27AM BLOOD freeCa-1.33*
Brief Hospital Course:
___ y/o F with hx of hyperkalemia, DM2, CKD (baseline Cr 1.7),
and recent incarcerated transverse colon s/p colectomy and
ileostomy who presents from outside hospital with hyperkalemia.
ACTIVE ISSUES:
=================
# Hyperkalemia:
Acute episode most likely multifactorial with ___ on CKD that
with the use ___ led to insufficient renal K excretion.
Additionally, on admission she was noted to have a non-anion gap
acidosis likely from her increased ileostomy output from her
recent surgery that may have led to potassium shifting due to
excess bicarbonate loss. Nephrology was following patient.
Initial interventions to correct significantly elevated K in the
7 range included Ca gluconate, IV insulin + Dextrose, bicarb and
IV lasix. Improvement was noted with IVF containing bicarb to
correct the acidosis and IV lasix (eventually to po lasix).
Additionally, her ___ was discontinued as a likely contributing
factor given her underlying CKD. . A corresponding decrease in
ileostomy output from a max of 2700 cc/ day to 1050cc/day on
___ on loperamide. Due to this RTA-like syndrome patient has
also been started on Fludrocortisone. Hyperkalemia downtrended
from 7 to 4.9 upon D/C
# Recent hernia surgery with ileostomy and gastric ulcer
clipping/Wound dehiscense.
Recent history of surgery, no e/o infection or significant
abdominal pain but had some leakage from opening that was
evaluated by wound/ostomy nurse who stated the wound was not
healing well. General surgery saw patient and determined a wound
vac was needed for improved wound healing. Wound vac placed on
___, removed eventually on ___ and now with wet to dry
dressings till follow up with primary surgeon.
#Hypertension
Elevated on admission to 190s as had not received home meds. BPs
improved after re-instating her medications. Her ___ was
discontinued due to above hyperkalemia. Clonidine 0.1 mg oral
BID was doubled to 0.2 mg oral BID and furosemide was increased
from 20 mg Daily to 80 mg daily. Blood pressure medications need
to be adjusted for longterm, adequate control while avoiding
ARBs or ACE-Is.
CHRONIC ISSUES:
===================
# DM2 with neuropathy
Stable on home insulin.
# Hyperlipidemia
Stable on home Pravastatin 80 mg PO DAILY
TRANSITIONAL ISSUES:
======================
#Follow-up appointments
- On arrival to rehab, please make appointment for follow-up
with Dr. ___, the surgeon who performed her
colectomy and ileostomy on ___, of ___ ___
___ Associates (phone ___ for continued
evaluation of surgical site and wound vacuum.
- Follow-up with PCP Dr ___ in ___s Dr ___.
Follow up also with cardiologist Dr ___ CHF
#Changes in Home medications
- Home regimen of clonidine 0.1 mg oral BID was doubled to 0.2
mg oral BID, given that valsartan was discontinued in setting of
hyperkalemia.
- Home regimen of Furosemide 20 mg daily but adjusted during
admission to Furosemide 60mg BID. Consider switching back to old
regimen. Blood pressure medications need to be adjusted for
longterm adequate control while avoiding ARBs or ACE-Is.
#Consider additional workup
- Consider work-up of amyloidosis, given FH of disease, chronic
renal insufficiency, CHF, and patient interest. Notably,
inpatient urine dipstick demonstrated normal protein levels,
inconsistent with amyloidosis-nephropathy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 80 mg PO DAILY
2. HydrALAzine 100 mg PO TID
3. Allopurinol ___ mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Gabapentin 300 mg PO HS
6. cloNIDine 0.1 mg oral BID
7. Furosemide 20 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10. Glargine 25 Units Bedtime
Humalog 7 Units Breakfast
Humalog 7 Units Lunch
Humalog 7 Units Dinner
11. Sodium Polystyrene Sulfonate 30 gm PO PRN Hyperkalemia
12. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q4H:PRN Pain
13. Valsartan 40 mg PO DAILY
14. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
15. Erythromycin 250 mg PO Q12H
16. LOPERamide 2 mg PO QID:PRN constipation
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. CloniDINE 0.2 mg PO BID
4. Gabapentin 300 mg PO HS
5. HydrALAzine 100 mg PO TID
6. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q4H:PRN Pain
7. Pantoprazole 40 mg PO Q24H
8. Pravastatin 80 mg PO DAILY
9. Vitamin D 800 UNIT PO DAILY
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Psyllium Wafer 1 WAF PO DAILY
12. Glargine 20 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
13. LOPERamide 4 mg PO QID
14. Diphenoxylate-Atropine 1 TAB PO Q8H Ostomy Output
Please decrease dose as needed if ostomy <200cc
15. Sodium Bicarbonate 1300 mg PO TID
16. Furosemide 60 mg PO BID
17. Fludrocortisone Acetate 0.1 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hyperkalemia
Secondary diagnosis:
Acute on chronic Kidney injury
CHF
Surgical wound dehiscense
Diabetes Mellitus
Hypertension
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 while you were in the
hospital. You were admitted to the hospital for high potassium
levels. We and the renal team believe this to be due to your
kidney disease and from the amount of fluid output from your
ostomy after the surgery.
While in the hospital, your potassium improved. Some of your
blood pressure medicines (valsartan) was stopped as it can
contribute to high potassium levels. Some other medications have
been added to help keep the potassium levels down
(fludrocortisone ). You will continue to take imodium, lomotil,
and metamucil as needed to help decrease the amount of fluid
from your ostomy. You should have less than 1 liter of output a
day. As discussed by the surgeons, continue to make sure you
stay well-hydrated. It will also be important for you to
continue to follow-up with your neprhologist for continued
management of your kidney disease and high potassium levels.
Additionally, we had our surgeons evaluate your surgical wound
and ostomy and felt that it was not healing well. As a result, a
wound vac was placed in your abdomen and eventually removed. It
will continue to need daily care while you are at rehab and you
will need to be followed-up by your surgeon Dr. ___
at ___.
- Your ___ Team
Followup Instructions:
___
|
19736706-DS-18
| 19,736,706 | 23,707,954 |
DS
| 18 |
2199-07-06 00:00:00
|
2199-07-06 17:16:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Atenolol / Lisinopril
Attending: ___.
Chief Complaint:
Shortness of breath, chest pain, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with type 2 diabetes,
hypertension, history of prostate cancer, GERD, dysphagia, and
achalasia, who presents with worsening several day history of
fatigue, dizziness, and shortness of breath.
Of note, patient reports that he started taking carvedilol in
___, and since then he has noticed intermittent nausea,
shortness of breath, and fatigue. Over the last 3 days, he has
experienced worsening dizziness and headache. He states that his
dizziness occurs periodically throughout the day and is not
positional in nature. He describes sub-acute fatigue ever since
stsarting carvedilol and describes left lateral chest wall pain
that started several days ago and is now sub-sternal and burning
in nature. He endorses palpitations that have been "off and on
for a year."
He denies fevers, chills, neck stiffness, cough, abdominal pain,
vomiting, or diarrhea.
Patient was recently seen in outpatient setting in ___ and
BPs were elevated to 160/68. Hydrochlorothiazide was increased
from 12.5 to 25mg PO QD at this time. On follow-up 1 week later,
there was no improvement in his blood pressure and metoprolol
was
subsequently changed to carvedilol 6.25 BID.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes mellitus type 2
- Hypertension
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- Left bundle branch block
3. OTHER PAST MEDICAL HISTORY
- Esophageal dysmotility
- Prostate cancer s/p radiation therapy in ___
- Benign colon polyp removed in ___
- Erectile dysfunction
- Left shoulder impingement tendonitis
- Sleep apnea, on CPAP
- Headaches
- Left shoulder impingement tendonitis
Social History:
___
Family History:
States his mother had HTN and some type of
cardiac disease, unknown. Denies any family history of DM or
cancer.
Physical Exam:
Admission Physical Exam
VS: T 98 BP 179/83 HR 78 RR 18 O2 99%2L
Gen: Comfortable, in NAD
HEENT: NC/AT, PERRL, EOMI
Lungs: Clear to auscultation bilaterally, no wheezes, rales, or
rhonchi
CV: Regular rate and rhythm, no murmurs, rubs, or gallops
Abd: Soft, NT/ND. Normoactive bowel sounds. No organomegaly
Ext: Warm, well perfused, no ___ edema
Neuro: CNII-XII intact. No focal neurological deficits. ___
motor
strength throughout. Sensation intact. FNF intact.
Discharge Physical Exam
Vitals: ___ 0753 Temp: 99.6 PO BP: 167/78 R Sitting HR: 65
RR: 14 O2
sat: 98% O2 delivery: Ra FSBG: 119
GENERAL: well-appearing man, NAD, in good mood, walking around
his room
HEENT: anicteric sclera, no conjunctival pallor, MMM
RESP: CTAB, no wheeze/crackles
CV: RRR, S1 and S2 normal, with possible S4 noted, ___ systolic
murmur best heard at R sternal border between ___ and 3rd ribs
ABOD: soft, non-tender, no distention, BS normoactive
EXTREMITIES: no lower extremity edema, warm and well-perfused
NEURO: A/O x3, mild right eyelid droop but otherwise grossly
intact
SKIN: no rashes/lesions
Pertinent Results:
Admission Labs
___ 09:00AM ___ PTT-29.7 ___
___ 09:00AM WBC-4.7 RBC-4.78 HGB-14.1 HCT-39.4* MCV-82
MCH-29.5 MCHC-35.8 RDW-12.2 RDWSD-37.3
___ 09:00AM NEUTS-63.3 ___ MONOS-7.0 EOS-0.8*
BASOS-0.2 IM ___ AbsNeut-3.00 AbsLymp-1.35 AbsMono-0.33
AbsEos-0.04 AbsBaso-0.01
___ 09:00AM OSMOLAL-253*
___ 09:00AM CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-1.8
___ 09:00AM proBNP-277
___ 09:00AM cTropnT-<0.01
Pertinent Labs
___ 08:10PM BLOOD Na-128*
___ 07:35AM BLOOD Glucose-115* UreaN-18 Creat-1.2 Na-127*
K-3.3 Cl-85* HCO3-26 AnGap-16
___ 01:08PM BLOOD Na-124*
___ 09:40PM BLOOD Glucose-131* UreaN-18 Creat-1.1 Na-125*
K-3.6 Cl-88* HCO3-26 AnGap-11
___ 08:05AM BLOOD Glucose-146* UreaN-14 Creat-0.9 Na-131*
K-4.4 Cl-93* HCO3-25 AnGap-13
___ 08:05AM BLOOD Glucose-146* UreaN-14 Creat-0.9 Na-131*
K-4.4 Cl-93* HCO3-25 AnGap-13
___ 04:06PM BLOOD Glucose-146* UreaN-14 Creat-0.9 Na-133*
K-4.1 Cl-96 HCO3-25 AnGap-12
___ 09:00AM BLOOD Osmolal-253*
___ 01:08PM BLOOD TSH-1.2
___ 01:08PM BLOOD T4-7.8
___ 08:05AM BLOOD Cortsol-11.3
___ 09:40PM BLOOD Cortsol-6.0
Discharge Labs
___ 08:00AM BLOOD Glucose-141* UreaN-13 Creat-1.0 Na-133*
K-4.7 Cl-96 HCO3-24 AnGap-13
___ 08:00AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1
Pertinent Findings
___ Renal U/S w/ Doppler
Normal renal ultrasound. Mildly delayed time to peak velocity
and mildly
diminished peak systolic velocity in the left renal artery
suggestive of
possible left renal artery stenosis. Normal waveforms on the
right.
RECOMMENDATION(S): Consider CTA or MRA for further evaluation
if clinically appropriate.
___ CT head w/o contrast
No evidence of an acute intracranial abnormality.
___ CXR
No acute cardiopulmonary process.
Brief Hospital Course:
Patient is a ___ year old male with history of type 2 diabetes,
hypertension, history of prostate cancer, GERD, dysphagia, and
achalasia, who presents with sub-acute history of worsening
dizziness, fatigue, and nausea after recently starting
carvedilol, observed to have intermittent episode of
non-sustained bradycardia to the ___ in the ED, admitted for
bradycardia work-up.
Hospital course:
=================================
#Fatigue
#Shortness of Breath
#Bradycardia - Patient presented with subacute worsening
fatigue, dizziness, and nausea after having started carvedilol
6.25mg BID earlier in ___ due to uncontrolled HTN. In the
ED noted to have 2 minute non-sustained episode of bradycardia
to the ___ with worsening SOB and dizziness. EKG showing stable
LBBB and 1st degree AV block. Given very low dose carvedilol and
low suspicion for overdose, suspicion for potential carvedilol
toxicity was low. Possible vasovagal etiology of bradycardia but
heart rate improved to 70-80s while off carvedilol. Low
suspicion for ischemic etiology of presentation, EKG without
ischemic changes and troponins negative. Metoprolol was started
as patient did not feel well on carvedilol.
#Hyponatremia - On admission, hyponatremia to 124. Initial serum
and urine electrolytes suggested diuretic-induced hyponatremia
in the setting of HCTZ dose being recently increased from 12.5
to 25mg PO QD for uncontrolled HTN. Serum sodium initially
improved with discontinuation of HCTZ and fluid repletion. As
patient's hypertension remained refractory to addition of
anti-hypertensive medications and patient had previously
tolerated lower dose 12.5 mg HCTZ for years without
hyponatremia, he was re-trialed with 12.5 mg HCTZ QD but failed
due to sodium serum decreasing. Rebound hyponatremia occurred
likely due to diuretic-induced sodium wasting and hypovolemia
diuresis. Serum sodium improved with fluid repletion.
#HTN
Started hydralazine 25mg PO Q8H and metoprolol 50 mg BID.
Continued home Felodipine 5 mg PO BID, Prazosin 5 mg PO BID,
Valsartan 320 mg PO/NG DAILY. D/c'd Hydrochlorothiazide 50 mg
PO/NG DAILY given hyponatremia per above. Held carvedilol per
above. On this regimen, systolic blood pressures continued to
trend up to 170-180s immediately prior to medication
administration, after which his blood pressure would improve to
appropriate levels. Changes to anti-hypertensive medications
were deferred given concerns of hypotension after taking
medications if regimen is too aggressive. Also, considered
secondary causes of HTN given pt's difficult-to-control BPs. Per
chart review, patient's excellent PCP had already evaluated for
many secondary etiologies that would be likely in this patient.
Although the presentation would be atypical given his BP
lability, we decided to evaluate for renal artery stenosis.
Renal ultrasound with dopplers showed possible left renal artery
stenosis. A MRA study of the kidneys could better characterize
this stenosis, which should be done the outpatient setting.
#Headache - Worsening headache without visual changes, nausea or
emesis at present. Without meningeal signs. No focal
neurological deficit. Patient described this tension headache to
be chronic and going for months. Treated with APAP 1G Q8H:PRN
and trended neurological exam QD. Resolved.
#Epigastric Pain - Has a history of PUD and describing
epigastric pain that is burning in nature. Lower suspicion for
cardiac etiology given EKG without ischemic changes and
troponins negative. Continued home Ranitidine 150 mg PO/NG QHS,
Omeprazole 40 mg PO BID, Simethicone 80 mg PO DAILY.
CHRONIC/STABLE ISSUES:
=================================
#Diabetes mellitus type 2: Held home GlipiZIDE 5 mg PO BID,
placed on SSI.
#CAD prevention: Continued on home Aspirin 81 mg PO/NG DAILY
#Esophageal dysmotility: Continued home Nitroglycerin SL 0.4 mg
SL Q5MIN:PRN chest pain. Did not require this. Took medications
with apple sauce and while sitting upright.
#Prostate cancer s/p radiation therapy in ___
#OSA on home CPAP
TRANSITIONAL ISSUES:
====================
Medications
[] Held carvedilol and hydrochlorthiazide given bradycardia and
electrolyte abnormalities, consider restarting with change in
regimen if appropriate per outpatient PCP or cardiology
[] Started hydralazine 25mg PO Q8H and metoprolol 50 mg BID for
hypertension
[] Please arrange Renal MRA for better evaluation of L renal
stenosis seen on renal ultrasound
[] Please recheck electrolytes to monitor
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prazosin 5 mg PO BID
2. Valsartan 320 mg PO DAILY
3. Simethicone 80 mg PO DAILY
4. Carvedilol 6.25 mg PO BID
5. Psyllium Powder 1 PKT PO DAILY
6. Felodipine 5 mg PO BID
7. Ranitidine 150 mg PO QHS
8. Multivitamins W/minerals Liquid 15 mL PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Omeprazole 40 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Loratadine 10 mg PO DAILY:PRN allergies
13. GlipiZIDE 5 mg PO BID
14. Hydrochlorothiazide 25 mg PO DAILY
15. Vitamin D 400 UNIT PO DAILY
16. Cromolyn Sodium (Nasal Inhalation) 1 SPRY NU DAILY:PRN
allergy symptoms
Discharge Medications:
1. HydrALAZINE 25 mg PO Q8H
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Cromolyn Sodium (Nasal Inhalation) 1 SPRY NU DAILY:PRN
allergy symptoms
5. Felodipine 5 mg PO BID
6. GlipiZIDE 5 mg PO BID
7. Loratadine 10 mg PO DAILY:PRN allergies
8. Multivitamins W/minerals Liquid 15 mL PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Omeprazole 40 mg PO BID
11. Prazosin 5 mg PO BID
12. Psyllium Powder 1 PKT PO DAILY
13. Ranitidine 150 mg PO QHS
14. Simethicone 80 mg PO DAILY
15. Valsartan 320 mg PO DAILY
16. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Bradycardia
Secondary diagnosis
Hyponatremia
Hypertension
Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you dizziness,
fatigue, and nausea and was found to have slow heart rate and
low sodium level in your blood.
WHAT HAPPENED WHILE I WAS HERE?
- We held your carvedilol and monitored your heart rate which
improved
- You were found to have low sodium levels and we gave your IV
fluids
- We held your diuretics
- We started you on new medications to control your blood
pressure
WHAT SHOULD I DO WHEN I GET HOME?
- Please continue to take your medications as prescribed. See
below for instructions.
- Please go to all of your scheduled doctor's appointments.
- You may need additional imaging to take a closer look at your
kidney function. Please discuss setting this up with your PCP,
___.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19736706-DS-24
| 19,736,706 | 27,118,527 |
DS
| 24 |
2200-01-26 00:00:00
|
2200-01-26 20:32:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Atenolol / Lisinopril
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ y/o M with PMH including hypertension,
chronic hyponatremia (idiopathic, requiring multiple admissions
in the last year), GERD/achalasia, OSA on CPAP, and type 2
diabetes presenting with headache and hypertensive urgency.
Mr ___ presented to the ED the evening of ___ with
complaints of headache, blurry vision, and elevated home BP
reading >180 systolic. He notes that his arms and legs were
painful and crampy during this time, and attributes all his
symptoms to his elevated blood pressure. He has had similar
symptoms for the last year, which have resulted in multiple
hospitalizations for refractory hypertension, as well as chronic
hyponatremia. In the ED, his Na is 123.
Thorough workup not find cause of hypoNa despite multiple
admissions since ___. Workup has also not revealed any source of
secondary hypertension. Most recently, he was discharged ___ for
symptomatic hyponatremia down to 116.
In the ED, he reports that his headache largely resolved after
bowel movement last night, and that his headaches are sometimes
associated with constipation. This bowel movement also resulted
in hypotension, with SBP in the 80___
Initial vital signs were notable for:
99.4 78 192/68 16 100% RA
Exam notable for: None
Labs were notable for: Hyponatremia (Na of 123)
Studies performed include:
CT Head: No acute intracranial abnormalities. Bilateral frontal
subcortical white matter hypodensities are unchanged since prior
CT head ___. Sulci and ventricles are normal in size
and configuration. There are no acute fractures.
Patient was given:
___ 19:06IVLORazepam .5 mg
___ 19:41POFelodipine 5 mg
___ 21:23PO/NGHydrALAZINE 20 mg
___ 21:23POLorazepam 1 mg
___ 21:23PO/NGDocusate Sodium 100 mg
___ 21:29IVFNS
___ 21:30POPantoprazole 40 mg
___ 22:16IVFNS 500 mL
___ 00:01PO/NGRanitidine 150 mg
___ 09:18POFelodipine 5 mg
___ 09:18PO/NGHydrALAZINE 20 mg
___ 09:18PO/NGDocusate Sodium 100 mg
___ 09:18PO/NGAspirin 81 mg
___ 09:18PO/NGValsartan 320 mg
___ 09:18POPrazosin 5 mg
___ 09:18PO/NGSertraline 25 mg
___ 09:18PO/NGSpironolactone 12.5 mg
___ 09:18PO/NGTorsemide 10 mg
___ 10:51IVFNS
___ 10:51PO/NGAcetaminophen 650 mg
___ 11:55SCInsulin ___
___ 14:33IVFNS ___
Consults: None
Vitals on transfer:
98.1PO 163 / 72R Lying 67 18 97 Ra
Upon arrival to the floor, the patient notes that he only
currently has a mild headache, which he describes as bilateral
and bandlike around his head. This is the typical for him.
He has been trying to adhere to a 2L fluid, low salt diet since
his last discharge, but notes that it is difficult. He also
states he feels that his headaches are associated with
hydralazine, as he never had issues with headaches before
starting this medication.
==================
REVIEW OF SYSTEMS:
==================
Complete ROS obtained and is otherwise negative.
Past Medical History:
- Hypertension
- Chronic Hyponatremia
- Alcohol use disorder (in remission for ___ years)
- Prostate cancer s/p XRT in ___
- GERD
- Achalasia
- Erectile dysfunction
- OSA on CPAP
- T2DM
Social History:
___
Family History:
States his mother had HTN and some type of cardiac disease,
unknown. Denies any family history of DM or cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: See above.
GENERAL: Alert, In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. II/VI
SEM
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. AOx3.
DISCHARGE PHYSICAL EXAM:
========================
VITALS:
___ 1549 Temp: 97.9 PO BP: 134/66 R Sitting HR: 90 RR: 18
O2 sat: 99% O2 delivery: Ra
GENERAL: pleasant, NAD
HEENT: NC/AT, MMM, anicteric sclera
CARDIAC: regular rate and rhythm, systolic ejection murmur, S1
and S3 present
LUNGS: Clear to auscultation bilaterally, no wheezes or
crackles,
no use of accessory muscles of respiration
ABDOMEN: soft, nontender, nondistended, normal bowel sounds
EXTREMITIES: No ___ edema
SKIN: Warm and well perfused, no rashes
NEUROLOGIC: oriented to person, place, time. Normal gait.
Pertinent Results:
ADMISSION LABS:
___ 06:45PM BLOOD WBC-7.3 RBC-4.37* Hgb-13.1* Hct-36.4*
MCV-83 MCH-30.0 MCHC-36.0 RDW-13.1 RDWSD-40.0 Plt ___
___ 06:45PM BLOOD Neuts-74.0* Lymphs-18.2* Monos-6.8
Eos-0.3* Baso-0.3 Im ___ AbsNeut-5.42 AbsLymp-1.33
AbsMono-0.50 AbsEos-0.02* AbsBaso-0.02
___ 06:45PM BLOOD ___ PTT-31.3 ___
___ 06:45PM BLOOD Glucose-107* UreaN-18 Creat-1.2 Na-124*
K-4.9 Cl-83* HCO3-20* AnGap-21*
___ 10:15PM BLOOD cTropnT-<0.01
___ 06:45PM BLOOD Calcium-9.7 Phos-2.9 Mg-1.8
___ 06:45PM BLOOD Osmolal-254*
___ 06:43PM BLOOD Glucose-100 Na-123* K-4.2 Cl-89*
calHCO3-19*
___ 06:43PM BLOOD Hgb-13.3* calcHCT-40
___ 05:35PM URINE Color-Straw Appear-Clear Sp ___
___ 05:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 05:35PM URINE Hours-RANDOM UreaN-203 Creat-23 Na-60
K-13
___ 05:35PM URINE Osmolal-214
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-3.8* RBC-3.83* Hgb-11.6* Hct-33.0*
MCV-86 MCH-30.3 MCHC-35.2 RDW-14.0 RDWSD-44.4 Plt ___
___ 01:40PM BLOOD Glucose-124* UreaN-20 Creat-1.3* Na-128*
K-5.1 Cl-94* HCO3-19* AnGap-15
___ 01:40PM BLOOD Calcium-9.0 Phos-4.0 Mg-1.8
___ 06:00AM BLOOD Cortsol-14.0
___ 10:40AM URINE Hours-RANDOM Creat-102 Na-36
___ 10:40AM URINE Osmolal-353
MICRO:
___ 5:35 pm URINE
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING REPORTS:
___ CT HEAD W/O CONTRAST
IMPRESSION:
No acute intracranial process.
Brief Hospital Course:
BRIEF SUMMARY:
Mr ___ is a ___ y/o M with PMH including hypertension,
chronic hyponatremia (idiopathic, requiring multiple admissions
in the last year), GERD/achalasia, OSA on CPAP, and type 2
diabetes presenting with hypertensive urgency and acute on
chronic hyponatremia.
ACTIVE ISSUES:
# Hypertensive urgency
Patient presented with complaints of headache, blurry vision,
and home BP reading of >180 systolic. In the ED his BP was
192/68. Exam Patient reported an episode of right-sided chest
pain, and EKG showed no changes, troponin was normal. Exam
revealed blurry vision. He was given home antihypertensives and
Ativan for anxiety. BPs improved. Hydralazine was held after a
period of hypotension after a bowel movement. Headache resolved
with his BM and Tylenol. Systolic BPs ranged from 120s-170s on
the floor and hydralazine was restarted. Can consider outpatient
blood pressure monitoring.
# Hyponatremia
Na was initially 124 on admission lower than his recent baseline
in the 130s. Patient was euvolemic and asymptomatic. The
etiology of the hyponatremia remained unclear and the urine
studies were not consistent with SIADH. Na improved to 131 with
fluid restriction.
CHRONIC ISSUES:
# Type II DM
- held home agents and was on HISS while inpatient.
# GERD/achalasia
- continued 20 mg BID omeprazole, ranitidine 150 mg
#OSA
- continued home CPAP
TRANSITIONAL ISSUES:
======================================
[] Needs repeat BMP drawn at next PCP appointment on ___
[] Consider ambulatory blood pressure monitoring.
[] Follow-up blood pressure and increase hydralazine dosing as
needed. Can also consider increasing spironolactone back to 25mg
daily.
[] Should follow-up with renal for workup of hyponatremia.
[] Discuss clonazepam dosing frequency with patient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrALAZINE 20 mg PO TID
2. ClonazePAM 0.5 mg PO QHS:PRN anxiety
3. Spironolactone 12.5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Cromolyn Sodium (Nasal Inhalation) 1 SPRY NU Q6H:PRN
allergies
6. Felodipine 5 mg PO BID
7. GlipiZIDE 2.5 mg PO BID
8. Loratadine 10 mg PO DAILY:PRN allergies
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Omeprazole 40 mg PO BID
11. Prazosin 5 mg PO BID
12. Psyllium Powder 1 PKT PO DAILY
13. Ranitidine 150 mg PO QHS
14. Sertraline 25 mg PO DAILY
15. Simethicone 80 mg PO TID:PRN gas pain
16. Torsemide 10 mg PO DAILY
17. Valsartan 320 mg PO DAILY
18. Vitamin D 400 UNIT PO DAILY
19. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
20. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. HydrALAZINE 10 mg PO TID Hypertension
RX *hydralazine 10 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Aspirin 81 mg PO DAILY
4. ClonazePAM 0.5 mg PO QHS:PRN anxiety
5. Cromolyn Sodium (Nasal Inhalation) 1 SPRY NU Q6H:PRN
allergies
6. Docusate Sodium 100 mg PO BID
7. Felodipine 5 mg PO BID
8. GlipiZIDE 2.5 mg PO BID
9. Loratadine 10 mg PO DAILY:PRN allergies
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Omeprazole 40 mg PO BID
12. Prazosin 5 mg PO BID
13. Psyllium Powder 1 PKT PO DAILY
14. Ranitidine 150 mg PO QHS
15. Sertraline 25 mg PO DAILY
16. Simethicone 80 mg PO TID:PRN gas pain
17. Spironolactone 12.5 mg PO DAILY
18. Torsemide 10 mg PO DAILY
19. Valsartan 320 mg PO DAILY
20. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hypertensive urgency
Hyponatremia
Secondary Diagnosis:
Type II diabetes
GERD
Obstructive sleep apnea
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 ADMITTED?
-You were admitted to the hospital for high blood pressure.
WHAT HAPPENED IN THE HOSPITAL?
-You were given blood pressure medications and your blood
pressure improved.
-You were given Tylenol and your headache improved.
WHAT SHOULD YOU DO AT HOME?
-Take your blood pressure medication as prescribed.
-Keep your fluid intake below 2 Liters ___ mL).
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
19736706-DS-25
| 19,736,706 | 27,722,057 |
DS
| 25 |
2200-04-18 00:00:00
|
2200-04-19 11:39:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Atenolol / Lisinopril
Attending: ___.
Chief Complaint:
headache, high blood pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with past medical
history most notable for hyponatremia and resistant hypertension
who presents with headache and hypertension noted in clinic. His
other medical issues are notable for GERD, obstructive sleep
apnea on CPAP, and type II diabetes.
The patient's hyponatremia dates back to at least ___. He
has been as low as 116. Initially this was attributed to
diuretic-induced hyponatremia in the setting of HCTZ (___),
which initially improved with discontinuation of HCTZ and fluid
repletion. He has had multiple subsequent admissions (once in
___ where hyponatremia was thought related to polydipsia
with low solute intake; in ___ hyponatremia suspected related
to be SIADH; and then most recently in ___, etiology of
hyponatremia was unclear and urine studies not consistent with
SIADH, however, Na improved with fluid restriction).
Review of recent work up reveals TSH 1.1 ___, AM cortisol
14.1 ___ but 2.1 in ___. Most recent set of urine lytes
from ___ with Na 34 and Uosm 395. It appears that the patient
has been instructed to adhere to fluid restriction of 1.5L. He
has been evaluated by renal, who thought that diuretic holiday
would be the ultimate way to make the diagnosis, but that in the
setting of hypertension, this is not advocated.
With regard to patient's hypertension: this is again
longstanding, with extensive workup in past not revealing for
clear secondary cause of hypertension. Specifically, RAS,
pheochromocytoma and hyperaldosteronism were ruled out.
There have been multiple recent medication changes. Most
recently, his eplerenone was increased from 25 to 50 mg
(___), and he was started on indapamide 1.25 mg
(___). He notes that he started taking indapamide on
___ (which was a switch from torsemide) and started
experiencing dizziness upon changing positions. After 3 days of
the new medication, he decided to switch back to torsemide.
He notes that his BPs have been fluctuating recently, often with
SBP 140 when he goes to bed, then 150s when he wakes up.
However, on ___, he noticed that his BP was elevated to
197/88. In this setting, he developed gradual worsening
posterior headache, which he described as constant, ___, not
associated with nausea, vomiting, or sensitivity to light/sound.
He rested a bit, laid down in a dark area, and BP improved to
175/75, with slight improvement of headache. He took Tylenol
___ mg, which helped his headache as well. No weakness,
numbness, tingling present.
He subsequently presented to ___ clinic. In clinic, SBP noted to
be 160-180, with nonfocal neurological exam. He was subsequently
referred to ED for further management and workup of his
hypertension and headache.
Past Medical History:
- Hypertension
- Chronic Hyponatremia
- Alcohol use disorder (in remission for ___ years)
- Prostate cancer s/p XRT in ___
- GERD
- Achalasia
- Erectile dysfunction
- Obstructive sleep apnea on CPAP
- Type II diabetes mellitus
Social History:
___
Family History:
States his mother had hypertension and some type of cardiac
disease, unknown. Denies any family history of diabetes mellitus
or cancer.
Physical Exam:
ADMISSION EXAM:
ED vitals: Temp 98.1, HR 82, BP 216/88, RR 22, 100% 4L NC
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM:
24 HR Data (last updated ___ @ ___
Temp: 97.4 (Tm 98.0), BP: 180/70 (138-183/58-77), HR: 64
(50-73), RR: 18, O2 sat: 100% (97-100), O2 delivery: RA, Wt:
168.65 lb/76.5 kg
GENERAL: Lying comfortably in bed, easily arousable
HEENT: No scleral icterus or conjunctival pallor. MMM.
Oropharynx clear.
NECK: Supple, no LAD, no elevated JVP.
CV: Normal S1 S2. No additional heart sounds. Faint holosystolic
murmur, grade I/VI heard best in the RUSB.
PULM: CTAB. No wheezes, rales, rhonchi.
GI: Soft, NT, ND. No rebound tenderness or guarding. No
abdominal bruits.
EXTREMITIES: No cyanosis, clubbing, or edema. Warm, well
perfused.
PULSES: 2+ radial pulses bilaterally.
NEURO: Cranial nerves II-XII intact. Moving all extremities with
purpose.
Pertinent Results:
ADMISSION LABS:
___ 05:55PM BLOOD WBC-5.8 RBC-4.66 Hgb-14.0 Hct-39.2*
MCV-84 MCH-30.0 MCHC-35.7 RDW-12.4 RDWSD-37.7 Plt ___
___ 05:55PM BLOOD Neuts-72.0* ___ Monos-7.6
Eos-0.7* Baso-0.3 Im ___ AbsNeut-4.15 AbsLymp-1.11*
AbsMono-0.44 AbsEos-0.04 AbsBaso-0.02
___ 05:55PM BLOOD Glucose-172* UreaN-13 Creat-1.0 Na-123*
K-4.1 Cl-81* HCO3-28 AnGap-14
___ 11:26PM BLOOD Osmolal-258*
___ 01:51AM URINE Osmolal-309
___ 01:51AM URINE Hours-RANDOM UreaN-411 Creat-74 Na-48
PERTINENT REPORTS:
Barium swallow ___:
There is a short segment of mild smooth narrowing noted in the
distal esophagus near the GE junction. At this region, there
was holdup of the 13 mm barium tablet the was administered.
Patient was observed for greater than 10 minutes; however, the
tablet did not pass. Thyroid is delayed esophageal transit with
tertiary contractions noted, consistent with mild esophageal
dysmotility. There is no esophageal dilation or mass and the
mucosa appeared normal. There is no inducible gastroesophageal
reflux or hiatal hernia. No overt abnormality in the stomach or
duodenum on limited evaluation. There is no obstruction a the
gastroduodenal junction.
DISCHARGE LABS:
___ 12:56PM URINE Hours-RANDOM Na-<20
___ 06:50AM BLOOD WBC-3.4* RBC-3.52* Hgb-10.9* Hct-30.7*
MCV-87 MCH-31.0 MCHC-35.5 RDW-13.1 RDWSD-41.4 Plt ___
___ 06:50AM BLOOD Glucose-131* UreaN-32* Creat-1.2 Na-131*
K-5.4 Cl-90* HCO3-27 AnGap-14
___ 06:50AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ year old male with a history of resistant
hypertension, type II diabetes mellitus, obstructive sleep apnea
on continuous positive airway pressure, and chronic hyponatremia
who presented with two days of headache and elevated blood
pressure and found to have worsening hyponatremia, admitted for
further workup.
ACTIVE ISSUES:
==============
# Hypertension
He is on multiple medications at home including felodipine,
eplerenone, hydralazine, losartan, prazosin. He was recently
started on indapamide, but after developing dizziness, he
substituted this medication for his previous home Torsemide.
Workup for secondary hypertension has been negative in the past.
He has been trialed on hydrochlorothiazide and spironolactone in
the past, but course was complicated by hyponatremia and
gynecomastia respectively. During this hospitalization, we
continued his home felodipine 5 mg BID, eplerenone 50 mg QD,
prazosin 5 mg BID, torsemide 10 mg QD. We transitioned from
losartan 100mg daily to losartan 50mg BID. We also stopped his
PO hydralazine and started PO clonidine 0.1mg TID. Initially, he
became dizzy on the first day of clonidine so held the afternoon
dose. Thereafter, transitioned him to clonidine patch and
discontinued PO clonidine, but his systolic blood pressure
increased to 150-160s. Thus, on discharge, the decision was made
to discontinue clonidine patch and restart clonidine 0.1mg BID
(written for afternoon and evening, as his blood pressure can
drop in the morning with his other blood pressure medications).
Lastly, we made his home clonazepam a standing medication, as he
has baseline anxiety.
# Hypotonic Hyponatremia
On ___, the patient was started on indapamide (as a
substitution for torsemide), and two days after starting this
medication, he developed dizziness and headache. On ___, he
stopped taking indapamide and switched to torsemide. Sodium upon
admission was 123. Etiology is recent initiation of indapamide
and increased fluid intake vs SIADH. Indapamide was held in the
hospital. Sodium improved after strict fluid restriction, salt
tablets, and glucerna supplementation. Renal was consulted and
felt that the patient would benefit from a high protein diet.
Nutrition saw the patient and provided education of good sources
of protein and ways to monitor fluid intake.
# Non-productive cough
Patient endorsed a dry cough on admission, indicating he had a
"tickle in his throat." His lungs were clear on exam. He had no
signs of an infection. Most likely etiology is his known GERD.
The patient reported considerable improvement with addition of
guaifenesin-codeine.
# Headaches
Thought to be secondary to hyponatremia or hypertension. There
was no evidence of end organ damage, focal neurologic deficits
on exam, or red flag symptoms. The patient responded well to
Tylenol 1,000 mg PO Q8hrs.
CHRONIC ISSUES:
===============
# Type II diabetes mellitus
Not on any antiglycemic agent at home. Most recent A1c is 6.6%.
Treated with sliding scale insulin in hospital.
# Obstructive sleep apnea
Used home CPAP.
# Anxiety
The patient has a history of anxiety controlled on clonazepam
prn and sertraline. As above, his clonazepam was made standing.
# GERD
# Achalasia
He is followed by Dr. ___ in the outpatient setting. He has a
history of Schatzki ring, distal esophageal spasm, and
esophagitis. Recent studies for him include a barium swallow in
___ that showed a 5cm stricture at the lower esophagus. In
___, had a GE junction biopsy showing mild esophagitis and a
gastric body biopsy showing mild chronic inflammation. Notably,
he has intermittent difficulty with swallowing solids and takes
nitroglycerin for relief. He often consumes additional water to
help with swallowing. In the hospital, continued his home
ranitidine and omeprazole. He had a barium swallow that showed
narrowing in the distal esophagus and mild esophageal
dysmotility. He will follow-up with Dr. ___ further
management.
TRANSITIONAL ISSUES:
====================
[ ] Follow-up with Dr. ___ hypertension management on
___.
[ ] Recommend following up sodium at PCP ___. If he continues
to improve, can consider discontinuing sodium tabs and
monitoring sodium as primary effect may have been indapamide.
[ ] If persistent issues with hyponatremia, can consider
discussion of alternative antidepressant rather than sertraline,
but current presentation more likely secondary to indapamide.
[ ] Follow-up with Dr. ___ dysphagia and findings from
barium swallow.
CORE MEASURES:
==============
#CODE: Full
#CONTACT: ___ (wife/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Prazosin 5 mg PO BID
2. Felodipine 5 mg PO BID
3. Losartan Potassium 100 mg PO DAILY
4. HydrALAZINE 10 mg PO Q8H
5. Torsemide 10 mg PO DAILY
6. Sertraline 25 mg PO DAILY
7. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous
gluconat;<br>multivitamin-iron-folic acid) 3,500-18-0.4
unit-mg-mg oral DAILY
8. Omeprazole 40 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10. Eplerenone 50 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Loratadine 10 mg PO DAILY
13. Ranitidine 150 mg PO QHS
14. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
15. Nitroglycerin SL 0.4 mg SL BID:PRN esophageal spasm or food
getting stuck
16. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
Discharge Medications:
1. CloNIDine 0.1 mg PO BID
RX *clonidine HCl 0.1 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
2. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
RX *codeine-guaifenesin 10 mg-100 mg/5 mL 5 ml by mouth at
bedtime Refills:*0
3. Sodium Chloride 1 gm PO TID
RX *sodium chloride 1 gram 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
4. ClonazePAM 0.25 mg PO BID
RX *clonazepam 0.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
5. Losartan Potassium 50 mg PO BID
RX *losartan 50 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
6. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
7. Aspirin 81 mg PO DAILY
8. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous
gluconat;<br>multivitamin-iron-folic acid) 3,500-18-0.4
unit-mg-mg oral DAILY
9. Eplerenone 50 mg PO DAILY
10. Felodipine 5 mg PO BID
11. Loratadine 10 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL BID:PRN esophageal spasm or food
getting stuck
13. Omeprazole 40 mg PO DAILY
14. Prazosin 5 mg PO BID
15. Ranitidine 150 mg PO QHS
16. Sertraline 25 mg PO DAILY
17. Torsemide 10 mg PO DAILY
18. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Hypoosmolar hyponatremia
Hypertension
Secondary Diagnoses:
Type II diabetes mellitus
GERD
Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHAT BROUGHT YOU INTO THE HOSPITAL?
You were referred from clinic as a result of high blood pressure
and a headache.
WHAT DID WE DO FOR YOU IN THE HOSPITAL?
In the hospital, we checked your sodium level, and it was low
(123). We think your sodium was low as a result of the
indapamide medication. You had stopped the indapamide medication
prior to coming to the hospital. We restricted your water intake
to 1L and gave you salt tablets. Your sodium level was 131 upon
leaving the hospital.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
-You should maintain fluid restriction of 1 L at home until you
see Dr. ___.
-You should check your blood pressure prior to taking your
clonidine. You should not take your oral clonidine if your
systolic blood pressure (top number) is less than 110.
-You should follow-up with your primary care doctor, ___
on ___.
We wish you the very best. It was a pleasure taking care of you
in the hospital.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19736706-DS-26
| 19,736,706 | 22,977,536 |
DS
| 26 |
2200-08-15 00:00:00
|
2200-08-19 14:02:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Atenolol / Lisinopril
Attending: ___.
Chief Complaint:
Left neck swelling and tenderness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ veteran with a history of
hypertension who presented ___ with left neck pain 1 day status
post EGD. Patient received an EGD (by Dr. ___ for dysphasia
where biopsies were taken. Patient tolerated the procedure well,
but day of presentation awoke with left lower neck pain and
swelling. Patient has had no dysphasia, no dysphonia, no
difficulty controlling secretions although has chronic need to
clear his throat frequently that's been going on for months. No
sore throat. No chest pain, no difficulty breathing, no cough.
No abdominal pain, no nausea or vomiting, no diarrhea, no
hematochezia or melena.
Initial vital signs in the ED: T 97.2, HR 95, BP 175/83, RR 16,
99% RA. In the ED there was concern for cellulitis and patient
got ceftriaxone and then vancomycin. Due to mild ___ (Cr 1.4)
and lactate of 2.2, he also go 1L LR.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Hypertension
- Chronic Hyponatremia
- Alcohol use disorder (in remission for ___ years)
- Prostate cancer s/p XRT in ___
- GERD
- Achalasia
- Erectile dysfunction
- Obstructive sleep apnea on CPAP
- Type II diabetes mellitus
- Hypertension
- Chronic Hyponatremia
- Alcohol use disorder (in remission for ___ years)
- Prostate cancer s/p XRT in ___
- GERD
- Achalasia
- Erectile dysfunction
- Obstructive sleep apnea on CPAP
- Type II diabetes mellitus
Social History:
___
Family History:
States his mother had hypertension and some type of cardiac
disease, unknown. Denies any family history of diabetes mellitus
or cancer.
Physical Exam:
Vital signs:
24 HR Data (last updated ___ @ 737)
Temp: 97.7 (Tm 97.7), BP: 156/69 (156-198/69-84), HR: 49
(49-65),
RR: 18 (___), O2 sat: 99% (97-100), O2 delivery: RA, Wt: 162.9
lb/73.89 kg
GENERAL: Pleasant older gentleman, in no apparent distress.
EYES: PERRL. EOMI. Anicteric sclerae.
ENT: Ears and nose without visible erythema, masses, or trauma.
Posterior oropharynx without erythema or exudate, uvula midline.
Slight asymmetry to face (pt reports is baseline, life-long).
Mild swelling left neck, left medial shoulder.
CV: Regular rate and rhythm. Normal S1 S2, no S3, no S4. No
murmur. No JVD.
PULM: Breathing comfortably on room air. Lungs clear to
auscultation. No wheezes or crackles. Good air movement
bilaterally.
GI: Bowel sounds present. Abdomen non-distended, soft,
non-tender
to palpation. No HSM appreciated.
GU: No suprapubic fullness or tenderness to palpation.
EXTR: No lower extremity edema. Distal extremity pulses palpable
throughout.
SKIN: No rashes, ulcerations, scars noted. See above regarding
swelling/tenderness of left neck/shoulder/chest wall.
NEURO: Alert. Oriented to person/place/time/situation. Face
symmetric. Gaze conjugate with EOMI. Speech fluent. Moves all
limbs spontaneously. No tremors, asterixis, or other involuntary
movements observed. Normal and symmetric distal extremity
strength and light touch sensation throughout.
PSYCH: Pleasant, cooperative. Follows commands, answer questions
appropriately. Appropriate affect.
Pertinent Results:
=====
LABS
=====
WBC 4.2, Hgb 11.4
Glu 177, BUN 21->15->16->18, Cr 1.4->1.0->1.0->1.3
CRP 12.0, ESR pending
=============
MICROBIOLOGY
=============
___ Ucx - contaminated
================
IMAGING & STUDIES
================
___ CT Chest with contrast
IMPRESSION:
1. Diffuse left-sided subcutaneous edema seen along the left
neck
and extending to the left upper chest wall as well as into the
superior and anterior mediastinum, along the left side of the
trachea indenting the tracheal wall. No discrete fluid
collection to suggest presence of an underlying abscess. No
mass
lesions identified.
2. There is asymmetric lack of opacification of the left
internal
jugular vein, which can be concerning for thrombus, a dedicated
ultrasound with Doppler may be obtained to evaluate the left
internal jugular vein.
3. Ascending thoracic aortic aneurysm measuring up to 3.7 cm in
diameter.
RECOMMENDATION(S): A dedicated ultrasound can be obtained for
further evaluation of the left internal jugular vein.
___ US Doppler Left IJ
IMPRESSION: No thrombosis, normal.
Brief Hospital Course:
___ veteran with a PMH pertinent for HTN, NIDDM2,
prostate cancer, and dysphagia who was sent to hospital for left
neck pain/swelling one day after an EGD.
==============================
BRIEF HOSPITAL COURSE BY PROBLEM
==============================
# Left neck/shoulder/chest wall tenderness
The swelling was in an eccentric distribution that might
correspond to how the patient was lying (on his left side)
during the recent EGD and colonoscopy. Fortunately it resolved
with time. CTA chest done initially, reviewed by multiple
radiologists, the edema doesn't seem consistent in distribution
to suggest esophageal perforation and clinically he is doing so
well it seems very unlikely. Out of abundance of caution, in
coordination with the patient's outpatient GI doctor, we
consulted with ENT and inpatient GI to evaluate further. GI
agreed that imaging and clinical exam didn't support a
complication from the EGD itself although he may have had some
kind of contact reaction that led to the edema. Fiberoptic
laryngoscopy by ENT showed no mass lesions or evidence of
infection. Barium swallow and CT neck/chest with contrast were
negative for evidence of an esophageal perforation (or
obstruction). He was continued on a combined PPI and H2 blocker
regimen like at home and was discharged with close GI clinic
follow-up.
# Dysphagia
# PUD
He has a history of Schatzki ring in the past. An EGD on ___, showed presbyesophagus and esophageal ring that was
dilated. The ring was at the GE junction. There was another
narrowing about 1 cm above that where there was a partial ring.
There was spasm in the distal esophagus. He had another EGD on
___, which
again showed abnormal motility of the esophagus and a tortuous
esophagus with a tight LES, although specific stenosis was not
seen. There was a possible partial ring above that where the
lumen took a mild turn but the area was not narrowed. The LES
was dilated with an esophageal balloon to 20 mm. The gastric
antrum was biopsied and showed focal intestinal metaplasia. His
latest EGD ___ showed little abnormal other than a hiatal
hernia; path pending. Per above, during the hospitalization he
was continued on omeprazole 40 daily and ranitidine 150 qHS and
had close GI follow-up.
# HTN
He has a history of difficult to manage chronic essential
hypertension which remained true during this hospitalization
with episodes of SBP as high as the 200s. He was continued on
his home clonidine 0.1 TID, eplerenone 25 daily, felodipine ER 5
BID, losartan 50 BID.
# HFpEF
He was continued on his home torsemide 10 daily.
# DM2
He was put on mealtime and bedtime fingersticks with as needed
insulin sliding scale. His home glipizide 2.5 daily (pt reported
dose) was initially held, then restarted given he was eating.
# Depression
Patient reports PCP discontinued clonazepam so this was held.
His home sertraline 25 daily was continued.
# BPH
He continued his home prazosin 5 BID.
# Hx of hyponatremia
He had been on salt tablets, recently followed up with
nephrology and recommended to discontinue since the low Na had
resolved. So sodium tablets were held. He continued his home
fluid-restricted, high-protein diet.
# Constipation
He was continued on his home psyllium powder daily, docusate 100
BID, and Miralax prn constipation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
2. Eplerenone 25 mg PO DAILY
3. Felodipine 5 mg PO BID
4. Losartan Potassium 50 mg PO BID
5. Prazosin 5 mg PO BID
6. Ranitidine 150 mg PO QHS
7. Sertraline 25 mg PO DAILY
8. Torsemide 10 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10. Aspirin 81 mg PO DAILY
11. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous
gluconat;<br>multivitamin-iron-folic acid) 3,500-18-0.4
unit-mg-mg oral DAILY
12. Loratadine 10 mg PO DAILY
13. Omeprazole 40 mg PO DAILY
14. CloNIDine 0.1 mg PO TID
15. Nitroglycerin SL 0.4 mg SL BID:PRN esophageal spasm or food
getting stuck
16. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
17. Docusate Sodium 100 mg PO BID:PRN Constipation
18. Sodium Chloride Nasal 1 SPRY NU 1 SPRAY IN EACH NOSTRIL
TWICE A DAY AS NEEDED
19. Simethicone 80 mg PO TAKE 1 TABLET WITH GLASS OF WATER
BEFORE OMEPRAZOLE
20. GlipiZIDE 2.5 mg PO BID
21. Psyllium Powder 1 PKT PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous
gluconat;<br>multivitamin-iron-folic acid) 3,500-18-0.4
unit-mg-mg oral DAILY
4. CloNIDine 0.1 mg PO TID
5. Docusate Sodium 100 mg PO BID:PRN Constipation
6. Eplerenone 25 mg PO DAILY
7. Felodipine 5 mg PO BID
8. GlipiZIDE 2.5 mg PO BID
9. Guaifenesin-CODEINE Phosphate 5 mL PO Q6H:PRN cough
10. Loratadine 10 mg PO DAILY
11. Losartan Potassium 50 mg PO BID
12. Nitroglycerin SL 0.4 mg SL BID:PRN esophageal spasm or food
getting stuck
13. Omeprazole 40 mg PO DAILY
14. Prazosin 5 mg PO BID
15. Psyllium Powder 1 PKT PO DAILY
16. Ranitidine 150 mg PO QHS
17. Sertraline 25 mg PO DAILY
18. Simethicone 80 mg PO TAKE 1 TABLET WITH GLASS OF WATER
BEFORE OMEPRAZOLE
19. Sodium Chloride Nasal 1 SPRY NU 1 SPRAY IN EACH NOSTRIL
TWICE A DAY AS NEEDED
20. Torsemide 10 mg PO DAILY
21. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left neck, shoulder, chest wall edema/tenderness of unclear
etiology
Potential hypertensivity reaction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted due to swelling and tenderness on the left
side of your neck/shoulder/chest after a scope by GI. You
initially got a dose of antibiotics and some imaging. Our
assessment is that you don't have an esophageal perforation or
other complication from the scope procedure, and this is not an
infection. It may have been an allergic-like reaction to
something you came in contact with during the procedure.
Fortunately the swelling and tenderness is fading away on its
own.
We have scheduled follow-up appointments with your primary care
doctor and with Dr. ___. Please continue taking your home
medications like usual.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19736918-DS-12
| 19,736,918 | 22,043,478 |
DS
| 12 |
2121-08-18 00:00:00
|
2121-08-18 16:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___ critical limb ischemia and ___ ___ toe ulcer, concern for
osteomyelitis
Major Surgical or Invasive Procedure:
1. Real-time ultrasound-guided access of the left common
femoral artery, placement of a ___ sheath. Number.
2. Selective catheterization of the right common iliac
artery ___ order vessel.
3. Abdominal aortogram.
4. Right and left lower extremity angiograms.
5. Right common femoral endarterectomy with bovine
pericardial patch angioplasty and profundoplasty.
6. Right common femoral artery to below-knee popliteal
artery bypass with nonreversed greater saphenous vein
tunneled subfascially.
7. Angioscopy and valve lysis with a valvulotome.
8. RIGHT ___ and ___ digit partial amputations
History of Present Illness:
Mr. ___ is a ___ yo M with a PMH of CAD s/p PCI in ___,
treatment of restenosis with DES in ___ (now off plavix, pt
unclear why plavix was d/c'ed recently), and NIDDM who presented
with 2 months of non-healing ___ ___ toe ulcer. Mr. ___
presented to ___ emergency department on ___ after being
evaluated by podiatry (Dr. ___ earlier that day. His
outpatient podiatry exam was concerning for osteomyelitis, and
thus he was transferred to ___ ED for further workup and
management.
Past Medical History:
Afib on warfarin
CHF- ECHO from ___, EF 34%, moderate MR, dilated L
atrium, RA SBP 50mmHg
CAD- s/p BMS in ___, repeat stenting with DES in ___. Last
cardiac cath in ___ shows mild diffuse left main/LAD and CA
disease, mild 40% proximal disease in circumflex, no
intervention performed
DM
anxiety
HTN
HLD
Social History:
___
Family History:
EtOH and cocaine abuse in the past
Physical Exam:
Admission Physical Exam:
98.4 94 121/56 16 100% RA
General: comfortable
___: irregular rhythm
Pulm: clear bilaterally
abdomen: soft, NT, ND
Ext: second toe distal ulceration with areas of necrosis, tender
no purulence can be expressed. Not malodorous.
L: -/D/D/- R: P/D/D/-
Discharge Physical Exam:
Gen: NAD, A&Ox3
___: irregularly irregular
Pulm: CTAB, no resp distress
Abd: soft, non-tender
Ext: ___ ace wrapped from foot to thigh. Dressing taken down,
leg examined on morning of discharge-- staples in place along
medial calf to thigh over GSV harvest site. R groin cutdown site
C/D/I, minimal bruising, no drainage from staple line, no
hematoma.
Pulses:
L: -/D/D/- R: P/D/D/-
Pertinent Results:
Admission Labs
___ 07:53PM BLOOD WBC-11.5* RBC-4.38* Hgb-11.0* Hct-36.3*
MCV-83 MCH-25.1* MCHC-30.3* RDW-23.6* RDWSD-68.2* Plt ___
___ 07:53PM BLOOD Neuts-68.3 Lymphs-17.5* Monos-11.2
Eos-1.9 Baso-0.7 Im ___ AbsNeut-7.83* AbsLymp-2.01
AbsMono-1.29* AbsEos-0.22 AbsBaso-0.08
___ 07:53PM BLOOD estGFR-Using this
___ 05:10PM BLOOD ALT-16 AST-28 AlkPhos-74 TotBili-0.6
___ 05:10PM BLOOD %HbA1c-5.4 eAG-108
___ 07:45AM BLOOD Vanco-17.5
___ 07:58AM BLOOD Vanco-24.5*
___ 08:00PM BLOOD Vanco-16.0
___ 08:19PM BLOOD Lactate-2.6*
___ foot x-ray (___)
IMPRESSION:
Apparent erosion at the distal phalanx of the second toe which
may represent
osteomyelitis.
CTA (___)
1. Occlusion of the right popliteal artery with distal
reconstitution.
Diminutive flow is seen in the posterior tibial artery and
proximal anterior
tibial artery. Flow is seen in the dorsalis pedis artery. The
peroneal artery
appears patent.
2. Minimal flow is present in the left posterior tibial artery.
Flow through
the anterior tibial artery is diminutive. The left peroneal
artery appears
patent throughout.
3. Additional extensive vascular disease as above.
ABIs (___)
FINDINGS:
On the right side, triphasic Doppler waveforms are seen in the
common femoral
but monophasic at the popliteal and an absent at the posterior
tibial and
dorsalis pedis arteries.
On the left side, triphasic Doppler waveforms are seen at the
common femoral
but monophasic at the popliteal, posterior tibial and dorsalis
pedis arteries.
The left ABI was 0.78.
Pulse volume recordings showed symmetric amplitudes bilaterally,
at all
levels.
IMPRESSION:
Evidence of severe right and moderate-to-severe left lower
extremity ischemia
at rest.
___ Venous Duplex (___)
FINDINGS:
RIGHT: The great saphenous vein is patent with diameters
ranging from 0.74 to
0.32 cm. The right small saphenous vein is patent with diameters
ranging from
0.20 to 0.25 cm
IMPRESSION:
The right great saphenous vein is patent. Please see digitized
image on PACS
for formal sequential measurements.
Angiography Findings (___):
ANGIOGRAM FINDINGS:
1. Normal caliber abdominal aorta without ectasia or
stenosis.
2. Bilateral renal arteries without stenoses and bilateral
nephrograms appreciated.
3. Patent bilateral common iliac arteries.
4. Patent bilateral external and internal iliac arteries.
5. Patent bilateral common femoral arteries with both
common femorals having greater than 50% stenoses
throughout their length.
6. Right profunda femoral patent.
7. Right SFA patent in the proximal two-thirds and occluded
over approximately 6 cm in the distal one-third with
multiple areas in the proximal two-thirds having
approximately 50% stenoses.
8. Right distal SFA occlusion as mentioned above,
reconstitutes slightly above-knee popliteal artery which
then feeds 1-vessel runoff to the foot via the peroneal
artery. Both anterior tibial and posterior tibial are
occluded at their origin. On the left, the profunda
femoris artery is patent, and the SFA is patent with
multiple areas of greater than 50% stenosis along its
length. The popliteal artery is also patent.
9. 1-vessel runoff on the left via the peroneal artery.
Both anterior tibial and posterior tibial are occluded
at their origin.
CXR (___):
FINDINGS:
There is no focal consolidation, sizeable pleural effusion or
pneumothorax.
The size of the cardiac silhouette is at the upper limits of
normal.
Degenerative changes are noted around the left acromioclavicular
joint.
IMPRESSION:
No radiographic evidence of acute cardiopulmonary disease.
ECHO (___):
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is mildly dilated. There is mild regional
left ventricular systolic dysfunction with basal
inferior/inferolateral hypokinesis. The remaining segments
contract normally (LVEF = 45-50%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. An eccentric, posteriorly-directed jet of
moderate (2+) mitral regurgitation is seen. Due to the eccentric
nature of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. At least moderate mitral regurgitation.
Discharge Labs:
___ 06:35AM BLOOD WBC-12.3* RBC-3.50* Hgb-8.9* Hct-28.6*
MCV-82 MCH-25.4* MCHC-31.1* RDW-22.2* RDWSD-64.9* Plt ___
___ 06:35AM BLOOD Glucose-108* UreaN-7 Creat-0.8 Na-138
K-4.2 Cl-99 HCO3-24 AnGap-15
___ 06:35AM BLOOD Calcium-7.8* Phos-3.3 Mg-2.0
Brief Hospital Course:
Mr. ___ presented to ___ ED on ___ with a chronic ___ ___
toe ulceration and concern for osteomyelitis. He was seen
earlier in the day on ___ at an outpatient ___ clinic. His
___ exam was concerning for osteomyelitis and thus he was
instructed to present to ___ ED for further evaluation/mgmt.
In the ED, Mr. ___ was started on IV antibiotics (vancomycin,
ciprofloxacin, flagyl) and underwent ___ foot x-ray, which was
concerning for osteomyelitis. Podiatry service was consulted,
who recommended vascular surgery consultation to evaluate
arterial inflow prior to debriding or amputating any ___ tissue.
Initial vascular surgery exam was notable for R second toe
distal ulceration with areas of necrosis, tender to palpation,
without purulence. ___ signal exam was notable for dopplerable
DP signal, no ___ signal. Mr. ___ underwent non-invasive
arterial studies which showed on the right side, triphasic
Doppler waveforms in the common femoral
but monophasic at the popliteal and an absent at the posterior
tibial and dorsalis pedis arteries.
To evaluate Mr. ___ for possible lower extremity bypass, CTA
of the right lower extremity was performed. CTA showed occlusion
of the right popliteal artery with distal reconstitution,
diminutive flow in the posterior tibial artery and proximal
anterior tibial artery, flow in the dorsalis pedis artery,
peroneal artery appeared patent. Venous duplex, also performed
to work Mr. ___ up for possible bypass procedure, showed
adequate right sided greater saphenous vein that could be used
as conduit material.
Mr. ___ was deemed a good candidate for R common femoral to
below knee popliteal bypass, and underwent ECHO and CXR for
pre-op workup. ECHO showed an EF of 45-50%, CXR was
unremarkable.
Mr. ___ underwent uncomplicated ___ common femoral
endarterectomy and ___ CFA to popliteal bypass with reversed
right greater saphenous vein. A drain was left in place in high
right groin post-op. He tolerated the procedure well, and after
recovering in the PACU for several hours post-operatively, he
returned to the floor in stable condition. He returned to the OR
on ___ with podiatry for R ___ and ___ toe amputation with
primary closure. Mr. ___ post-operative course was
complicated by tachycardia (HR intermittently 130s-140s), ___
swelling, and high R groin drain output. Regarding his
tachycardia, the medicine service was consulted, who recommended
continuing him on his home antihypertensive regimen (lisinopril
2.5 QD and carvediolo 12.5 BID). Home lasix was initially held
given concern for overall hypovolemia being the etiology of his
tachycardia. Mr. ___ HR stabilized in the 100-110s on his
home antihypertensive regimen, and he was able to be
subsequently be restarted on his home lasix. He was diuresed in
house with gradually improved swelling of his ___, which was
initially quite edematous post-operatively. His groin drain,
which had high serous output on post-op day 1, was able to be
pulled by post-op day 2 without complication. Mr. ___ groin
remained C/D/I after pulling the drain.
Mr. ___ remained in house for several days CFA
___ bypass/R ___ and ___ toe amp. During this
time, he advanced his diet without difficulty, was voiding and
stooling without difficulty, and worked with ___ intermittently.
___ recommended home with services given his mild deconditioning
in the setting of hospitalization.
Of note, home coumadin was held perioperatively. Mr. ___ was
restarted on his home coumadin post-operatively. His INR was 2.2
at time of discharge, on ___
Regarding his antibiosis, Mr. ___ was maintained on
vanc/cipro/flagyl until OR cultures (obtained by podiatry) were
obtained. His OR cultures grew E coli resistant to cipro but
sensitive to bactrim. Mr. ___ was discharged on Bactrim with
instructions to complete a ___nd follow up in both
podiatry and vascular surgery clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Carvedilol 3.125 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Furosemide 40 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Omeprazole 40 mg PO BID
8. Sertraline 25 mg PO BID
9. Clopidogrel 75 mg PO DAILY
10. ___ MD to order daily dose PO DAILY16
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe
4. Senna 8.6 mg PO BID:PRN Constipation - First Line
5. Sulfameth/Trimethoprim DS 2 TAB PO BID
6. Carvedilol 12.5 mg PO BID
7. Atorvastatin 80 mg PO QPM
8. Clopidogrel 75 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Furosemide 40 mg PO DAILY
12. Lisinopril 2.5 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. Sertraline 25 mg PO DAILY
15. ___ MD to order daily dose PO DAILY16
16.Rolling Walker
Dx: critical right lower extremity limb s/p CFA/profunda EAPA &
byspass R CFA to BK pop with GSV and gangrenous right first and
second toes with osteomyelitis s/p 2 partial toe amputation.
Px: good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
___:
Right ___ toe tissue loss associated
with atherosclerosis.
Discharge Condition:
stable to home
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. You are now being
discharged after undergoing bypass surgery of your right leg.
This was performed to improve your circulation. You are
recovering well. Please follow the below instructions for an
uncomplicated recovery:
WHAT TO EXPECT:
1. It is normal to feel tired. This might last for ___ weeks
You should get up out of bed every day and gradually increase
your activity each day
Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on.
Elevate your leg above the level of your heart (use ___ pillows
or a recliner) every ___ hours throughout the day and at night
Avoid prolonged periods of standing or sitting without your
legs elevated. You should wear an ACE wrap to this leg each
day. You can remove the ACE bandage for sleeping.
3. It is normal to have a decreased appetite. Your appetite
will return with time.
You will probably lose your taste for food and lose some weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
MEDICATION:
Follow your discharge medication instructions below. These
have been carefully reviewed by your providers.
Use Tylenol (Acetaminophen) 1000mg every 8 hours. Be aware
that there are some over-the-counter and prescription
medications that contain acetaminophen. Be sure never to
consume more than 3000mg of Tylenol/Acetaminophen in one day.
Use narcotic pain medication sparingly. You should require
smaller amounts and doses this less often as time goes on.
NEVER DRIVE OR OPERATE MACHINERY WHILE ON NARCOTIC PAIN
MEDICATION. If you are taking narcotics, keep in mind that you
may become constipated. You can take over-the-counter stool
softeners or laxatives to prevent or treat this.
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
Unless you were told not to bear any weight on operative foot:
You should get up every day, get dressed and walk
You should gradually increase your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
Keep your leg elevated and ACE bandaged to prevent swelling and
pain.
CALL THE OFFICE FOR: ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 100.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
___
|
19736957-DS-2
| 19,736,957 | 24,029,252 |
DS
| 2 |
2190-10-03 00:00:00
|
2190-10-04 11:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ year old male with ___ disease and
dementia is transferred from ___ s/p mechanical fall
down stairs at his home.
It was an unwitnessed fall. He said he tripped on his carpet
and fell. He denies LOC. His wife found him on the floor
approximately 20 minutes after the fall. He was alert and at
his baseline. He was not able to get up, EMS was called. He
was taken to ___ where he was reportedly hypotensive,
he was given 2L of IVF, a FAST exam was negative. CT scans of
his
head and c-spine were obtained and negative per report. CXR
showed a right clavicle fracture. He was transferred to ___
for further evaluation and management. He denies any pain at
this time. He denies lightheadedness, headache, numbness,
weakness, facial droop, slurred speech, nausea, emesis, chest
pain, dyspnea, abdominal pain, dysuria, diarrhea, melena. His
wife states he fell similarly about ___ years ago.
Past Medical History:
PMH: ___ disease, dementia, hypothyroidism
PSH: resection of base of tongue
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On admission:
PE: 98.2, 92, 139/103, 22, 100% on room air
Gen: no distress, alert and oriented to self and situation (not
to time or place)
HEENT: c-collar in place, 2cm scalp laceration over right
temporal ___, EOMI, anicteric
Chest: RRR, lungs clear bilaterally
Abd: soft, nontender, nondistended
Ext: warm, minimal edema, no long bone tenderness
Neuro: strength ___ throughout, sensation intact
On discharge:
VS 97.8, 71, 105/72, 16, 97% on room air.
Neuro: Oriented to person, place (when given choice between two
options), and time (when given choice between ___ years). Can
state what brought him to the hospital. Occasionally has "word
salad", using words that aren't appropriate to the conversation
at hand. MAE x 4 (4+/5).
Card: S1, S2 diminished. Unable to appreciate m/r/g.
Pulm: Clear bilaterally from anterior aspect.
GU: Abdomen soft, non-tender, non-distended. Bowel sounds
present throughout.
Extrem: Cool, fair perfusion with fingernails slightly
cyanotic. Pulses palpable. Right arm with sling.
Pertinent Results:
___ 10:20AM BLOOD WBC-4.6 RBC-2.48* Hgb-7.8* Hct-22.7*
MCV-92 MCH-31.4 MCHC-34.2 RDW-15.1 Plt ___
___ 08:45PM BLOOD WBC-6.9 RBC-2.72* Hgb-8.4* Hct-24.8*
MCV-91 MCH-31.0 MCHC-34.0 RDW-15.0 Plt ___
___ 04:57AM BLOOD WBC-10.6 RBC-3.10*# Hgb-9.6*# Hct-28.7*#
MCV-93 MCH-30.9 MCHC-33.4 RDW-14.5 Plt ___
___ 04:57AM BLOOD Neuts-94.8* Lymphs-2.9* Monos-1.9*
Eos-0.2 Baso-0.1
___ 10:20AM BLOOD Plt ___
___ 08:45PM BLOOD Plt ___
___ 04:57AM BLOOD Plt ___
___ 04:57AM BLOOD ___ PTT-31.5 ___
___ 10:20AM BLOOD Glucose-93 UreaN-29* Creat-0.6 Na-142
K-3.6 Cl-107 HCO3-29 AnGap-10
___ 08:45PM BLOOD Glucose-100 UreaN-30* Creat-0.6 Na-141
K-4.0 Cl-108 HCO3-31 AnGap-6*
___ 04:57AM BLOOD Glucose-181* UreaN-27* Creat-0.7 Na-138
K-4.0 Cl-107 HCO3-28 AnGap-7*
___ 04:57AM BLOOD cTropnT-<0.01
___ 10:20AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.9
___ 08:45PM BLOOD Calcium-9.3 Phos-2.4* Mg-2.0
___ 10:20AM BLOOD TSH-3.7
___ 10:20AM BLOOD T4-6.9
___ 09:17PM BLOOD Type-ART Temp-37.0 pO2-104 pCO2-40
pH-7.47* calTCO2-30 Base XS-4 Intubat-NOT INTUBA
Comment-UNCAPPED S
___ 09:17PM BLOOD Lactate-0.8
PERTINENT IMAGING:
___ ECG: Sinus rhythm. Left axis deviation. Right
bundle-branch block. Left anterior fascicular block. Borderline
low precordial voltage.
___ Head CT without contrast:
No acute intracranial process. Subgaleal hematoma with soft
tissue air seen overlying the right temporal bone, likely from
laceration. No fracture.
___ CT abdomen/pelvis with contrast
1. Comminuted mid right clavicle fracture. No acute
intra-thoracic or
intra-abdominal injury identified.
2. Multiple subcentimeter hypodensities in the liver,too small
to
characterize, likely represent cysts.
3. Multiple subcentimeter hypodensities in both kidneys,too
small to
characterize, likely represent cysts. Stable 2.5 cm cyst in the
lower pole of the left kidney.
4. Enlarged prostate.
___ CXR (AP)
Portable AP radiograph of the chest was reviewed in comparison
to ___. Heart size is mildly enlarged, unchanged.
Mediastinum is stable. Lungs are essentially clear. No pleural
effusion or qneumothorax is seen. Multiple rib fractures on the
left and several fractures on the right are noted. Slightly
elevated left hemidiaphragm is unchanged.
___ Right wrist radiographs
1. Chondrocalcinosis without signs for acute bony injury. If
persistent
pain, repeat images in ___ days is recommended.
2. Mild degenerative changes.
Brief Hospital Course:
Mr. ___ was admitted to the Acute Care Surgery team on ___
after suffering a mechanical fall at home. It was believed that
he had no loss of consciousness at the time. He was taken to an
outside hospital where he underwent radiologic imaging that
showed a right-sided clavicle fracture and right scalp
laceration. Per medical records, there was concern of a
potential bleed on the patient's head CT, so he was sent to
___ for further evaluation and management.
Once at ___, Mr. ___ was evaluated by orthopedics for his
clavicle fracture. As a non-operative injury, their
recommendation was for the patient to wear a sling for comfort.
An appointment was made for orthopedic follow-up in
approximately two weeks.
Mr. ___ was started on a regular diet and tolerated it well.
He was started on his home medications. There were no issues of
voiding. On the evening of ___, nursing staff indicated that
the patient hadn't slept much. The next morning, family and
staff found the patient to be extremely delirious. Although he
has baseline dementia, he was much more confused per family
report. Both physical therapy and occupational therapy were
asked to Mr. ___ due to his recent fall and acute on chronic
delirium. Between ACS, ___ and OT, it was believed that patient
would improve cognitively when back in his home environment
where his surroundings are familiar and his sleep-wake cycle
would be normalized.
Prior to discharge on the evening of ___, Mr. ___ became
extremely lethargic and was found to be difficult to arouse.
Due to its uncertain etiology, an ABG was obtained, a chest
radiograph was performed and urine was sent for urinalysis. The
ABG was unimpressive and there were no infectious processes
observed on the chest radiograph or urinalysis. The patient was
hemodynamically and afebrile. A neurology consult was also
called. Their impression that Mr. ___ delirium was likely
secondary to secondary to a toxic/metabolic encephalopathy which
may have been precipitated by concussion, poor sleep for past 2
nights, dehydration with
high BUN, and unfamiliar surroundings. The patient was kept
inpatient one more night for further observation.
On the morning of ___, Mr. ___ was extremely lethargic and
difficult to arouse. Electrolytes and CBC results were within
normal limits. Bedside blood glucose was 99. With strong
tactile stimulation, the patient awoke. He had no neurologic
abnormalities on exam. While he was still somewhat somnolent,
he was kept NPO and given IV fluids. Later that day, he awoke,
ate lunch and was conversive with his family. Physical therapy
re-evaluated the patient prior to going home.
Incidentally, the patient stated he was having right wrist pain
prior to discharge. On exam, he flinched on flexion and
extension of his wrist. Standard radiographs were obtained
which showed no acute fracture of the wrist.
Mr. ___ was discharged the evening of ___ in the care of
his family. He will have 24 hour assistance from his wife and
daughters. ___, OT and ___ services were established prior to
discharge. The patient was afebrile and hemodynamically stable.
Medications on Admission:
Carbidopa-levodopa 50/200 tid, doxycycline 100", istalol 0.5%
gtt ___, levothyroxine 50', ranitidine 150", ropinirole 1",
trihexyphenidyl 2 tid, rivastigmine 1.5", latanoprost
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Carbidopa-Levodopa CR (50-200) 1 TAB PO TID
3. Doxycycline Hyclate 100 mg PO Q12H
4. Istalol *NF* (timolol maleate) 1 DROP ___ DAILY Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Ranitidine 150 mg PO BID
8. rivastigmine *NF* 1.5 mg Oral BID Reason for Ordering: Wish
to maintain preadmission medication while hospitalized, as there
is no acceptable substitute drug product available on formulary.
9. Ropinirole 1 mg PO QAM
10. Ropinirole 1 mg PO QPM
11. Trihexyphenidyl 2 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right clavicle fracture
Right temporal scalp laceration
Acute delerium
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after
you sustained a fall at home. Upon further evaluation, you were
found to have a right clavicle fracture and right temporal
laceration. You were admitted for further management and
observation. Orthopedic surgery evaluated your clavicle
fracture and found it was a non-operative injury. You were also
evaluated by Physical and Occupational Therapy. You have
recovered well and are now being discharged with the following
instructions.
At the time of discharge, you had tenderness to your right
wrist. Xrays were done and confirmed that you had no acute
fracture.
o If you experience pain, you may take acetaminophen (Tylenol)
as needed.
o Resume all medications you were taking prior to being admitted
to the hospital.
o Apply an arm sling to your right arm as needed for comfort.
o Follow up appointments have been scheduled with Orthopedic
Surgery to assess your clavicle fracture. See below for
appointment time.
o A visting nurse ___ come to your house to remove the staples
from your scalp. This should be done within ___ days from your
injury.
o Seek medical attention if you experience any of the below
symptoms listed under "danger signs".
Followup Instructions:
___
|
19737402-DS-25
| 19,737,402 | 28,598,214 |
DS
| 25 |
2168-08-03 00:00:00
|
2168-08-04 06:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Aphasia and R Sided Weakness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 2 minutes
Time (and date) the patient was last known well: ___ at
17:00
___ Stroke Scale Score:
t-PA given: yes
___ Stroke Scale score was : 10
1a. Level of Consciousness: 0
1b. LOC Question: 1
1c. LOC Commands: 2
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 2
6a. Motor leg, left: 0
6b. Motor leg, right: 2
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 2
10. Dysarthria: 1
11. Extinction and Neglect: 0
HPI:
Mr. ___ is a ___ year old right handed man with history of L
temporoparietal emoblic stroke ___, HTN, HLD, DM II who
presents
with suddent onset aphasia and right sided weakness. Patient
was
in his usual state of health today. He was on the phone with
his
friend. Then, at 5pm, he stopped talking. Friend was concerned
and called ___. When EMS arrived, pt was found down on the
ground, aphasic, with right sided hemiparesis, incontinent. Pt
was taken to OSH where tPA was not administered because with
history of stroke, they thought pt had seizure. Pt was
transferred here for further care. At baseline per family, pt
has no speech deficits (Creole is primary language, but does
speak ___ well). He has no deficits from prior stroke. Of
note, pt was on Coumadin since ___ given stroke was thought to
be embolic in setting of EF 35%. As EF normalized and pt was
noncompliant with widely fluctuating INRs, coumadin was
discontinued on ___. On arrival to the ED, pt was aphasic
with a right sided hemiparesis. Initially, his SBP was 194, he
was treated with labetalol 10mg IV x1 and SBPs decreased to
170s.
tPA was administered at 20:45 given significant deficits and no
contra-indiations. (Risks/benefits were discussed with patient's
brother and he agreed with administration of tPA.)
Of note, pt was seen in stroke clinic by Dr. ___ on ___
for follow up of prior stroke. (Had not been seen since ___
In ___, pt presented with a global aphasia. Head MRI revealed
small focus of acute infarct in the left Wernicke's area. No
significant surrounding mass effect. TTE negative for
thrombi/PFO, but showed many areas of hypokinesis with a low EF
of 35%. As a consequence, the etiology of his stroke was
suspected to be cardioembolic, and he was started on coumadin.
He
was lost to follow up in neurology until ___. Per review
of records, in ___ pt was admitted o OSH and had an
MRI (no acute stroke but several chronic ones and significan
amount of diffuse white matter lesions, MRA with basilar (60%)
and cavernous carotid stenosis (75%) as well as atherosclerotic
narrowing of other intracranial vessels (Right PCA). A nuclear
stress echo showed an EF of 45% with some areas of hypokinesis.
Carotid US without carotid stenosis extracranially. As above,
given poor compliance with coumadin/frequently subtherapeutic
INRs and improved EF, coumadin was discontinued. It was
recommended that pt modify his risk factors including HTN, DM II
and HLD. Most recent labs from ___ showed HbA1c 9.8 and LDL
176.
ROS: unable, pt aphasic
Past Medical History:
Prior infarcts on bilateral frontal lobes and right posterior
parietal lobes - seen on imaging from ___
Asthma
Diabetes
HTN
HLD
CAD (s/p PCI in ___ vessel CABG in ___.
CHF EF 35-40%
Chronic kidney disease
MGUS
Migraine
Social History:
___
Family History:
- positive for stroke (GM in ___
- negative for migraine, seizure
Physical Exam:
Admission Physical Exam:
Vitals: HR 110 BP 194/71 RR 20 O2 100% RA
___: Awake, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: awake, alert, says his name, then ___
on it, also says hospital and ___ on that; cannot name
or repeat; does not follow midline or appendicular commands.
-Cranial Nerves:
I: Olfaction not tested.
II: R pupil 3.5-->2.5, L 3-->2. Blinks to threat b/l.
III, IV, VI: Crosses midling to right and left without
nystagmus. Normal saccades.
VII: No facial droop, facial musculature symmetric.
-Motor: Normal bulk, tone throughout. Moves LUE and LLE
spontaneously. Initially, LUE plegic. On repeat exam, lifts
LUE antigravity but has drifts down. LLE with occasional
spontaneous movements, but has drift.
-Sensory: grimaces to noxious in all extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response was flexor on left, extensor on right.
-Coordination, gait: unable to assess
=================================
Discharge Physical Exam:
___: Awake, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: awake, alert, perseverates after stating his
name; cannot name or repeat
-Cranial ___: No facial droop, facial muscles are symmetric.
-Motor: Moves LUE and LLE spontaneously. Lifts LUE antigravity
but has drifts down. LLE with occasional spontaneous movements,
but has drift.
-Sensory: grimaces to noxious stimuli.
Pertinent Results:
ADMISSION LABS:
___ 08:25PM BLOOD WBC-10.7# RBC-4.71 Hgb-13.8* Hct-42.2
MCV-90 MCH-29.3 MCHC-32.7 RDW-13.3 Plt ___
___ 08:25PM BLOOD Neuts-85.9* Lymphs-9.3* Monos-4.5 Eos-0.1
Baso-0.2
___ 08:25PM BLOOD ___ PTT-31.4 ___
___ 08:21PM BLOOD Glucose-155* UreaN-25* Creat-1.6* Na-143
K-4.4 Cl-109* HCO3-25 AnGap-13
___ 08:25PM BLOOD ALT-26 AST-36 AlkPhos-65
___ 08:25PM BLOOD Phos-2.5* Mg-1.8
___ 08:21PM BLOOD %HbA1c-11.1* eAG-272*
___ 08:21PM BLOOD Triglyc-77 HDL-66 CHOL/HD-2.6 LDLcalc-89
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-5.8 RBC-4.14* Hgb-12.1* Hct-38.6*
MCV-93 MCH-29.4 MCHC-31.5 RDW-13.7 Plt ___
___ 07:20AM BLOOD Glucose-242* UreaN-21* Creat-1.4* Na-145
K-3.8 Cl-111* HCO3-24 AnGap-14
___ 07:20AM BLOOD Calcium-9.0 Phos-2.7 Mg-2.1
TROPONINS:
___ 08:25PM BLOOD CK-MB-4 cTropnT-<0.01
___ 08:21PM BLOOD CK-MB-2 cTropnT-0.03*
___ 03:07AM BLOOD cTropnT-0.03*
___ 02:07AM BLOOD cTropnT-0.02*
URINE:
___ 06:51AM URINE Color-Yellow Appear-Clear Sp ___
___ 06:51AM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 06:51AM URINE RBC-5* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
MICROBIOLOGY:
Blood culture: NGTD
Urine culture: NGTD
========================================
IMAGING:
CTP Brain ___:
There is no evidence of acute intracranial hemorrhage. Low
attenuation areas appear unchanged in the subcortical white
matter, more significant in the frontal lobes. The CT and
profusion demonstrate some mild increased mean transit time
decreased flow along the left anterior cerebral artery vascular
territory, suggestive of ischemia, correlation with MRI of the
head is recommended. Significant stenosis is re- demonstrated in
the mid segment of the basilar artery with interval progression
and also more narrowing in the V4 segment of the left vertebral
artery. Both common carotid arteries are patent with no flow
limiting stenosis.
CTA head/neck ___:
There is no evidence of acute intracranial hemorrhage. Low
attenuation areas appear unchanged in the subcortical white
matter, more significant in the frontal lobes. The CT and
profusion demonstrate some mild increased mean transit time
decreased flow along the left anterior cerebral artery vascular
territory, suggestive of ischemia, correlation with MRI of the
head is recommended. Significant stenosis is re- demonstrated in
the mid segment of the basilar artery with interval progression
and also more narrowing in the V4 segment of the left vertebral
artery. Both common carotid arteries are patent with no flow
limiting stenosis.
CXR ___: No evidence of pneumonia
MRI ___:
1. Extensive "late acute-early subacute" infarction involving
the territory of the left anterior cerebral artery, including
both its terminal callosomarginal and pericallosal branches.
This involves much of the cingulate gyrus and corpus callosum,
as well as left periatrial region, with associated hemorrhagic
transformation.
2. Relatively symmetric and later subacute infarcts, also with
hemorrhagic conversion, involving the posterior left frontal and
right frontoparietal regions, new since the ___ study.
3. Extensive cystic encephalomalacia involving the right
frontal pole and
parieto-occipital regions, related to previous infarction,
perhaps of a
"watershed" type; this should be correlated with more detailed
clinical
history.
4. Grossly preserved principal vascular flow-voids, including
those of the intracranial left ICA and ACA; however, this should
be closely correlated with the very recent CTA, once the
reconstructed images from that study become available.
ECHO ___: Mild symmetric LVH with regional left ventricular
systolic dysfunction as described above. No significant valvular
abnormality. No cardiac source of embolism seen. Negative bubble
study.
NCHCT ___: Evolving infarct in the region of the left ACA, with
no evidence of new hemorrhage or new infarction.
CXR ___: unremarkable
Brief Hospital Course:
Mr. ___ is a ___ year-old right-handed man with history of
right temporoparietal ischemic stroke in ___ (cardioembolic in
setting of reduced EF), HTN, HLD, DM II who presented after
onset aphasia and right sided weakness at 17:30pm on ___.
He first presented first to ___ where his
presentation was felt to be due to seizure (bowel incontinence
and found down) and he was not given TPA. ___ was negative
for bleed.
At ___, he continued to have persistent deficits and was given
tPA at 20:45 after BP was controlled with labetalol. Post TPA
exam was stable. He was admitted to the Neuro ICU for post-TPA
monitoring. 24-hour NCHCT on ___ showed hemorrhagic conversion.
Blood pressures were maintained SBP < 140 with clivedipine and
then switched to oral agents (amlodipine and labetalol). He
passed initial swallow evaluation. MRI brain showed left ACA
territory subacute stroke. Etiology of his stroke was most
likely embolic as he was recently taken off coumadin on ___ and
his imaging shows other prior embolic strokes. There is also
small vessel disease contributing to his poor substrate as he
has multiple poorly controlled risk factors (DM, HTN, HLD).
Stroke risk factors were assessed and revealed poorly controlled
diabetes (A1c 11.1%) for which ___ was consulted given
unclear insulin compliance in the past. He was started on a
Humalog insulin sliding scale and glargine. LDL was 89 and he
was started on atorvastatin 80mg daily. ECHO showed marginal
LVH and regional left ventricular systolic dysfunction which is
similar to that of ___. He continued his Aspirin and was
restarted on coumadin. He will restart his oral metoprolol on
discharge but his losartan will be held. If he becomes
hypertensive, his home dose of losartan can be added back. He
was evaluated by physical therapy who recommended that he be
discharged to a rehab facility.
=
=
=
=
=
=
=
=
=
=
================================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by swallow therapist]
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) No- given hemorrhagic conversion
4. LDL documented (required for all patients)? (x) Yes (LDL =89)
5. Intensive statin therapy administered? (x) Yes () No bc LDL
<100
6. Smoking cessation counseling given? () Yes - (x) No, remote
ex-smoker.
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes
9. Discharged on statin therapy? (x) Yes - home rousuvastatin
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - () N/A
Medications on Admission:
The Preadmission Medication list has been generated from 2
pharmacy lists and after discussion with son. However, his son
acknowledges that he does not take these mediations on a daily
basis.The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Rosuvastatin Calcium 40 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Aspirin 81 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Glargine Unknown Dose
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Rosuvastatin Calcium 40 mg PO DAILY
4. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
5. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
6. Citalopram 10 mg PO DAILY
7. Labetalol 200 mg PO QID
8. Warfarin 5 mg PO DAILY16
9. Senna 8.6 mg PO BID:PRN constipation
10. Docusate Sodium 100 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
1. Left Anterior Cerebral Artery Stroke
Secondary Diagnosis:
1. Uncontrolled Diabetes Mellitus
2. Hypertension
3. Hyperlipidemia
Discharge Condition:
Mental Status: Confused - unable to verbalize his thoughts, not
following verbal commands
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 difficulty speaking and
right sided 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:
- Diabetes
- Hypertension
- Hyperlipidemia
We are changing your medications as follows:
- We are RESTARTING your COUMADIN for your atrial fibrillation.
- For other changes, please refer to medication sheet included.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
19737717-DS-8
| 19,737,717 | 26,704,952 |
DS
| 8 |
2153-03-16 00:00:00
|
2153-03-18 19:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bloody urine
Major Surgical or Invasive Procedure:
none- continuous bladder irrigation, hand irrigation for clots,
irrigation d/c after foley removed
History of Present Illness:
___ year old male transferred from ___ after a
mechanical
fall. He reports slipping in his bathroom and falling on his
right side/back. He broke the fall with his right arm and
endorses wrist pain. Denies headstrike or LOC. He presented to
___ where a CT scan showed hemorrhage into a right
renal cyst. He denies fevers, chills, nausea, vomiting, or
dysuria. He has had frank hematuria and currently does not have
a
foley in place. Patient transferred here for further care.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION upon admission
Temp: 98.2 HR: 84 BP: 144/84 Resp: 15 O(2)Sat: 98 Normal
Constitutional: General: no apparent
distress
Head: Atraumatic, normocephalic
Eyes: PERRLA, EOMI
ENT: Oropharynx normal, no tonsillar edema
Neck: No cervical lymphadenopathy. No midline tenderness.
Chest: Nontender
Cor: Regular rate and rhythm, no murmur.
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, nontender, nondistended
Extremities: Warm and well perfused, no cyanosis.
Skin: No rash, warm and dry
Neurology: Cranial nerves symmetric and intact. No
lateralizing deficits.
Physical examination upon discharge: ___:
General: NAD
CV: ns1, s2, no murmurs
LUNGS: clear, right sided chest wall tenderness
ABDOMEN: soft, non-tender
EXT: no pedal edema bil., no calf tenderness bil., tender mass
dorsal surface with hand, + radial pulse bil.
NEURO: via ___ interpreter, alert and oriented x 3,
speech clear
Pertinent Results:
___ 10:10AM BLOOD WBC-4.4 RBC-3.75* Hgb-12.6* Hct-38.5*
MCV-103* MCH-33.6* MCHC-32.7 RDW-10.7 RDWSD-40.9 Plt ___
___ 06:49AM BLOOD WBC-6.1 RBC-3.84* Hgb-13.0* Hct-38.7*
MCV-101* MCH-33.9* MCHC-33.6 RDW-10.8 RDWSD-40.3 Plt ___
___ 08:16AM BLOOD WBC-4.5 RBC-4.14* Hgb-14.0 Hct-42.0
MCV-101* MCH-33.8* MCHC-33.3 RDW-11.1 RDWSD-41.4 Plt ___
___ 11:50AM BLOOD Neuts-74.9* Lymphs-11.8* Monos-11.5
Eos-0.5* Baso-1.0 Im ___ AbsNeut-2.99# AbsLymp-0.47*
AbsMono-0.46 AbsEos-0.02* AbsBaso-0.04
___ 10:10AM BLOOD Plt ___
___ 10:10AM BLOOD Glucose-131* UreaN-24* Creat-0.8 Na-138
K-3.9 Cl-101 HCO3-24 AnGap-17
___ 06:49AM BLOOD Glucose-104* UreaN-22* Creat-0.7 Na-137
K-4.7 Cl-100 HCO3-26 AnGap-16
___ 01:35AM BLOOD CK(CPK)-241
___ 10:10AM BLOOD Calcium-9.5 Phos-3.4 Mg-2.1
___: second opinion reads: CT
. Findings compatible with renal laceration with acute
hemorrhage in a renal cyst extending into the renal collecting
system. There is a small amount of associated ___
hemorrhage. Pre and post-contrast MRI would be helpful to
exclude underlying solid renal lesion.
2. Minimally displaced acute fracture of the right eighth and
ninth ribs
posteriorly.
3. Probable small lung contusion at the right lung base.
4. Congenital mal-rotation without bowel obstruction.
5. Large heterogeneously enhancing right thyroid nodule. This
could be
further evaluated with thyroid ultrasound.
RECOMMENDATION(S):
1. Follow-up MRI of the kidneys with and without contrast would
be helpful to exclude underlying renal tumor.
2. Follow-up thyroid ultrasound can be performed on a
nonemergent basis.
___: right wrist:
No fracture or traumatic mal-alignment. If there is high
concern for
non-displaced fracture, cross-sectional imaging or repeat images
in ___ days could be performed.
___: chest x-ray :
No previous images. The cardiac silhouette is at the upper
limits of normal in size. There is some engorgement of
pulmonary vessels, suggesting some elevation of pulmonary venous
pressure. Bibasilar opacifications most likely reflect small
pleural effusions and underlying atelectasis, more prominent on
the right.
No evidence of acute focal pneumonia. However, in the
appropriate clinical setting, this would be difficult to
unequivocally exclude, especially in the absence of a lateral
view.
___ 1:28 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 CFU/mL.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
___ 1:45 am BLOOD CULTURE
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 ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ @ 8:40 AM ON
___.
Brief Hospital Course:
___ year old male who was admitted to the hospital after a fall
at home, landing on his right side. The patient reported bloody
urine and was seen at an OSH. He underwent imaging and was
reported to have bleeding into a right renal cyst. The patients
hematocrit was stable at 41. The patient was transferred here
for management. Upon admission, the patient was made NPO, and
given intravenous fluids. Second opinion reads were done of the
initial cat scan which confirmed a renal laceration with acute
hemorrhage into a renal cyst extending into the renal collecting
system. There was a small amount of associated ___
hemorrhage. The patient had a foley catheter placed and required
continuous irrigation to prevent clots and maintain patency.
Serial hematocrits remained stable. The patient also reported
right wrist pain and further imaging was undertaken. No fracture
was identified. Because the patient continued to report hand
pain, the Hand service was consulted and upon examination
reported a ganglion cyst. A splint was provided for comfort. On
review of imaging, the patient was also noted to right right
sided ___ rib fractures. His pain was controlled with oral
analgesia. He was provided an incentive spirometer and
instructed in its use.
The patient remained stable throughout his hospitalization. His
foley catheter was removed on HD #11 and the patient voided
without difficulty. On HD #5, the patient was febrile to 102.8,
blood and urine cultures were sent. The patient's cultures
showed staph. coag. negative in both the blood and urine. The
ID service was consulted and recommendations made for a 10 day
course of linezolid.
The patient was discharged home on HD #8. His vital signs were
stable and he was afebrile. He was tolerating a regular diet
and voiding clear yellow urine without difficulty. His white
blood cell count normalized at 4.4. Discharge instructions were
reviewed with the ___ interpreter. Follow-up
appointments were made in the acute care, renal and hand clinic.
A repeat MRI was scheduled for ___. A follow-up appointment
was made with his primary care provider and for further
follow-up imaging of his thyroid nodule.
++++++++++++++++++++++++++++++++++++++
___ interpreter assisted with discharge instructions:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Do not take more than 3000 mg per day
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*15 Capsule Refills:*1
3. Linezolid ___ mg PO Q12H
10 days ( last dose ___
RX *linezolid ___ mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*20 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
Reason for PRN duplicate override: changed to oxycodone
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
renal laceration with hemorrhage into renal cyst and small
perirenal hemorrhage
right ___ and ___ rib fractures
small lung contusion at right lung base
congenital malrotation without obstruction
New finding:
right thyroid nodule, further imaging recommended
right hand ganglion cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were transferred to ___
after you fell onto your right side resulting in right sided
pain and bloody urine (hematuria). You were seen at ___
___ and were found to have bleeding into a renal (kidney)
cyst. A catheter was placed into your bladder and fluid was
irrigated to clean out blood and clots. Your blood count was
monitored and remained stable. You also were found to have
right ___ rib fractures. For your wrist pain and swelling,
you had x-rays which did not find any fracture. Hand surgery was
involved and felt you have a ganglion cyst, and recommend you
should wrap your wrist with the splint given to you as you need
for comfort and elevate your hand to help reduce the swelling.
You should follow up with the Hand team, Urology team, and the
Acute Care Surgery team. Your pain has been well controlled,
you are eating a regular diet, and you are able to urinate on
your own without any problems.
* Your injury caused right ___ and 9th rib fractures which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Please follow-up in the emergency room if you experience
difficulty urinating or blood in your urine
It is important to keep your follow-up appointments, if you are
unable, please call and reschedule
On imaging you were noted to have a right thyroid nodule and
will need further follow-up with an ultrasound
You have an MRI scheduled on ___ to review your kidney
status.
Followup Instructions:
___
|
19737741-DS-23
| 19,737,741 | 20,963,391 |
DS
| 23 |
2160-11-20 00:00:00
|
2160-11-20 22:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ceftriaxone / ciprofloxacin
Attending: ___.
Chief Complaint:
Dysuria
Major Surgical or Invasive Procedure:
R knee bedside arthrocentesis
R knee joint washout on ___ due to concern for sepsis
History of Present Illness:
___ with hx of prostate Ca, UTIs, urinary retention and
obstructive uropathy who presents from PCP with dysuria,
weakness and urinary hesitancy since ___. He also reports fevers
and chills as well as pyuria. Patient was seen in clinic and
noted to be febrile to 100, tachycardic to the 130s. He reported
diarrhea x3 days which was brown and liquid but has subsequently
resolved since coming to the ED. No N/V. No sick contacts. No
recent abx. Has has also had decrease appetite/PO intake x 3
days.
In the ED, initial vitals notable for temp 99.4, HR 122, BP
123/81, RR 24, 100%RA. Patient spiked fever to 101.2 while in
the ED. No exam documented in ED. Labs notable for Chem 10 with
BUN/Cr 72/5.6 (baseline Cr 1.5-1.8), Bicarb 17. LFTs with
ALT/AST 44/56, Lactate 1.2. CBC without leukocytosis, Hgb 12.6.
UA with >182 WBCs, ___, Bacteria. Blood/Urine Cx obtained. CXR
without evidence of acute pathology. Renal US with bilateral
prevoid hydroureteronephrosis with minimal improvement post
foley catheterization and dependent debris within bladder.
Patient given 1gm Tylenol, 1L NS, Zosyn. Foley placed and
patient admitted to medical service for further monitoring and
acute renal failure.
On the floor, patient reports that he feels much improved since
presenting to the ED. He continues to have chills. He states
that as soon as the foley was placed, he feels like the pressure
in his abdomen resolved. He reports that he has a urologist (Dr.
___ and something similar to this happened to him in the
past.
Past Medical History:
-Prostate Ca
-Urethral Strictures thought ___ radiation
-recurrant UTIs
Social History:
___
Family History:
Diabetes in his mother and in his uncle. No family history of
prostate cancer
Physical Exam:
Admission Physical Exam:
========================
Vital Signs: 98.3; 150/86; 120; 24; 100%RA
General: Alert, oriented, no acute distress though noted to be
rigoring in bed
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PER,
neck supple, JVP not elevated, no LAD
CV: tachycardic, no MRG appreciated
Lungs: distant breathsounds, however clear to auscultation
bilaterally, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: Foley draining light pink, frothy urine
Ext: Warm, well perfused, clubbing, cyanosis or edema
Neuro: A&Ox3, ___ strength upper/lower extremities, grossly
normal sensation, 2+ reflexes bilaterally, gait deferred.
Discharge Physical Exam:
=======================
Vitals: 98.3 PO 118/75 97 18 100 RA
I/O: 24 Hr 3.4L/3.1L 8HR ___
General: Alert, oriented
HEENT: Sclera anicteric, no conjunctival injection, MMM
Lungs: On room air, no increased work of breathing, no wheezes,
rales or ronchi. Pain with deep inspiration over the L rib cage.
CV: Regular rate and rhythm, no m/r/g, no JVD.
Abdomen: soft, non-tender, +BS
Ext: Warm, well perfused, no edema.
GU: foley in place draining clear yellow urine
Neuro: grossly moving extremities, distal pulses intact.
Pertinent Results:
Admission Labs:
============
___ 04:40PM BLOOD WBC-9.9 RBC-4.51* Hgb-12.6* Hct-39.7*
MCV-88 MCH-27.9 MCHC-31.7* RDW-13.1 RDWSD-42.5 Plt ___
___ 04:40PM BLOOD Neuts-83* Bands-0 Lymphs-6* Monos-11
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.22*
AbsLymp-0.59* AbsMono-1.09* AbsEos-0.00* AbsBaso-0.00*
___ 04:40PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
___ 04:40PM BLOOD ___ PTT-30.8 ___
___ 04:40PM BLOOD Plt Smr-NORMAL Plt ___
___ 04:40PM BLOOD Glucose-111* UreaN-72* Creat-5.6*# Na-136
K-4.3 Cl-100 HCO3-17* AnGap-23*
___ 04:40PM BLOOD ALT-44* AST-56* AlkPhos-112 TotBili-1.2
___ 04:40PM BLOOD Albumin-4.0 Calcium-9.7 Phos-4.4 Mg-2.1
___ 05:51AM BLOOD PSA-16.3*
___ 05:17AM BLOOD CRP-197.5*
___ 04:40PM BLOOD Lactate-1.2
___ 05:30
SED RATE
Test Result Reference
Range/Units
SED RATE BY MODIFIED >130 H < OR = 20 mm/h
___
Other fluid:
===========================
___ 06:52AM JOINT FLUID ___ RBC-1125* Polys-90*
___ Macro-9
___ 06:52AM JOINT FLUID Crystal-NONE
Urine:
====
___ 04:30PM URINE Osmolal-277
___ 04:30PM URINE Hours-RANDOM UreaN-328 Creat-88 Na-37
TotProt-1200 Prot/Cr-13.6*
___ 03:31PM URINE Eos-NEGATIVE
___ 04:30PM URINE WBC Clm-MANY
___ 04:30PM URINE RBC-180* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
___ 04:30PM URINE Blood-SM Nitrite-NEG Protein-300
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 04:30PM URINE Color-YELLOW Appear-TURBID Sp ___
Microbiology:
==========
___ 8:30 am FLUID,OTHER JOINT FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
___ 8:30 am SWAB JOINT RIGHT KNEE.
**FINAL REPORT ___
___ 6:52 am JOINT FLUID Source: Knee.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
___ 1:28 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 4:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Imaging:
=======
CHEST (PA & LAT)Study Date of ___ 5:10 ___
IMPRESSION:
No acute intrathoracic abnormalities identified.
RENAL U.S.Study Date of ___ 5:58 ___
IMPRESSION:
1. Moderate to severe bilateral prevoid hydroureteronephrosis,
with minimal
improvement post Foley catheterization.
2. Trabeculated, moderately distended lobulated bladder,
overall unchanged in
morphology compared to the prior CT from ___, potentially
secondary to
chronic outflow obstruction. Dependent debris is seen within
the bladder.
RENAL U.S.Study Date of ___ 1:57 ___
IMPRESSION:
1. A Foley catheter remains in situ.
2. Interval decrease in the degree of bilateral
hydroureteronephrosis which
is now mild
BONE SCANStudy Date of ___
IMPRESSION: No evidence of metastatic disease
CT ABD & PELVIS W/O CONTRASTStudy Date of ___ 10:47 AM
IMPRESSION:
1. There is new (compared to CT from ___ bilateral
moderate
hydronephrosis and hydroureter. The ureters are dilated in
their entire
extent up to the ureterovesical junction. Given the lack of
intravenous
contrast it is difficult to ascertain if the obstruction is
caused by
extensive bladder wall thickening or progression of prostatic
mass.
2. There is worsening diffuse bladder wall thickening likely
related to
chronic bladder outlet obstruction. The bladder is present the
decompressed by a Foley catheter.
3. There are enlarged celiac axis, retroperitoneal (left
para-aortic) lymph
nodes measuring up to 12 mm in short axis. These are slightly
larger than the prior CT dated ___.
4. Please note that CT has limited sensitivity in optimal
characterization of a prostatic mass and a prostate MRI may be
considered to look for local
progression.
5. No suspicious osseous metastases.
RECOMMENDATION(S): MRI pelvis is a more sensitive exam to look
for local
progression of the prostatic mass.
ECGStudy Date of ___ 11:10:00 AM
Clinical indication for EKG: E87.5 - Hyperkalemia
Sinus tachycardia with premature ventricular contractions.
Non-specific
inferior ST-T wave changes. Compared to the previous tracing of
___
sinus tachycardia is now present. Inferior ST-T wave changes are
new.
Premature ventricular contractions are now present.
KNEE (AP, LAT & OBLIQUE) RIGHTStudy Date of ___ 2:51 ___
FINDINGS:
AP, cross-table lateral and obliques views of the right knee
provided. There is mild osteoarthritis with marginal spurring
and mild flattening of joint surfaces. There is a small joint
effusion. No fracture or dislocation is seen.
IMPRESSION:
As above.
___ B/L Lower Extremity Ultrasound:
IMPRESSION:
1. Acute partial deep venous thrombosis in the left common
femoral vein and proximal and mid femoral veins. Calf veins not
well-visualized.
2. No evidence of deep venous thrombosis in the right lower
extremity veins.
___ TTE
The left atrium is normal in size. 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 = 65%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. 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. No gross evidence of
right ventricular strain
DISHCARGE LABS:
===============
___ 05:00AM BLOOD WBC-10.4* RBC-3.53* Hgb-9.6* Hct-31.7*
MCV-90 MCH-27.2 MCHC-30.3* RDW-13.5 RDWSD-44.4 Plt ___
___ 05:00AM BLOOD Plt ___
___ 03:00PM BLOOD ___ PTT-67.0* ___
___ 05:00AM BLOOD Glucose-76 UreaN-34* Creat-1.6* Na-133
K-5.1 Cl-98 HCO3-21* AnGap-19
___ 05:00AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.8
Brief Hospital Course:
Summary:
========
___ with hx of prostate Ca, UTIs, urinary retention and
obstructive uropathy who presents with dysuria, weakness and
urinary hesitancy since ___ subsequently found to have
acute renal failure and E. coli bacteremia due with urinary
source, likely secondary to obstruction from prostate cancer. He
was initially treated with zosyn, narrowed to unasyn, and
discharged on augmentin. He was also started on tamsulosin.
Urology was consulted and recommended repeat TURP as an
outpatient. He did not pass a voiding trial and was discharged
with a foley. Hospital stay was also complicated by right knee
effusion concerning for septic joint. Joint arthrocentesis
performed at bedside; synovial fluid analysis showed fewer WBC
than would be expected for septic joint, but given tap performed
s/p 3 days of zosyn and while on unasyn, concern for partially
treated septic joint persisted. Patient taken to operating room
for joint washout by orthopedic surgery which showed no evidence
of infection. His course was also complicated by DVT/PE after
immobilization in the setting of prostate cancer. He was
anticoagulated with heparin while inpatient and switched to
rivaroxaban. Unfortunately, it was discovered that he did not
have insurance coverage for medications, making the cost of
medications such as rivaroxaban, apixaban, and lovenox anywhere
from $300-4,000 per month. He therefore was discharged to rehab
on a loveox bridge to warfarin.
#Acute DVT/PE: Working with ___ consistent tachycardia and
orthostasis. EKG on ___ showed sinus tachycardia. ___ on
___ with L acute partially occlusive common femoral DVT. PE
exceedingly likely given tachycardia, hemodynamic symptoms. CTA
deferred due to high pre-test probability and likely detriment
of contrast to renal function. His left-sided rib pain is likely
a result of a pulmonary infarct. His TTE showed no evidence of R
heart strain. Heparin drip was started and he was switched to
Xarelto on ___. Per above, he was then discharged on a lovenox
bridge to warfarin. A discussion was held regarding whether the
patient would qualify for a study trial but he did not qualify
as his anticoagulation may be stopped prior to ___ year. He should
be reassessed in 3 months to see if his mobility has improved
enough to reduce his risk of future PE (risk factors for him
included surgery, immobility, infection, and malignancy). Per
heme-onc, his anticoagulation may be managed by his PCP.
#Hyperkalemia: On low potassium diet. ___ be due to renal
failure although Cr appeared to be improved. Stable between
5.0-5.5 without any EKG changes. Electrolytes should be
followed-up on ___.
#Right knee swelling:
Hospital course complicated by onset of R knee swelling and
pain. Denies prior history of gout or osteoarthritis. X-ray w
small joint effusion. Bedside arthrocentesis performed; gram
stain with no organisms and culture with no growth to date.
While WBC count lower than would be expected for septic joint,
concern for partially treated septic joint given history of IV
antibiotics for bacteremia and urinary tract infection. After
discussion with orthopedic surgery, taken to OR for washout.
Drain placed. Plan for 2 week follow up for wound evaluation and
suture removal.
#Acute renal failure: Pt presented with obstructive renal
failure with Cr. 5.6 on admission to ED (baseline ~1.8). Repeat
renal ultrasound interval decrease in bilateral
hydroureteronephrosis after foley placement, and creatinine
downtrending. Tamsulosin 0.4 mg PO QHS started. Noted to have
urinary retention and creatine increase on ___ after voiding
trial so foley replaced. Had also recently been changed to
bactrim for UTI so this was change to IV unasyn due to concern
for nephrotoxicity. Creatinine subsequently downtrending. Plan
for urology follow up for palliative TURP with Dr. ___. Will
discharge with foley in place.
#E coli bacteremia from urinary source: Pt with cultures growing
pan sensitive e coli from ___. Patient was initially treated
with zosyn that was narrowed to Bactrim on ___. Patient
allergic to CTX (hives) and cipro (AIN). Given c/f Bactrim
nephrotoxicity and uptrending WBC count and up trending
creatinine (per above), antibiotic regimen was changed to
unasyn. Creatinine improved with change of abx and foley
replacement. He is now s/p 2 week course of Unasyn (last day:
___
#Diarrhea: Patient reported diarrhea for week prior to
presentation with loose stools noted during hospital stay. C
diff negative. Resolved. He was ultimately discharged with prn
bowel meds for constipation.
#Prostate Cancer:
Per most recent onc note, patient has castrate resistant
prostate Ca as his PSA actually rose despite leupron which he
receives q3months (last ___. PSA 14.6 ___, 16.3 ___
concerning for slow progression. CT scan unable to assess for
progression given absence of contrast, but bone scan was without
evidence of mets. Primary team in communication with patient's
oncologist Dr. ___. Urology contacted regarding repeat TURP
per above and tamsulosin started.
Transitional Issues:
===================
-***Will need an INR, electrolytes, and Cr check on ___. He
is being discharged on a lovenox bridge to warfarin and will
need subsequent titration of his warfarin dose via INR checks.
Please note that it is safe to continue lovenox as long as his
Cr remains <3.
-Provoked DVT/PE: discharged with plan for 3 month
anticoagulation course, then will need to reassess risk factors
to determine whether course will need to be extended.
-Scheduled for outpatient TURP with Dr. ___.
-Discharged with foley given continued obstruction
-s/p 2 week course for E. coli bacteremia, treated with Unasyn
(last day: ___
-R knee aspirate had no growth
-started tamsulosin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Leuprolide Acetate Dose is Unknown IM Q3MONTH
Discharge Medications:
1. Crutches
Prognosis: good
Length of need: 13 months
M19.0 osteoarthritis
2. Enoxaparin Sodium 100 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
3. Tamsulosin 0.4 mg PO QHS
4. Leuprolide Acetate Determined by physician mg IM Q3MONTH
5. Warfarin 5 mg PO DAILY16
Please titrate according to INR checks for goal ___. On lovenox
bridge.
6. Acetaminophen 650 mg PO Q6H:PRN fever, pain
7. Bisacodyl 10 mg PR QHS:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 2.5 tablet(s) by mouth every 4 hours Disp
#*10 Tablet Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Proximal Deep Vein Thrombosis
Pulmonary Embolus
Bacteremia
Septic Joint
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 Mr. ___,
It was our pleasure caring for you during your hospitalization.
You were admitted to the hospital due to pain with urination.
You were found to have an infection in your bloodstream and
urinary tract. This is likely due to difficulty urinating from
your prostate cancer. Due to this infection and your difficulty
urinating, a marker of your kidney function was also elevated.
We gave you antibiotics for your infection and placed a foley to
help you urinate. With these interventions, your kidney function
improved.
During your hospital stay, you also began experiencing pain and
swelling in your right knee. We performed a procedure to remove
some fluid from that joint to check for infection. Given that we
had found bacteria in your blood earlier during your hospital
admission, the orthopedic surgeons decided to take you to the
operating room to wash out your joint. You tolerated that
procedure well and your knee did not show any evidence of
infection.
After this procedure, you unfortunately developed a clot in your
left leg which went to your lung (pulmonary embolism). We put
you on a blood thinner call heparin while you were in the
hospital and you will need to stay on an anticoagulant
medication until your physician determines that it is safe to
stop this medication.
You were unable to urinate on your own at the time of discharge
and we therefore placed a foley that you will keep in until you
follow up with the urology team.
We also started you on a new medication called Flomax that will
help you urinate. In addition to following up with your primary
care physician, you should also follow up with the urology team
to see if you are a candidate for surgery (TURP) that may also
help with urination.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19738181-DS-18
| 19,738,181 | 26,287,919 |
DS
| 18 |
2126-03-26 00:00:00
|
2126-03-27 15:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o dementia, HTN, and HLD presents from a nursing home
with syncope. It was an witnessed event in a bathroom at the
nursing home where the patient has been residing. Patient was
sitting down, and did not fall or hit her head. Abnormal
movement was observed by nursing home staff. Patient reported
feeling dizzy this AM. No headache, chest pain, palpitation,
nausea, vomiting, or diarrhea. She denies fever or chills.
In the ED, the patient was oriented to place, and knew that she
was at a hospital. EKG was negative for ischemia, but had PR of
204ms. CXR had no focal infiltrate, and head CT showed no acute
intracranial process. UA was concerning for UTI (+Leuk,
+nitrate, >182 WBC, moderate bact0, and received 1g of
ceftriaxone. Her cr was 1.3, which is her baseline. FSBS was
wnl. She received 500cc NS.
In the ED, initial vitals: 97.3 80 118/59 18 93%
Vitals prior to transfer: 98.1 75 120/50 18 95%
Currently, she is reports feeling well.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing. No cough, no shortness of breath, no
dyspnea on exertion. No chest pain or palpitations. No nausea or
vomiting. No diarrhea or constipation. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
Dementia
HTN
HLD
Social History:
___
Family History:
father old had stroke in ___.
Physical Exam:
ON ADMISSION:
VS: 97.6 126/41 66 20 100%
GENERAL: Alert, no acute distress. oriented to self, knows she
is in hospital, but does not know the which one or which city.
not oriented to time.
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
RESP: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: No excoriations or rash.
ON DISCHARGE:
98.3 137/50 63 18 94%RA. orthostatic vitals significantly
improved after IVF, now with SBP decrease of only about 15 but
with increased DBP by 10, without any dizziness or other
symptoms.
GENERAL: Alert, no acute distress. oriented to self, knows she
is at hospital. not oriented to time.
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
RESP: CTAB no wheezes, rales, rhonchi
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: No excoriations or rash.
Pertinent Results:
ON ADMISSION:
-------------
___ 11:21AM ___ PO2-27* PCO2-48* PH-7.34* TOTAL
CO2-27 BASE XS--1
___ 11:00AM LACTATE-1.7
___ 11:00AM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 11:00AM URINE BLOOD-MOD NITRITE-POS PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-LG
___ 11:00AM URINE RBC-36* WBC->182* BACTERIA-MOD
YEAST-NONE EPI-7
___ 11:00AM URINE WBCCLUMP-MANY MUCOUS-MANY
___ 10:55AM GLUCOSE-125* UREA N-23* CREAT-1.3* SODIUM-143
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-23 ANION GAP-16
___ 10:55AM estGFR-Using this
___ 10:55AM ALT(SGPT)-21 AST(SGOT)-28 ALK PHOS-104 TOT
BILI-0.3
___ 10:55AM LIPASE-35
___ 10:55AM cTropnT-<0.01
___ 10:55AM ALBUMIN-3.7 CALCIUM-9.1 PHOSPHATE-3.7
MAGNESIUM-2.3
___ 10:55AM WBC-6.4 RBC-5.85* HGB-12.4 HCT-38.9 MCV-67*
MCH-21.3* MCHC-31.9 RDW-16.8*
___ 10:55AM NEUTS-56.6 ___ MONOS-8.8 EOS-3.5
BASOS-0.5
___ 10:55AM PLT COUNT-154
ON DISCHARGE:
-------------
___ 06:20AM BLOOD WBC-5.5 RBC-5.25 Hgb-11.3* Hct-35.6*
MCV-68* MCH-21.6* MCHC-31.8 RDW-17.0* Plt ___
___ 06:20AM BLOOD Glucose-92 UreaN-22* Creat-1.1 Na-142
K-4.3 Cl-112* HCO3-21* AnGap-13
___ 06:20AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.1
EKG:
---
___: HR 70, sinus, non-specific ischemic change, left axis, PR
204.
MICRO:
------
___ 11:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
--------
CT HEAD W/O CONTRAST Study Date of ___ 11:07 AM
No acute intracranial process. (wet read)
CHEST (PA & LAT) Study Date of ___ 11:27 AM
Low lung volumes. Somewhat under penetrated due to body habitus.
Given the above, subtle medial right base opacity most likely
reflects overlap of vascular structures or possibly atelectasis,
with aspiration or infection felt less likely.
Brief Hospital Course:
___ with h/o dementia, HTN, and HLD presented from a nursing
home with syncope.
ACTIVE ISSUES:
# Syncope: Without recurrence during hospitalization. This was
thought to be multifactorial in origin. The most likely etiology
was thought to be orthostatic hypotension in combination with
possible neurocardiogenic etiology from concurrent UTI. BP
132/70 while supine, 112/50 while sitting, and 102/48 while
standing. She improved with IVF. Given the prodrome of
lightheadedness and concurrent UTI, neurocardiogenic syncope
precipitated by cystitis, especially in the setting of possible
valsalval exertion in the bathroom, was also considered. We
treated her UTI as below. She was put on tele but had no event,
and her EKG was unremarkable. Similarly, metabolic causes are
less likely given normal sugar level, unremarkable eletrolytes,
and VBG is essentially correcting to normal pH and pCO2. No
murmur on exam to raise suspicion of structural cardiac
etiology.
# UTI: Patient's UA and urine culture were consistent with UTI
from E-coli. She was symptomatic with incontinence; unclear if
she had dysurea. She was treated with ceftriaxone (start date
___ initially, and was switched to oral Bactrim at
discharge ___ to complete a 5-day course of antibiotics.
CHRONIC ISSUES:
# Dementia: AOx1 at baseline, and so she appeared to be at
baseline. The cause of her chronic AMS was probably
multifactorial. She likely had delirium on top her dementia at
baseline. We continued her home donepezil and memantine. We also
gave her thiamine, as it is found to be helpful in hospitalized
delirius patients regardless of alcohol history. She was also
frequently reassured, OOB, and reoriented. We closed her
curtains at sundown and opened them in the morning. She was
evaluated by ___ who recommended returning to her assisted-living
on discharge. We maximized her ___ services on discharge.
# HTN: Continued home lisinopril.
# HLD: Continued home atorvastatin.
# CODE STATUS: DNR, ___
# CONTACT: ___ (sister, ___) ___
TRANSITIONAL ISSUES
-------------------
- check orthostatic BP to ensure no recurrence of orthostasis
Need to make an appointment with her PCP:
Name: ___.
Location: ___ - ADULT
MEDICINE
Address: ___, ___
Phone: ___
Fax: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Docusate Sodium 100 mg PO DAILY
3. Donepezil 10 mg PO QHS
4. Lisinopril 2.5 mg PO DAILY
5. Memantine 10 mg PO BID
6. Acetaminophen 650 mg PO Q8H:PRN pain
7. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Atorvastatin 10 mg PO QPM
3. Docusate Sodium 100 mg PO DAILY
4. Donepezil 10 mg PO QHS
5. Lisinopril 2.5 mg PO DAILY
6. Memantine 10 mg PO BID
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth Once a day Disp
#*30 Tablet Refills:*0
9. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Days
To start on ___, continue through ___.
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*4 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
------------------
Syncope
UTI
SECONDARY DIAGNOSES:
-------------------
Orthostatic hypotension
Discharge Condition:
Oriented to self, and partly oriented to place, but not to date.
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 pleasure caring for you at ___
___. You were admitted for fainint in the bathroom. We
assessed conduction system of your heart with EKG, and it was
normal. We also put you on telemetry to continously monitor your
heart, and you had no undesirable event. You were found to have
low blood pressure when you were standing relative to when you
were sitting. We call this orthostasis hypotension, and it could
have been a reason that caused you to faint. We treated this by
giving you some intravenous fluid. You were also found to have
an infection of your urinary tract, which could also have
contributed to your passing out. We started you on a 5-day
course of antibiotics (first day ___.
We are glad you are feeling better, and we wish you the best of
luck!
Regards,
___ Team
Followup Instructions:
___
|
19738416-DS-22
| 19,738,416 | 24,809,974 |
DS
| 22 |
2151-01-05 00:00:00
|
2151-01-06 09:00:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Red Dye / lisinopril / Oxycodone
Attending: ___
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of PCKD s/p renal
transplant in ___, referred by outpatient nephrologist for 4
days of hematuria, associated with one day of lighheadedness
The patient saw Dr. ___ in clinic on ___ and at that
time was having hematuria. UA notable for > 182 rbcs and h/h was
at baseline. The hematuria has persisted and she was also
feeling lightheaded and weak and referred to the ED to be
evaluated. The patient' has had hematuria in the past in the
setting of ruptured cysts, however she reports that she knows
when a cysts ruptures because she has associated pain. She
denies any abdominal pain, flank pain, not passing clots, and no
hx of kidney stones.
In the ED initial vitals were 0 98 64 151/81 18 96% 0
Labs notable for normal chem, including baseline cr, h/h of
11.2/34.6 ( baseline hct ___, stable leukopenia. Repeat UA
with 14 RBCs.
Imaging was notable for stable appearance of polycystic native
kidneys including some hemorrhagic cysts but no change, no
stones and light new fat standing near renal graft.
She was given her home dose cyclosporine, and admitted for
further evaluation and management.
Past Medical History:
PCKD s/p transplant ___
PCLD - polycystic liver disease
HTN
s/p partial liver resection in the ___
hx of erosive esophagitis
Social History:
___
Family History:
All 4 siblings with PCKD and renal transplants.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.6 98.6 120/63 71 18 94% UOP 400/8hrs, urine w/gross
hematuria no clots
General: NAD, resting in chair
HEENT: MMM
Neck: supple
CV: nl S1 ___ SM
Lungs: CTAB
Abdomen: obese, TTP RLQ no guarding or rebound
GU: no foley
Ext: 1+ pitting edema bilaterally, right upper extremity with
fistula and palable thrill
Neuro: AOx3, grossly normal
DISCHARGE PHYSICAL EXAMINATION:
VSS
General: NAD, resting in chair
HEENT: MMM
Neck: supple
CV: nl S1 ___ SM
Lungs: CTAB
Abdomen: soft, nontender, TTP RLQ no guarding or rebound
GU: no foley
Ext: 1+ pitting edema bilaterally, right upper extremity with
fistula and palable thrill
Neuro: grossly normal
Pertinent Results:
LABS ON ADMISSION
___ 07:00PM BLOOD WBC-3.8* RBC-3.47* Hgb-11.2* Hct-34.6*
MCV-100* MCH-32.2* MCHC-32.3 RDW-13.1 Plt ___
___ 07:00PM BLOOD Neuts-79.3* Lymphs-10.8* Monos-7.7
Eos-1.9 Baso-0.3
___ 07:00PM BLOOD ___ PTT-34.8 ___
___ 07:00PM BLOOD Plt ___
___ 07:00PM BLOOD Glucose-105* UreaN-22* Creat-1.0 Na-137
K-4.6 Cl-104 HCO3-23 AnGap-15
___ 06:40PM URINE RBC-14* WBC-3 Bacteri-FEW Yeast-NONE
Epi-0
LABS ON DISCHARGE
___ 09:25AM BLOOD WBC-2.8* RBC-3.36* Hgb-11.3* Hct-34.2*
MCV-102* MCH-33.5* MCHC-32.9 RDW-13.1 Plt ___
___ 09:25AM BLOOD Plt ___
___ 09:25AM BLOOD ___ PTT-33.1 ___
___ 09:25AM BLOOD Glucose-144* UreaN-16 Creat-1.0 Na-138
K-4.1 Cl-103 HCO3-23 AnGap-16
___ 09:25AM BLOOD Calcium-9.5 Phos-2.7 Mg-1.7
___ 09:25AM BLOOD Cyclspr-195
___ 04:00PM URINE Color-YELLOW Appear-Hazy Sp ___
___ 04:00PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 04:00PM URINE RBC-94* WBC-1 Bacteri-FEW Yeast-NONE
Epi-0
___ 04:00PM URINE BK VIRUS BY PCR, URINE-PND
MICRO
___ 2:29 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
___ 2:30 pm SWAB Source: Rectal swab.
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Pending):
IMAGING
CT ABD & PELVIS WITH CONTRASTStudy Date of ___
1. Multiple hyperdense renal cysts bilaterally, likely
representing
hemorrhagic or proteinaceous components, with no evidence of
enhancement
compared to the noncontrast CT from 1 day prior.
2. Transplanted kidney in the right lower quadrant with contrast
seen draining
from the collecting system into the bladder. Some thickening of
the
urothelium in the hilum and proximal ureter without obstruction,
likely
chronic (c/w ___ CT).
3. Simple fluid collection in the anterior abdominal wall in the
right lower quadrant, measuring 3.5 x 2 x 5.4 cm. This is
unchanged since at least ___.
RENAL TRANSPLANT U.S. RIGHTStudy Date of ___
Normal renal transplant ultrasound.
CT ABD & PELVIS W/O CONTRASTStudy Date of ___
1. Polycystic kidneys including some hyperdense cysts, but
without change; no evidence for stones or hydronephrosis.
Evaluation for whether any solid masses may be present is very
limited without intravenous contrast administration.
2. Slight fat stranding about the renal graft of uncertain
significance; this is new and may be due to slight edema from
fluid overload although
inflammation of the graft is a possibility.
Chest xray ___: No evidence of acute cardiopulmonary disease.
Brief Hospital Course:
Hospital course: Ms. ___ is a ___ year old woman with a history
of PCKD s/p transplant presenting with gross hematuria and one
day of lightheadedness, with reassuring CT abd/pelvis w/contrast
and renal transplant ultrasound, discharged with plans for
outpatient primary care, transplant nephrology, and urology
follow up.
Active issues:
# Hematuria- Differential includes cyst rupture given her
history of this in the past (despite the absence of flank pain),
malignancy along urinary tract from kidney to ureters to
bladder, nephrolithiasis, or UTI although no e/o of stones on CT
or UTI on UA. Outpatient cystoscopy may be considered to
evaluate this further, and she was advised to follow up with
urology.
#Lightheadedness: Resolved. She presented after experiencing
lightheadedness at home, concurrent with hematuria, and was
found to have a stable h/h. She denied syncope, chest pain or
pressure. ECG showed no significant change from prior, and she
was hemodynamically stable. Oral intake was encouraged.
Chronic issues:
#PCKD s/p renal transplant
-continued immunosupression w/ cyclosporine, azothioprine, and
dapsone for PCP ___
#Hx of erosive esophagitis- continued home PPI
#HTN- continued home metoprolol and furosemide
Transitional issues:
-she will arrange outpatient primary care, transplant
nephrology, and urology follow up; this couldn't be done for her
as she was discharged on a ___
-no medication changes were made during this hospitalization
FYI:
#CODE: Full confirmed on this admission
#CONTACT: ___ (husband)
Phone number: ___ (W) Cell Phone: ___ Home
Phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azathioprine 50 mg PO DAILY
2. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
3. Dapsone 100 mg PO DAILY
4. Furosemide 20 mg PO DAILY PRN edema
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Azathioprine 50 mg PO DAILY
2. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
3. Dapsone 100 mg PO DAILY
4. Furosemide 20 mg PO DAILY PRN edema
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home
Discharge Diagnosis:
Hematuria
Polycystic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with blood in your urine. We are not sure what
caused this. However, your CT abdomen/pelvis, renal transplant
ultrasound, and urine culture did not show any concerning
findings. We recommend follow up with your primary care and
transplant nephrology doctors. ___ also suggest follow up with a
urologist to evaluate the blood in your urine further.
Followup Instructions:
___
|
19738416-DS-23
| 19,738,416 | 25,641,872 |
DS
| 23 |
2152-01-06 00:00:00
|
2152-01-08 00:19:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Red Dye / lisinopril / Oxycodone
Attending: ___
Chief Complaint:
painless hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ lady with polycystic kidney disease
previously on HD s/p DD renal transplant (___), prior kidney
cyst rupture, and HTN p/w painless hematuria.
Patient awoke on ___ night with urge to void and initially had
difficulty. An hour later, voided bright red urine w/ clots.
Since then has been unable to void except for clots. Also has
abdominal bloating. Previously occurred several times prior to
transplant, most recently in ___ due to cyst rupture.
+chronic RUQ pain (known liver cysts) No trauma, flank/groin
pain, f/c, dysuria, dizziness. Also no CP, SOB, HA, melena,
BRBPR, vision change, cough or rash.
ED COURSE
In the ED, vitals were: 98.2, HR 90, BP 140/79, RR 16, 100%RA
- Labs were significant for Hgb 13.2, Cr 0.9 UA w/ large number
of blood and WBCs w/ few bacteria, ___.
- Renal transplant US was normal.
- Foley was placed with hand irrigation. The patient was given
Tylenol, protonix, cyclosporine.
Vitals prior to transfer were: 98.3F, HR70, BP 124/69, HR 15,
96%RA
Upon arrival to the floor, has a headache but otherwise well.
Past Medical History:
PCKD s/p transplant ___
PCLD - polycystic liver disease
HTN
s/p partial liver resection in the ___
hx of erosive esophagitis
Social History:
___
Family History:
All 4 siblings with PCKD and renal transplants.
Physical Exam:
ADMISSION:
General: Well appearing elderly woman resting comfortably
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, soft systolic
murmur (III/VI) LUSB loudest
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, TTP throughout abdomen no rebound g
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE:
Vitals: 97.7 123/84 HR 61 RR16 99% RA
General: pleasant lady laying in bed in NAD.
HEENT: anicteric sclera, dry mucous membranes
CV: RRR no m/r/g
Lungs: CTA b/l
Abdomen: RUQ tenderness (stable); nondistended; no LUQ or CVA
tenderness.
Ext: no edema
Pertinent Results:
ADMISSION LABS:
___ 03:50PM BLOOD WBC-9.9# RBC-4.23 Hgb-13.2 Hct-40.0
MCV-95 MCH-31.2 MCHC-33.0 RDW-12.7 RDWSD-43.6 Plt ___
___ 03:50PM BLOOD Glucose-117* UreaN-24* Creat-0.9 Na-133
K-5.8* Cl-101 HCO3-22 AnGap-16
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-3.7* RBC-3.75* Hgb-11.9 Hct-36.1
MCV-96 MCH-31.7 MCHC-33.0 RDW-12.2 RDWSD-42.9 Plt ___
___ 06:00AM BLOOD Glucose-107* UreaN-25* Creat-1.1 Na-140
K-4.3 Cl-105 HCO3-26 AnGap-13
MICRO:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. OF TWO COLONIAL
MORPHOLOGIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
TRANSPLANT Renal U/S ___
1. Polycystic kidneys including some hyperdense cysts, but
without change; no
evidence for stones or hydronephrosis. Evaluation for whether
any solid
masses may be present is very limited without intravenous
contrast
administration.
2. Slight fat stranding about the renal graft of uncertain
significance; this
is new and may be due to slight edema from fluid overload
although
inflammation of the graft is a possibility.
Brief Hospital Course:
Ms. ___ is a ___ lady with polycystic kidney disease
previously on HD s/p DD renal transplant (___), prior kidney
cyst rupture, and HTN p/w painless hematuria but stable Hgb c/w
kidney cyst rupture. No symptoms of infection but with urine
culture growing pan-sensitive E.coli.
# Hematuria: Most likely cyst rupture within native kidney,
although other possibilities included UTI, Kidney stone, GU
malignancy. No e/o renal transplant problem per imaging. Patient
received continuous bladder irrigation through a triple lumen
foley which was removed prior to discharge without any issues of
further clotting or inability to void.
UTI:
UCx + for pan-sensitive E.coli sensitive to cipro. Patient
entirely asymptomatic but warrants treatment to protect
transplant kidney.
- Ciprofloxacin 500mg BID for fourteen days for complicated UTI.
- Tolerating foley removal.
# ESRD s/p DDRT: No graft tenderness. No elevation in creatinine
and normal transplant US.
- Continued cyclosporine and azathioprine without issues.
TRANSITIONAL ISSUES:
- Contact: ___ (husband) ___
- Code Status: FULL CODE
- Should have an MRI to screen for Renal Cell Carcinoma given
increased risk with APKD
- Urine cytology pending at time of discharge
- Urology to perform follow-up cystoscopy as an outpatient
- Patient to complete a two-week total antibiotic course with
ciprofloxacin 500mg Q12H (last dose ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Alendronate Sodium 70 mg PO QMON
3. Azathioprine 50 mg PO DAILY
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
5. Pantoprazole 40 mg PO Q12H
6. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
Discharge Medications:
1. Azathioprine 50 mg PO DAILY
2. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
3. Pantoprazole 40 mg PO Q12H
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 12 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
hours Disp #*24 Tablet Refills:*0
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Alendronate Sodium 70 mg PO QMON
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: hematuria; complicated urinary tract
infection.
secondary diagnosis: APKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a privilege to care for you at the ___
___. You were admitted for blood in your urine that
likely resulted from rupture of the known cysts in your kidneys.
Because you had many clots that caused you difficulty with
urinating, a foley catheter was placed to continually irrigate
your bladder and wash away the clots. Ultimately, the catheter
was removed ad you were able to urinate without complication. In
time, the red discoloration should subside.
We also evaluated your transplant kidney with an ultrasound and
found nothing of concern. However, we tested your urine for
bacteria and found an organism known as E. coli. Fortunately,
our lab studies determined that your current antibiotic regimen
is effective at treating this bacteria. You will need to
complete a total 14 day course of antibiotics to eradicate this
bacteria and help protect your transplanted kidney.
Please continue taking all of your other medications as
instructed, including your immunosuppressive medications. We
also recommend that you have an MRI of your kidneys as an
outpatient as a screening test for renal cell carcinoma. Having
poycystic kidney disease places you at greater risk for this
condition. Feel free to contact the hospital or your regular
doctor if you have any additional questions or concerns.
Followup Instructions:
___
|
19738437-DS-8
| 19,738,437 | 26,352,134 |
DS
| 8 |
2182-05-08 00:00:00
|
2182-05-10 04:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / aspirin / egg / mayonnaise
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a history of CAD s/p
stenting at ___ about 8 months ago, HTN, and IDDM
who presents with chest pain. He reports a history of DOE for
two weeks and today comes in after having an episode of chest
pain at rest. The pain was ___ on the L side of his chest,
without radiation and lasted about 45 minutes. It occurred 20
minutes after smoking a joint which he does not think contained
cocaine. He has not been taking any medications (including
plavix) for the last month since he got in a fight with his
neighbor and lost ___ services. EMS gave him nitro and aspirin -
he says aspiring makes him itchy so he doesn't normally take it.
On arrival in the ED initial vitals were 98.2 86 146/60 16 99%.
Exam was benign.
EKG at 1800: ST depressions and TWI in V4-V6
EKG at 0015: TWI in V4-V6, ST depressions improved
EKG at 0142: deepening TWI in V3, ST depressions as TWI in V4-V6
Initial troponin at 6:15PM was negative. Repeat troponin at
12:05am was 0.37, with a CKMB of 23 and MBI of 7.2. UA
significant for glu of 1000, ___lood. Chem 7
signifcant for BUN of 24 and Cr of 1.3 (unknown baseline), and
glucose of 428. HCT 39.9 (unknown baseline) and WBC 10.8. Coags
wnl. CXR showed no acute process.
He was given insulin, plavix and started on a heparin gtt as
well as his home meds and he was chest pain free by 01:41.
Vitals on transfer were 98.1 75 156/83 13 98% RA
on arrival to the floor he is chest pain free and has no
complaints.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:
recent stents placed at ___ in ___, not clear exactly
when
3. OTHER PAST MEDICAL HISTORY:
asthma
IDDM
allergic rhinitis
antisocial personality disorder
eczema
depression (patient denies)
OSA
pruritius
renal insufficiency
shoulder pain
Social History:
___
Family History:
He does not know about his family history other than that his
PGF died of an MI, age unknown.
Physical Exam:
ADMISSION
VS: 97.8 135/74, 66, 16, 99%RA, pain ___
General: WD/WN, NAD
HEENT: Oropharynx clear
Neck: Supple, no JVD
CV: RRR, no m/r/g
Lungs: CTAB
Abdomen: soft, nt/nd
Ext: no c/c/e, wwp
Neuro: aox3, mae
Skin: no rash
DISCHARGE
VS: 98.3 (max 98.7) 118/74 (115-149/54-76) 60 (60-68) 18 98%
RA (98-100%)
Blood sugar range 142 to 449
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI.
NECK: No JVD
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No tenderness, rebounding or guarding.
EXTREMITIES: No edema. WWP. No calf TTP.
SKIN: Dry
Pertinent Results:
ADMISSION LABS
___ 06:15PM ___ PTT-27.6 ___
___ 06:15PM PLT COUNT-206
___ 06:15PM NEUTS-81.4* LYMPHS-13.1* MONOS-3.4 EOS-1.4
BASOS-0.6
___ 06:15PM WBC-10.8 RBC-4.79 HGB-14.0 HCT-39.9* MCV-83
MCH-29.2 MCHC-35.0 RDW-12.8
___ 06:15PM cTropnT-<0.01
___ 06:15PM GLUCOSE-428* UREA N-24* CREAT-1.3* SODIUM-134
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-24 ANION GAP-16
___ 07:50PM URINE MUCOUS-RARE
___ 07:50PM URINE HYALINE-7*
___ 07:50PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 07:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 07:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
OTHER LABS
___ 12:05AM BLOOD CK-MB-23* MB Indx-7.2* cTropnT-0.37*
___ 07:10AM BLOOD CK-MB-31* cTropnT-0.86*
___ 12:40PM BLOOD CK-MB-27* MB Indx-7.5* cTropnT-0.73*
___ 07:40PM BLOOD CK-MB-17* MB Indx-6.3* cTropnT-0.60*
___ 10:00AM BLOOD CK-MB-8 cTropnT-0.44*
___ 07:10AM BLOOD %HbA1c-13.4* eAG-338*
___ 07:10AM BLOOD Triglyc-128 HDL-50 CHOL/HD-4.3
LDLcalc-141*
IMAGING/STUDIES
CXR ___
No definite focal consolidation is seen. There is no pleural
effusion or
pneumothorax. Mild right middle lobe and basilar atelectasis is
noted. The
cardiac and mediastinal silhouettes are unremarkable. No
displaced fracture
is seen. 6 mm ovoid calcification adjacent to the lateral right
humeral head
likely represents calcific tendinosis.
IMPRESSION:
Minor atelectasis. Otherwise, no acute cardiopulmonary process.
TTE ___
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild aortic regurgitation.
DISCHARGE LABS
___ 07:00AM BLOOD WBC-8.1 RBC-5.21 Hgb-15.2 Hct-44.7 MCV-86
MCH-29.1 MCHC-33.9 RDW-13.3 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-141* UreaN-17 Creat-1.2 Na-140
K-4.2 Cl-100 HCO3-32 AnGap-12
___ 07:00AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ with a history of IDDM and CAD s/p stenting
in ___ who presents with unstable angina, ST depressions and
troponin bump concerning for NSTEMI after discontinuing all
medications including plavix about one month ago, also in the
setting of positive urine tox for cocaine.
ACTIVE DIAGNOSES
# Acute Coronary Syndrome: Pt has h/o CAD s/p BMS to LAD in
___. He presented with chest pain, EKG with ST depressions,
and troponinemia consistent with NSTEMI. Underlying cause of
NSTEMI was likely cocaine-induced vasospasm given positive urine
toxin screen. He has also been noncompliant with his
medications for two months due to discontinuation of his ___
services. Cardiac enzymes were trended down, and serial ECGs
were monitored. Pt remained free of chest pain throughout
hospitalization.
Medical management included aspirin (pt self-administered 325mg
at home, received 81 mg here), clopidogrel 75mg daily, atorva
80mg daily, and a heparin drip x 48 hrs. He may have received a
dose of metoprolol, but this medication was discontinued when
urine toxin screen returned positive for cocaine in order to
avoid unopposed alpha effect. He continued to receive losartan
25mg daily, and amlodipine 5mg daily was restarted. Echo was
checked the day prior to discharge and showed normal global and
regional biventricular systolic function.
Pt was seen by physical therapy prior to discharge to assess
functional capacity. He was found to have independent and safe
mobility with stable vital signs.
#Diabetes mellitus: Pt has had poor control of diabetes since
discontinuation of ___ services two months ago. A1c was
measured at 13.4. ___ c/s was obtained, and pt was placed on
glargine daily with an escalating Humalog sliding scale
throughout the day while in hospital. On discharge, the
recommendation was to take 25 units 70/30 before breakfast and
35 units before dinner. He was given samples of insulin to
maximize chance for compliance after discharge and prior to
obtaining the rest of his necessary insulin supplies.
CHRONIC DIAGNOSES
#Renal Insufficiency: Cr ranged 1.1 to 1.3 while here, and was
1.2 on the day of discharge. Monitored daily Cr and avoided
nephrotoxins. Losartan was continued as part of CAD regimen.
#Asthma: No acute exacerbation of chronic disease. Restarted
home Proair HFA and Flovent
#HTN: No acute exacerbation of chronic disease. Treated with
amlodipine and losartan. Beta-blocker was held ___ positive
urine toxin screen for cocaine.
#Allergic rhinitis: No acute exacerbation of chronic disease.
Continued loratadine.
TRANSITIONAL ISSUES
#CAD: f/u with Cardiology for further management and titration
of medications.
#Diabetes mellitus: f/u with ___ diabetes clinic
#F/u with PCP for other medical issues
#Medication noncompliance: pt was DCed with home ___ services.
In absence of ___, he has poor medication compliance.
#CODE: Full
#CONTACT: Patient, mother in law ___ ___,
___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium Dose is Unknown PO Frequency is Unknown
2. BuPROPion (Sustained Release) Dose is Unknown PO Frequency
is Unknown
3. Simvastatin 20 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Loratadine 10 mg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
8. 70/30 15 Units Breakfast
70/30 15 Units Dinner
9. ProAir HFA (albuterol sulfate) 108mcg 2 puffs Inhalation q 6
hrs
10. Amlodipine 5 mg PO DAILY
11. Flovent HFA (fluticasone) 220 mcg/actuation Inhalation BID
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Aspirin 81 mg PO DAILY
If swelling of the lips, tongue or throat occurs, call an
ambulance or go to Emergency Department
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*30 Tablet Refills:*0
5. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. BuPROPion (Sustained Release) 0 mg PO Frequency is Unknown
7. Docusate Sodium 0 mg PO Frequency is Unknown
8. Loratadine 10 mg PO DAILY
9. ProAir HFA (albuterol sulfate) 108mcg 2 puffs Inhalation q 6
hrs
10. Flovent HFA (fluticasone) 220 mcg/actuation Inhalation BID
11. 70/30 25 Units Breakfast
70/30 35 Units Dinner
RX *insulin NPH & regular human [Humulin 70/30] 100 unit/mL
(70-30) as directed SC 25 Units before BKFT; 35 Units before
DINR; Disp #*1 Box Refills:*0
RX *blood sugar diagnostic [FreeStyle Lite Strips] Please use
as directed Please use as directed BID Disp #*50 Unit Refills:*0
RX *blood-glucose meter [FreeStyle Lite Meter] Use as directed
Use as directed Disp #*1 Kit Refills:*0
RX *lancets [FreeStyle Lancets] 28 gauge Please use as directed
Please use as directed bid Disp #*1 Box Refills:*0
RX *insulin syringe-needle U-100 [BD SafetyGlide Insulin
Syringe] 30 gauge x ___ Please use as directed Please use as
directed BID Disp #*50 Syringe Refills:*0
12. Nitroglycerin SL 0.3 mg SL PRN chest pain
___ take up to three times, separated by five minutes.
RX *nitroglycerin 0.4 mg 1 tab sublingually once Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Cocaine induced vasospasm
Poorly controlled diabetes mellitus
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 during your admission
to ___. As you know, you were
admitted for chest pain, likely due to stress on your heart from
cocaine. Ultrasound of your heart (echocardiogram) showed no
structural abnormalities. It is very important that you avoid
cocaine or cocaine-containing substances in the future; these
substances can have very dangerous consequences for your heart.
In addition, it is very important that you continue to take your
insulin after you are discharged from the hospital. Poorly
controlled diabetes has many health consequences, including
increased risk of heart disease.
Please see attached for specific medication changes. Your
atorvastatin requires pre-authorization, so it will need to be
picked up from the pharmacy.
Followup Instructions:
___
|
19738521-DS-3
| 19,738,521 | 24,918,977 |
DS
| 3 |
2135-08-02 00:00:00
|
2135-08-02 21:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Penicillins / Cipro
Attending: ___.
Chief Complaint:
Right hand fifth metacarpal fracture status post a fall
Major Surgical or Invasive Procedure:
- Right hand laceration repair (2cm vertical laceration in
middle of palm)
- Reduction of right fifth metacarpal fracture and splinting
History of Present Illness:
___ is a ___ with h/o aortic insufficiency, CKD,
HTN who was from OSH for a open right ___ metacarpal
fracture/dislocation. The patient landed on her right hand after
mechanical vs. syncopal episode at 6 pm on the day of admission.
She fell to her knees and the palm of her right hand was impaled
with a cabinet handle, which was thin, metal, and blade-like.
She did not ___ her head and denies LOC. CT head at OSH did
not show an acute intracranial process. She also denies
lightheadedness, numbness/tinlging, chest pain, SOB, N/V. She
was able to ambulate after getting up from the fall. She
received cefalexin 1g at OSH before being transferred to the
___ for further treatment of her fracture. Her tetanus is UTD.
In the ED, initial VS were: Pain 7, T 98.0, HR 54, BP 152/58, RR
16, O2 100%. Labs were significant for WBC 12.1 (84.9 PMNs, 8.8
Lymphs, no bands), Hct 31.3, Trop 0.03, Cr 4.2. She was seen by
plastics, and had a open fracture to base of RT metacarpal. A
2cm laceration was closed using sutures, and reduction was
attempted but the fracture was highly mobile. She was placed in
a volar splint. Postreduction films showed a realigned right
proximal ___ metatarsal fracture, with presence of subcutaneous
air. Knee x-ray showed severe bilateral arthritis, mild soft
tissue swelling in L knee, no fractures. EKG showed prolonged
QTC interval. She received morphine 5mg x 2, and was admitted to
medicine for syncope workup and prolonged QTc.
VS prior to transfer were: T 98.1, HR 82, BP 146/79, RR 16, O2
95%
Past Medical History:
- Chronic renal failure (not on dialysis), baseline Cr. 4.2
- Hypertension
- HL
- Suspected thoracic aortic aneurysm from an x-ray, patient
declined further imaging and workup
- Appendectomy
- Afib, paroxysmal
- Baseline AV conduction delay
Social History:
___
Family History:
Noncontributory
Physical Exam:
On admission:
VITALS: T 98.1, HR 82, BP 146/79, RR 16, O2 95% RA
___: Alert, awake, fully oriented
HEENT: PERRL, EOMI, oropharynx clear
NECK: no carotid bruits, JVD
LUNGS: clear bilaterally, no wheezes or rales
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: R hand in volar splint. Sensation intact. Swelling
and ecchymosis. s/p closure of 2cm vertical laceration in middle
of palm. Swelling and ecchymosis of both knees
NEUROLOGIC: A+OX3, CN II-XII grossly intact. Moves all four
extremities
On discharge:
Vitals: T 98.3, HR 58, BP 134/62, RR 21, O2 98% RA
___: Alert, awake, fully oriented
HEENT: PERRL, EOMI, oropharynx clear
NECK: no carotid bruits, JVD
LUNGS: clear bilaterally, no wheezes or rales
HEART: RRR, normal S1 S2, ___ systolic murmur at apex
ABDOMEN: Soft, NT, NABS, large, reducible ventral hernia
EXTREMITIES: R hand in volar splint. Sensation intact. Swelling
and ecchymosis. s/p closure of 2cm vertical laceration in middle
of palm. Swelling and ecchymosis of both knees, full ROM in
knees.
NEUROLOGIC: A+OX3, Moves all four extremities
Skin: erythematous patch under bilater breasts and axilla, per
pt she had the rash before admission and it has not changed
Pertinent Results:
On admission:
___ 01:46AM BLOOD WBC-12.1* RBC-3.24* Hgb-10.0* Hct-31.3*
MCV-97 MCH-31.0 MCHC-32.1 RDW-13.1 Plt ___
___ 01:46AM BLOOD Neuts-84.9* Lymphs-8.8* Monos-3.6 Eos-2.4
Baso-0.3
___ 01:46AM BLOOD ___ PTT-30.0 ___
___ 01:46AM BLOOD Plt ___
___ 12:00PM BLOOD
___ 01:46AM BLOOD Glucose-102* UreaN-101* Creat-4.2* Na-143
K-4.4 Cl-106 HCO3-23 AnGap-18
___ 12:00PM BLOOD CK(CPK)-63
___ 01:46AM BLOOD cTropnT-0.03*
___ 12:00PM BLOOD Calcium-9.7 Phos-4.7* Mg-1.8
On discharge:
___ 08:40AM BLOOD WBC-5.9 RBC-3.18* Hgb-9.9* Hct-31.3*
MCV-98 MCH-31.0 MCHC-31.5 RDW-13.1 Plt ___
___ 08:40AM BLOOD Plt ___
___ 08:40AM BLOOD Glucose-96 UreaN-120* Creat-4.2* Na-142
K-4.0 Cl-104 HCO3-22 AnGap-20
___ 08:40AM BLOOD Calcium-9.1 Phos-6.0* Mg-2.0
EKG ___:
Sinus bradycardia with atrio-ventricular conduction delay. Left
axis
deviation. Q-T interval prolongation. Delayed R wave transition.
Diffuse
non-specific ST segment changes. No previous tracing available
for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
53 ___ 19 -39 7
EKG ___:
Sinus bradycardia with premature ventricular complex. Borderline
atrio-ventricular conduction delay. Borderline Q-T interval
prolongation.
Non-diagnostic Q waves in the high lateral leads. Delayed R wave
transition. Non-specific ST segment changes. Left ventricular
hypertrophy. Compared to the previous tracing of ___ the Q-T
interval is shorter.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
55 ___ 22 -29 2
Imaging:
___
--THREE VIEWS OF THE RIGHT HAND:
Detail is limited due to an overlying cast. Within these
limitations, the proximal fifth metacarpal fracture is again
seen, in gross anatomic alignment. The fracture extends into
the carpometacarpal joint and, on the oblique view, a small
displaced fragment is noted. Again seen is marked soft tissue
swelling with considerable subcutaneous gas. Also again noted is
severe osteoarthritis of the ___ CMC and multiple IP joints.
IMPRESSION:
1) Fracture of the proximal ___ metacarpal with intra-articular
extension. Aligbnment as described.
2) Unchanged swelling and subcutaneous gas which raises concern
for infection.
___
--THREE VIEWS OF BOTH KNEES:
There is severe bilateral osteopenia. Allowing for this, no
fracture or
dislocation is detected. There are advanced osteoartheiritis
steoarthritis with near bone-on-bone articulation in both knees.
There is a small right knee joint effusion. No fat-fluid level
is detected in either knee. There is bilateral soft tissue
swelling, including prepatellar soft ___ swelling on the
right. Dense vascular calcification noted.
IMPRESSION:
1) Severe osteopenia. No fracture detected. Given the severe
osteopenia, a non-displaced fracture might not be detected, but
no fat-fluid level is seen to suggest occult intra-articular
fracture. Soft tissue swelling is seen bilaterally and is
suggestive of post-traumatic change.
2) Severe bilateral osteoarthritis.
Brief Hospital Course:
___ year old female with baseline PR delay, CKD, HTN presented
with open right fifth metacarpal fracture s/p a fall.
Active issues:
#Right fifth metacarpal fracture: Pt had an open right fifth
metacarpal fracture and was transferred from OSH for definitive
care. She was seen by plastic/hand surgery and underwent a 2cm
vertical laceration repair in middle of palm, and had
non-surgical reduction of the fracture and placement of volar
splint. Post reduction x-ray showed near alignment. Hand surgery
elected conservative therapy with outpatient follow-up given the
patient's advanced age and comorbid conditions. The pt's right
hand had been stable, with minimal pain, intact cap refill,
intact finger movements and sensations. She was given a tetanus
shot on ___. She was discharged with a course of Keflex to
be finished on ___ for a total 7 day antibiotic course.
#Fall: The pt and her husband, who witnessed the fall, gave an
account that was consistent with a mechanical fall. Her head CT
from OSH showed no acute processes, her UA was normal. She did
not have any focal signs of infection. Her orthostatic signs on
HD1 in the setting of prolonged NPO which resolved on the
following day s/p PO hydration. Her knee x-ray showed no
fractures. Telemetry showed first degree AV delay and
asymptomatic Mobitz 1 (while she was on verapamil and atenolol),
but she was without symptoms. Her verpamil and atenolol were
discontinued. The fall was unlikely from the asymptomatic
Mobitz 1. ___ recommended rehab placement re high risk for fall
s/p fracture, required platform walking aid at baseline.
#Mobitz Type I heart block: The pt had baseline first degree AV
block at baseline per old EKG. She developed bradycardia (HR low
___, and a self-limited Mobitz Type I block on HD 1 on home
medications Atenolol and Verapimil. Cardiology was consulted and
attributed rhythm change to iatrogenic cause re overdosing nodal
agents. Atenolol and Verapimil were discontinued, and the
patient's telemetry and follow up EKGs showed stable rhythm at
baseline. Her outpatient cardiologist, Dr. ___ was
contacted regarding the change and agreed with the plan. Her
blood pressure remained normal (110-130s/40-60s), and she
remained asymptomatic. Her subsequent EKGs have returned to
baseline of AV conduction delay (First degree heart block) and
mild QTc prolongation.
# Yeast/Fungal skin infection. The pt had erythematous patch
under breasts and in bilat axilla prior to admission, she denied
any change of rash, and was given home med Miconazole powder.
Ancef/Keflex were given, with the knowledge of penicillin
allergy re rash. Serial exam did not identify new rashes.
Inactive issues:
#CKD: The pt has stage 5 CKD, not on dialysis, with baseline Cr.
of 4.2-4.5. Her Cr. stayed in this range. Her nephrologist was
informed about patient's admission and agreed with holding
atenolol and verapamil at this time given the Mobitz 1 seen on
telemetry. Patient will need to have a follow up with her
nephrologist within ___ weeks of her discharge from the
hospital, as there is plan to re-address the potential need for
dialysis.
#HTN: As above, Atenolol and Verapamil were discontinued re
Mobitz I heart block. She was discharged with home medication
furosemide as the only anti-hypertensive agent. She remained
normotensive on furosemide alone. If blood pressure begins to
increase, would consider a non-nodal agent for BP control.
# Anemia of chronic dz: The pt's HCT was stable. There was no
signs of acute bleeding.
Transitional issue:
# Things to do:
[]Keflex to be finished on ___
[]Serial skin exam re on Keflex, had rash on penicillin. If new
rash develops d/c Keflex and switch to another abx for infxn ppx
for open fracture
[]check EKG on post discharge day 1 re resolution of second
degree heart block (Mobitz 1)
# Follow up:
- please assist patient in transport to her follow up
appointments
- please arrange follow up appointment for patient with her
nephrologist within ___ weeks of her discharge
- please arrnage follow up appointment for patient with her
primary care provider.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
PatientFamily/Caregiver.
1. Verapamil 120 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Lovastatin *NF* 10 mg Oral Daily
5. Furosemide 20 mg PO DAILY
6. Calcitriol 0.25 mcg PO DAILY
7. Calcitrate *NF* (calcium citrate) 666 mg Oral QD
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
5. Cephalexin 250 mg PO Q12H
To be finished on ___ for a total of ___. Miconazole Powder 2% 1 Appl TP BID:PRN rash
7. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
8. Calcitrate *NF* (calcium citrate) 666 mg Oral QD
9. Lovastatin *NF* 10 mg Oral Daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Open right hand fifth metacarpal fracture
Secondary Diagnosis:
- Chronic kidney disease
- Hypertension
- Bradycardia with First Degree AV delay and Mobitz Type I heart
block
- paroxymal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Right hand in volar splint, sensation intact, mild pain well
controlled on tylenol/tramadol.
Bradycardia heart rate range
Discharge Instructions:
Dear ___,
___ has been a pleasure taking care of you at the ___
___. You were transferred from the ___
___ to here because of an open fracture of your
right hand after a fall. We have repaired your hand wound, and
placed a splint to re-enforce your realignment. Your hand xray
with the splint showed near alignment. Your knee xray showed no
fractures. Hand surgeons chose not to do surgeries and will
follow up with you as an outpatient. We gave you a tetanus
vaccine shot here to prevent a toxic reaction from open wounds.
As for your fall, based on your account we think it is most
likely due to a mechanical cause, such as losing your footing;
however, you had low heart rate on admission, and then developed
an arrhythmia (Mobitz Type I), which can be common in elderly
patients, but also can be attributed to the Atenolol and
Verapimil that you were taking at home. We have discontinued
these two medications in the hospital, and since you blood
pressure was in a safe range, did no prescribe new blood
pressure medications. Your heart rhythm returned to baseline
after the medication changes. We have been giving you an
antibiotic to prevent infections form your wound. Please take
your home medications and the antibiotics at the facility as
instructed below. Please follow up with Dr. ___, a hand
surgeon, as instructed below.
Please not the changes in your medications:
PLEASE STOP YOUR ATENOLOL
PLEASE STOP YOUR VERAPIMIL
PLEASE TAKE YOUR OTHER HOME MEDICATIONS
PLEASE TAKE ULTRAM EVERY ___ HOURS IF YOU ARE IN PAIN
PLEASE TAKE KEFLEX, AN ANTIBIOTICS, UNTIL ___ (A total of 7
day course)
PLEASE USE MICONAZOLE POWDER FOR THE YEAST INFECTION ON YOUR
SKIN.
Followup Instructions:
___
|
19738754-DS-18
| 19,738,754 | 22,589,653 |
DS
| 18 |
2125-03-19 00:00:00
|
2125-03-19 11:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tikosyn / salicylates
Attending: ___.
Chief Complaint:
Palpitations, monomorphic ventricular tachycardia, ICD shocks
Major Surgical or Invasive Procedure:
Ventricular Tachycardia Ablation ___
History of Present Illness:
Mr. ___ is a ___ yo male with h/o ischemic cardiomyopathy
and VT s/p ablation and ICD for secondary prevention who was
discharged home after an ED visit <24 hours presents
again with two ICD shocks. Patient was evaluated in the ED
___ for palpitations. Interrogation of his device during
that evaluation he was noted to have VT1 at 178 BPM, 179 BPM,
179
BPM on ___, no therapies delivered though changes were made
to the ICD settings. His dose of metoprolol was increased
from 25 mg BID to 25 mg qAM and 50 mg qPM.
In the ED:
- Initial vitals: AF 87 170/98 17 98% RA
- Interrogation of device (see interrogation note and uploaded
report) showed 2 episodes of monomorphic VT lasting 00:01:15 and
00:01:13. Both episodes were refractory to multiple attempts at
ATP and terminated with 36J shocks.
- Labs/studies notable for:
- normal CBC and chemistry other than Ca ___
- troponin negative x1
- normal CXR
- Patient was given: Lorazepam 1mg PO (1AM)
- Vitals on transfer: AF 73 110/67 16 98% RA
On the floor, pt endorses the above history. He feels well and
has not had any symptoms since arriving to the ED. Pt reports
that he felt some mild fluttering after discharge yesterday but
no other symptoms. At approximately 17:30, patient has episode
of palpitations which was followed by shock from his device.
Note
that this occurred after a party where he drank 2 beers. After
the initial shock patient took the increased dose of his
metoprolol as described above. He notes mild diaphoresis and
anxiety at that time. At approximately 11 ___ as the patient was
trying to go to sleep, he again noticed palpitation symptoms
which was followed by another ICD shock. He denies any chest
pain, lightheadedness, dizziness, presyncope or syncope prior to
the above ICD shocks. Patient presented to the emergency room
in
the setting of second ICD shock. He has not been sick and 10
point review of symptoms is otherwise negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Coronary artery disease - large anterolateral myocardial
infarction in ___ s/p CABG x 3 - LIMA to LAD, RIMA to RPDA
(occluded ___, rSVG to ramus (occluded ___ cath ___ with
100% pLAD; 40% pOM1 and 60-70% dRCA; patent LIMA to LAD. RIMA
and
rSVG were occluded
- Ventricular tachycardia - s/p ablation and ICD ___,
single-chamber, ___ ICD, secondary prevention)
- Atrial septal defect
- Mitral regurgitation
3. OTHER PAST MEDICAL HISTORY
- Seasonal allergy
- Elevated homocystine
- Hepatitis ___ - drug induced from salicylates (?)
- Cervical disc disease - moderate degenerative disease C5-6
Social History:
___
Family History:
His parents are deceased (father, ___, CAD; mother, ___,
dementia). He has 2 siblings- a brother ___ years, CAD s/p
stent; little contact) and a sister ___ years, osteoporosis/hip
fracture, arthritis upcoming knee replacement). He has one son
(___, well; little contact) and a granddaughter (1.5 - well).
Physical Exam:
On Admission:
VS: ___ 0348 Temp: 99.0 PO BP: 126/82 L Lying HR: 82 RR: 18
O2 sat: 96% O2 delivery: RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: frequent extra beat but otherwise RRR, nl S1/S2, no murmurs
PULM: CTAB
GI: abdomen soft, nondistended, nontender in all quadrants
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
At discharge:
Physical Exam:
Vitals: ___ 0624 Temp: 98.3 PO BP: 97/59 HR: 60 RR: 16 O2
sat: 96% O2 delivery: RA
Weight: 73.6 kg
GEN: AAOx3, NAD
HEENT: NC, AT, MMM, no JVD, no carotid bruits
___: S1 S2 RRR no MRG appreciated
RESP: CTAB, good respiratory efforts
ABD: soft, NT, ND, NBS, no hepatomegaly
EXT: warm, well-perfused, nonedematous
B/L groins: dressings are clean/dry/intact, groins are soft with
2+femoral pulses b/l, nontender, with no ecchymosis or swelling
appreciated
NEURO: CN II-XII grossly intact, grossly normal/nonfocal exam
Pertinent Results:
___ 07:50AM BLOOD WBC-8.9 RBC-4.39* Hgb-13.6* Hct-41.8
MCV-95 MCH-31.0 MCHC-32.5 RDW-12.2 RDWSD-42.9 Plt ___
___ 03:50PM BLOOD WBC-9.4 RBC-4.31* Hgb-13.8 Hct-41.0
MCV-95 MCH-32.0 MCHC-33.7 RDW-12.1 RDWSD-42.5 Plt ___
___ 12:30AM BLOOD WBC-8.0 RBC-4.78 Hgb-15.4 Hct-46.0 MCV-96
MCH-32.2* MCHC-33.5 RDW-12.3 RDWSD-43.8 Plt ___
___ 03:50AM BLOOD WBC-6.7 RBC-4.55* Hgb-14.6 Hct-43.6
MCV-96 MCH-32.1* MCHC-33.5 RDW-12.2 RDWSD-42.5 Plt ___
___ 12:30AM BLOOD Neuts-71.9* ___ Monos-6.8
Eos-0.9* Baso-0.7 Im ___ AbsNeut-5.78 AbsLymp-1.55
AbsMono-0.55 AbsEos-0.07 AbsBaso-0.06
___ 03:50AM BLOOD Neuts-66.6 ___ Monos-6.0 Eos-5.7
Baso-0.8 Im ___ AbsNeut-4.43 AbsLymp-1.37 AbsMono-0.40
AbsEos-0.38 AbsBaso-0.05
___ 06:39AM BLOOD ___
___ 07:50AM BLOOD Glucose-98 UreaN-20 Creat-1.0 Na-143
K-4.4 Cl-105 HCO3-26 AnGap-12
___ 03:50PM BLOOD Glucose-100 UreaN-19 Creat-0.9 Na-142
K-4.5 Cl-108 HCO3-24 AnGap-10
___ 09:28PM BLOOD Na-139 K-3.9 Cl-100 HCO3-24 AnGap-15
___ 06:39AM BLOOD Glucose-114* UreaN-20 Creat-1.0 Na-141
K-4.5 Cl-102 HCO3-22 AnGap-17
___ 12:30AM BLOOD Glucose-132* UreaN-23* Creat-1.1 Na-140
K-4.6 Cl-101 HCO3-23 AnGap-16
___ 03:50AM BLOOD Glucose-118* UreaN-32* Creat-1.1 Na-138
K-4.4 Cl-100 HCO3-24 AnGap-14
___ 12:30AM BLOOD cTropnT-<0.01
___ 07:50AM BLOOD Mg-2.3
___ 03:50PM BLOOD Mg-2.0
___ 09:28PM BLOOD Mg-2.3
___ 06:39AM BLOOD Albumin-4.8 Calcium-10.2 Phos-3.6 Mg-2.2
___ 12:30AM BLOOD Calcium-10.4* Phos-3.7 Mg-2.4
___ 03:50AM BLOOD Calcium-10.0 Phos-3.6 Mg-2.4
___ 03:50AM BLOOD TSH-2.9
EP Report ___: Findings
Non inducible with mild anesthesia from RV and LV. Mapped LV
with RV pacing - large area of anterior scar. large area of LPs
on septal border of scar and along apical border of scar. Did
substrate modification targeting LPs along septal aspect of
transition between scar and normal tissue. After ablation,
triples from RV induced NSVT which then induced MMVT at 280 ms
___/ RBRS axis. Not HD tolerated. ATP not successful. DCCV to SR.
Did additional ablation along the area of LPs. Repeat stim with
up to triples and burst pacing from RV and LV without any
arrhythmias. No complications.
TTE ___: CONCLUSION:
The left atrial volume index is moderately increased. The
estimated right atrial pressure is ___ mmHg.
There is normal left ventricular wall thickness with a SEVERELY
increased/dialted cavity. There is
moderate-severe regional left ventricular systolic dysfunction
with near akinesis of the septum and
anterior wall and mildly dyskinetic apex (see schematic) and
mild global hypokinesis of the remaining
segments. No thrombus or mass is seen in the left ventricle.
Quantitative biplane left ventricular ejection
fraction is 24 %. Due to severity of mitral regurgitation,
intrinsic left ventricular systolic function may
be lower. Left ventricular cardiac index is depressed (less than
2.0 L/min/m2). There is no resting left
ventricular outflow tract gradient. Mildly dilated right
ventricular cavity with mild global free wall
hypokinesis. 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) appear structurally normal.
There is no aortic valve stenosis. There is trace aortic
regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
moderate to severe [3+] mitral regurgitation.
There is significant pulmonic regurgitation. The tricuspid valve
leaflets appear structurally normal.
There is physiologic tricuspid regurgitation. The pulmonary
artery systolic pressure could not be
estimated. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Marked left ventricular
cavity dilation with regional systolic
dysfunction most c/w multivessel CAD. Moderate mitral
regurgitation.
Brief Hospital Course:
A/P: ___ with infarct CM s/p 3vCABG- with patent LIMA, EF 25%,
mod-severe MR, presented with stable mmVT and ICD shocks. After
ICD reprogramming to allow for maximal ATP therapy, the patient
was successfully ATP'd for 4 additional MMVT events. He was on
lidocaine on evening of ___. He underwent uncomplicated VT
ablation yesterday with substrate modification in borderzone of
septal scar.
He has had no recurrence of sustained VT post ablation compared
to frequent VT requiring device ATP and lidocaine before the
procedure. Nonsustained VT observed overnight is slower and can
be monitored clinically.
He is otherwise hemodynamically and clinically stable for
discharge home today.
- continue home medications
- Already has outpatient f/u with EP and device clinic next
___. Patient will keep these visits.
- discharge home today
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclobenzaprine 10 mg PO HS
2. Baclofen 20 mg PO DAILY
3. Rosuvastatin Calcium 40 mg PO QPM
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO QAM
6. Metoprolol Succinate XL 50 mg PO QPM
7. FoLIC Acid 1 mg PO DAILY
8. Finasteride 1 mg PO 4X/WEEK (___)
9. Aspirin 81 mg PO QHS
10. azelastine 137 mcg (0.1 %) nasal 1 puff BID:PRN
11. red yeast rice 600 mg oral BID
12. Cyanocobalamin 100 mcg PO BID
13. Fish Oil (Omega 3) 1200 mg PO BID
14. flaxseed oil 1300 mg oral QHS
15. Co Q-10 (coenzyme Q10) 30 mg oral QAM
16. Multivitamins 1 TAB PO DAILY
17. ___ with Bioflavonoids (ascorbate calcium-bioflavonoid)
500-200 mg oral DAILY
18. acai berry extract ___ mg oral BID
19. ipratropium bromide 0.03 % nasal 1 puff BID:PRN post nasal
drip
Discharge Medications:
1. acai berry extract ___ mg oral BID
2. Aspirin 81 mg PO QHS
3. azelastine 137 mcg (0.1 %) nasal 1 puff BID:PRN
4. Baclofen 20 mg PO DAILY
5. Co Q-10 (coenzyme Q10) 30 mg oral QAM
6. Cyanocobalamin 100 mcg PO BID
7. Cyclobenzaprine 10 mg PO HS
8. ___ with Bioflavonoids (ascorbate calcium-bioflavonoid)
500-200 mg oral DAILY
9. Finasteride 1 mg PO 4X/WEEK (___)
10. Fish Oil (Omega 3) 1200 mg PO BID
11. flaxseed oil 1300 mg oral QHS
12. FoLIC Acid 1 mg PO DAILY
13. ipratropium bromide 0.03 % nasal 1 puff BID:PRN post nasal
drip
14. Lisinopril 10 mg PO DAILY
15. Metoprolol Succinate XL 25 mg PO QAM
16. Metoprolol Succinate XL 50 mg PO QPM
17. Multivitamins 1 TAB PO DAILY
18. red yeast rice 600 mg oral BID
19. Rosuvastatin Calcium 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Ischemic Cardiomyopathy
Ventricular Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ because you were having a dangerous
irregular heart rhythm, ventricular tachycardia, for which you
were shocked by your ICD.
You had an ablation procedure to treat the ventricular
tachycardia.
Activity restrictions and information regarding care of the
access site in the groin are included in your discharge
instructions.
Continue all your current medications without changes.
Notify your cardiologist if your ICD shocks. If you have more
than one shock you should come to the emergency room.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
If you have any urgent questions that are related to your
recovery from your procedure or are experiencing any symptoms
that are concerning to you and you think you may need to return
to the hospital, please call the ___ HeartLine at ___
to speak to a cardiologist or cardiac nurse practitioner.
It has been a pleasure to have participated in your care and we
wish you the best with your health!
Your ___ Cardiac Care Team
Followup Instructions:
___
|
19738794-DS-10
| 19,738,794 | 25,979,002 |
DS
| 10 |
2116-03-20 00:00:00
|
2116-03-22 09:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
s/p Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an independent ___
year old woman with a history of CAD and MI s/p CABG ___ at
___, anatomy unknown), CKD, DM2, COPD and frequent falls
previous
negative work-up who presents with fall found to have sudhural
hematoma.
Pt's falls began several months prior. She estimates a total of
6 fall episodes until this time. Previous to this episode, all
of her previous fall episodes were very similar. She would note
acute onset weakness of the left side of the body and left leg.
She would often times fall within seconds of these symptoms.
She
denies symptoms of chest pain, dyspnea, lightheadedness,
dizziness, pre-syncope, or syncope when these symptoms were
started. She denies ever losing consciousness. She does
endorse
prior head strikes which have been worked up at outside
hospitals. Notably, she lost 143lbs (263lbs to 126slbs) over
the
last several months. This was intentional weight loss. Her
first fall episode occurred in the setting of this weight loss.
She felt that the first fall event occurred almost after all of
her weight loss had been achieved.
With regards to this most recent fall, she has been feeling well
other than a viral URI recently (cough, phlegm, weakness). She
feels her cold had been improving. On ___, she noted
attempting to go down the stairs of her home. She went down 2
steps. The next thing she remembers are fireman surrounding
her.
Her ___ was at home at the time and noted that
___
had lost consciousness. Her fall was not witnessed. She denies
any warning signs including lightheadedness, dizziness,
pre-syncope, or the feeling of weakness she normally notes.
On presentation to an OSH, ___ showed small subdural along the
falx. Pt. was transferred for neurosurg eval which recommended
clinical observation. No surgical indication was recommended.
Otherwise, she denies any chest pain, dyspnea, lightheadedness,
dizziness, pre-syncope, syncope, palpitations, orthopnea, PND,
or
___ edema.
Past Medical History:
CAD s/p MI and CABG ___ at ___, unknown anatomy)
DM2 (diet controlled-off metformin x8mo after A1C returned at 5)
COPD (no hx. of smoking0
Chronic Kidney failure (baseline Cr of 2.5-3.2)
Social History:
___
Family History:
No family history of coronary artery disease, congestive heart
failure, sudden death, arrhythmia. She does note a strong
history of DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.9; 166/77; 69; 18; 97 RA
Gen: Pleasant, NAD
HEENT: NC/AT. EOMI. MMM
CV: RRR. No MRG
Pulm: CTAB. No w/r/r
Abd: Soft, NTND. No HSM appreciated
Ext: Trace ___ edema
Skin: Well-healing pressure ulcer on Left heel
Neuro: CNII-XII gross intact.
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: 99.5 159-187/68-75 HR 72 RR 16 96 RA
EKG: first degree AV block, p waves present
GENERAL: Alert, oriented, sitting up
HEENT: pupils round and reactive, atramatic head, moist mucous
membranes
NECK: JVP about 8 cm, no lymphadenopathy
LUNGS: clear to auscultation bilaterally
CV: regular rate/ rhythm, normal S1 S2, no murmurs
ABD: soft, non-distended, bowel sounds present, no guarding
EXT: Warm, well perfused, strength intact ___ UE and ___, left
heel ulcer dry and intact, healing, without purulence
Pertinent Results:
ADMISSION LABS:
================
___ 01:07AM BLOOD WBC-9.3 RBC-3.07* Hgb-9.2* Hct-28.7*
MCV-94 MCH-30.0 MCHC-32.1 RDW-14.0 RDWSD-47.5* Plt ___
___ 01:07AM BLOOD Glucose-119* UreaN-74* Creat-3.7* Na-134
K-5.3* Cl-105 HCO3-17* AnGap-17
___ 06:34AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.8
___ 01:07AM BLOOD cTropnT-0.02*
___ 01:07AM BLOOD Hapto-168
DISCHARGE LABS:
================
___ 06:57AM BLOOD WBC-8.9# RBC-2.73* Hgb-8.3* Hct-26.1*
MCV-96 MCH-30.4 MCHC-31.8* RDW-14.5 RDWSD-50.4* Plt ___
___ 06:57AM BLOOD Glucose-113* UreaN-63* Creat-3.4* Na-139
K-5.0 Cl-110* HCO3-14* AnGap-20
IMAGING:
===========
TTE ___
IMPRESSION: Suboptimal image quality. No structural cardiac
cause of syncope identified. Mild symmetric left ventricular
hypertrophy with preserved global systolic function. Technically
suboptimal to exclude focal wall motion abnormality. Mild
pulmonary hypertension.
CT-Torso w/o con ___
1. No evidence of acute intrathoracic or intraabdominal injury
within the limitation of an unenhanced scan. No acute fracture
is identified.
2. Mild subpleural ground-glass opacities are seen the left
upper lobe, possibly mild pulmonary contusion.
3. Diverticulosis is noted in the descending and sigmoid colon,
without evidence of acute diverticulitis.
CT-head w/o con ___ (___)
Impression: There is a submilliliter subdural hemorrhage along
the falx between the frontal lobes. There is atrophy and changes
consistent with small vessel ischemic disease. The patient was
subsequently transferred to ___.
CT-C spine ___ (___): Impression: Marked degenerative
changes. No fracture.
EKG: HR 65, NA, PR 217, no ischemic changes
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of CAD and MI
s/p CABG ___ at ___, anatomy unknown), CKD, DM2, COPD and
frequent falls previous negative work-up who presents with fall
found to have subdural hematoma. Her subdural hematoma did not
need any surgical intervention. Pt. has had 6 fall events. The
first 5 seem to be clearly mechanical events preceded by
weakness. This fall is the first fall to have led to loss of
consciousness.
#Bradycardia: On telemetry, she was noted to have episodes of
bradycardia to ___ with pauses, rhythm most consistent with
first degree AV block. Given falls, EP was consulted as her most
recent episode is somewhat concerning for cardiac etiology. She
likely has time. Mobitz 1 and sinus slowing likely due to
increased vagal tone. For this they recommended ___ of Hearts
monitoring and outpatient followup. They recommended continuing
metoprolol tartrate 12.5 mg BID, with outpatient followup.
#Anemia: She had mild Hct drop from 28.7 to 24.7 in the ED in
the setting of IVF resuscitation. Has known anemia, most likely
___ CKD, previously on Procrit. Pt's most recent Hb 6.5-8.5 in
___ at ___. No evidence of bleeding while
inpatient.
# Fall, possible syncope: Patient did not remember the events
that led to her fall. She was walking down her stairs when she
suddenly woke up surrounded by medical providers. It is possible
that her loss of memory was due to her head strike, however she
may have also had true syncope. As above, her her findings of
bradycardia this was concerning for cardiac etiology. EP
recommended downtitrating metoprolol and placement ___ of
Hearts monitor prior to considering permanent pacemaker
placement. She will follow up with them as an outpatient.
#Subdural Hematoma: Assessed by neurosurgery for small falx
subdural hematoma, with no need for intervention.
#CKD: Her bicarbonate was noted to be low to 14, likely from
CKD, no other source of acidosis, so she was started on sodium
bicarbonate with instructions to follow up with renal. It is
unclear whether she was taking sodium bicarbonate previously and
why it was stopped.
#HTN: Home amlodipine and imdur, metoprolol started at lower
dose (25 BID to 12.5 BID) given concern for bradycardia
#CAD s/p CABG ___: continued home statin. She does not see a
cardiologist, thus EP appointment made, with further plans for
regular outpatient cardiology followup.
#Depression: continued home wellbutrin, fluoxetine
TRANSITIONAL ISSUES:
========================
-New medications:
Sodium Bicarbonate 650 mg twice a day
-Changed medications:
Metoprolol 25 mg changed to HALF a tablet= 12.5 mg , twice a day
-Please repeat labs at next PCP ___ (___). For reference
discharge Hgb 8.3, WBC 8.9, K 5, Bicarb 14, and creatinine 3.4.
-Discharge with ___ of hearts event monitor for 4 weeks in
attempt to capture rhythm information during a fall episode
-Consideration of pacemaker in the future if evidence of
arrhythmia correlating with fall episodes
-Renal followup should be pursued given chronic anemia and
chronic acidosis with discharge bicarbonate of 14
-Patient with small falx subdural hematoma not requiring
intervention. Please repeat imaging if worsening neurological
symptoms
-For your records, echo done with EF>55%, no structural cardiac
cause of syncope identified.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 25 mg PO BID
2. amLODIPine 10 mg PO DAILY
3. Calcitriol 0.25 mcg PO 3X/WEEK (___)
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. FLUoxetine 40 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Ferrous Sulfate 325 mg PO HS
9. Atorvastatin 20 mg PO QPM
10. Docusate Sodium 100 mg PO BID
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Sodium Bicarbonate 650 mg PO DAILY
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*30 Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. BuPROPion XL (Once Daily) 150 mg PO DAILY
6. Calcitriol 0.25 mcg PO 3X/WEEK (___)
7. Docusate Sodium 100 mg PO BID
8. Ferrous Sulfate 325 mg PO HS
9. FLUoxetine 40 mg PO DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
-Mechanical Fall
-Subdural Hematoma
-First degree AV block
Secondary:
-CAD s/p CABG
-COPD
-Chronic kidney disease
-Diabetes Type II
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on ___ after you fell and were
found to have a small bleed in your head. The brain surgeons did
not feel any surgery was needed and the bleed will resolve over
the time.
Your heart monitoring showed some slowing of your heart which
could explain some of your falls. We had the heart rhythm
doctors (___) see you here and they recommended
you wear the heart monitor given to you for FOUR (4) Weeks and
follow up with them then (Dr. ___.
They will also help you set up with a cardiologist.
It is important you see your PCP on ___ and have your
labs checked and then have followup with your kidney doctor.
Best wishes
Your ___ Care team
Followup Instructions:
___
|
19738950-DS-18
| 19,738,950 | 22,810,590 |
DS
| 18 |
2110-12-19 00:00:00
|
2110-12-19 17:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
sulfa / labetalol / metoprolol / Levaquin / methyldopa /
sulfamethoxazole / trimethoprim
Attending: ___
Chief Complaint:
Nausea, vomiting, chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with H/O CAD s/p CABG ___, paroxysmal atrial fibrillation
on apixaban (Eliquis), S/P pacemaker for sick sinus syndrome,
ESRD on HD ___, presenting with chest pressure, nausea,
vomiting with elevated troponin-T.
Patient states he has had ongoing left shoulder and left sided
rib pain s/p recent fall. He was discharged from the
___ 3 days ago to a
rehabilitation facility for this pain. On the day of admission,
he had nausea, lightheadedness, and left sided chest pressure as
well. Chest discomfort was exertional, dull, achy, persistent,
___ in intensity, with associated nausea, vomiting, and
diaphoresis. Patient is unsure if chest pressure is similar or
different from prior anginal discomfort and shoulder pain. The
patient's chest pain began at his assisted living facility when
he was eating and swallowed food. EMS was called and took the
patient to ___ where patient was found to have
ventricularly paced rhythm. Troponin-T at ___ was elevated
at 0.18. Patient was given ___ 325 mg, morphine 6 mg,
ondansetron and started on nitroglycerin gtt. Patient was
ordered for a clopidogrel loading dose, but he was vomiting and
did not receive this. Patient generally receives care at ___ but
was transferred to ___ for further care as ___ was reportedly
full.
In the ED, initial vitals were Pain 2, T 97.1, HR 77, BP 136/76,
RR 20, SaO2 100% on Nasal Cannula. Labs notable for WBC of 5.7,
Hgb/Hct 9.2/28.9, Plt 120, INR 1.6, Chem 7 with Cr 6.2.
Troponin-T 0.14. Lacate 1.4. EKG notable for ventricular paced
rhythm with isolated native QRS in V2-3 ___epression and T
wave inversions. Patient given ondansetron and started on Hep
gtt. Nitro gtt continued which was started at ___.
Patient was unable to take clopidogrel due to nausea; also did
not take atorvastatin or beta ___ in ED. Patient also given
lorazepam for unclear reasons. Patient also vomited several
times in ED and there was concern for aspiration as patient with
O2 requirement. He was seen by cardiology in ED who recommended
heparin gtt, clopidogrel load, beta ___, and statin and
admission to ___ Service vs CCU depending on amount
of nitro gtt.
On arrival to cardiology floor, patient was resting comfortably.
He stated that pain had improved to ___. Otherwise, patient
fatigued and not overly cooperative with interview though
pleasant.
Past Medical History:
- Hypertension
- CAD s/p CABG ___
-- TTE ___ at ___: Left atrial enlargement, trace mitral
regurgitation. Aortic sclerosis without stenosis. LVEF 43% with
diffuse hypokinesis, LV dilatation. Normal RV. Unable to assess
PASP. Decreased LVEF from ___.
-- Coronary angiogram ___ at ___ as part of renal transplant
evaluation (TnT 0.12, 0.18, 0.22): right dominant. LAD mid
occluson after D1. D1 iregular with diffuse 60%. Distal LAD and
D2 supplied by patent LIMA. ___ CX 60%. Mid CX occluded after
OM1. OM2 and OM3 fed by patent sequential SVG-OM2-OM3 with
retrograde filling of the CX. RCA mid 90%, RPL1 60% ostial. RPDA
and AM branches supplied by patent sequential SVG-AM-RPDA.
- S/P PPM implantation
- ESRD on HD MWF
- ___ Disease
- Gout
- Iron Deficiency Anemia
Social History:
___
Family History:
non-contributory
Physical Exam:
On admission
General: Tired-appearing elderly white man, lying in bed, easily
arousable and responding appropriately but speaks with eyes
closed
Vitals: T 97.3; BP 142/68; HR 63; RR 18; SaO2 100% on 2 Lpm on
admit
Weight on admission: 73.9 kg
HEENT: NCAT. PER, EOMI. MMM.
Neck: No LAD, JVP not appreciated
CV: RRR; no murmurs, rubs or gallops
Lungs: CTA in anterolateral fields. Patient unable/too weak to
sit up to allow auscultation of posterior lung sounds
Abdomen: BS+. Non-tender, non-distended. No HSM appreciated
Extr: Warm and well perfused. No Peripheral Edema. LUE fistula
with palpable thrill.
Neuro: A&Ox3. Flat facies. Moving all extremities.
Skin: Excoration along Left calf, no other lesions noted
At discharge
Vitals: T= 97.7 BP 119-151/61-91 HR ___ RR 20 SAO2 97% on
RA
Weight: 73.3 kg
Exam otherwise unchanged from admission, but patient more
conversant and awake
Pertinent Results:
___ 04:00PM BLOOD WBC-5.7 RBC-2.83* Hgb-9.2* Hct-28.9*
MCV-102* MCH-32.5* MCHC-31.8* RDW-14.2 RDWSD-52.8* Plt ___
___ 04:00PM BLOOD Neuts-84.6* Lymphs-8.1* Monos-5.8
Eos-0.9* Baso-0.4 Im ___ AbsNeut-4.83 AbsLymp-0.46*
AbsMono-0.33 AbsEos-0.05 AbsBaso-0.02
___ 04:00PM BLOOD ___ PTT-35.4 ___
___ 04:00PM BLOOD Glucose-138* UreaN-41* Creat-6.2* Na-137
K-4.1 Cl-97 HCO3-30 AnGap-14
___ 04:00PM BLOOD CK(CPK)-44* CK-MB-3 cTropnT-0.14*
___ 02:10AM BLOOD CK-MB-3 cTropnT-0.16*
___ 05:17AM BLOOD cTropnT-0.15*
___ 04:45AM BLOOD CK-MB-2 cTropnT-0.16*
___ 12:50PM BLOOD HCV Ab-NEGATIVE
___ 12:50PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE
___ 04:45AM BLOOD WBC-4.3 RBC-2.85* Hgb-8.9* Hct-29.2*
MCV-103* MCH-31.2 MCHC-30.5* RDW-14.2 RDWSD-53.2* Plt ___
___ 04:45AM BLOOD ___ PTT-31.3 ___
___ 04:45AM BLOOD Glucose-100 UreaN-40* Creat-6.5*# Na-137
K-4.2 Cl-96 HCO3-29 AnGap-16
___ 04:45AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.4
ECG ___ 3:47:36 ___
Artifact is present. Regular ventricular pacing with occasional
native ventricular conduction. Underlying atrial fibrillation.
Limited evaluation of native ventricular conduction shows
diffuse ST-T wave changes. No previous tracing available for
comparison.
ECG ___ 5:32:44 ___
Baseline artifact. Atrial fibrillation or atrial flutter with a
variable response. The first beat is probably ventricular. Q
waves in leads V1-V2. Consider septal myocardial infarction.
ST-T wave abnormalities. On the tracing of ___ the rate was
slower and flutter waves were present. Then, there was
ventricular pacing at a rate of 70. At 70, there were fusion
complexes. Thus, compare to the previous tracing the ventricular
rate has increased and is more irregular. Clinical correlation
is suggested. There are no ventricular paced beats on the
present tracing.
ECG ___ 9:25:20 ___
Atrial flutter with variable block. Compared to the previous
tracing the rate is lower. However, not slow enough for
ventricular pacing. The pacing demand rate was decreased. Since
there is conduction with cycle lengths of one second.
CHEST (PORTABLE AP) ___ 7:04 AM
Heart size and mediastinum are unchanged including cardiomegaly.
There is interval increase in right pleural effusion, currently
large. There is mild vascular congestion but no overt pulmonary
edema noted. No pneumothorax.
Vasodilator nuclear pharmacological stress test ___
This ___ year old man with a history of HTN, HL, ESRD s/p CABG
and pacemaker in ___ was referred to the lab for evaluation of
chest discomfort. The patient was infused with 0.142 mg/kg/min
of dipyridamole over 4 minutes. No arm, neck, back or chest
discomfort was reported by the patient throughout the study. The
baseline EKG showed atrial flutter, 3:1 block, ivcd rbbb type
ventricular pacing rates, less than 60 with nssttws making the
ST segments uninterpretable. Occasional isolated vpbs were
observed throughout the study. Appropriate hemodynamic response
to the infusion and recovery. The dipyridamole was reversed with
125 mg of aminophylline IV. IMPRESSION: No anginal type symptoms
or interpretable ST segments.
IMAGING: The image quality is adequate but limited due to soft
tissue and left arm attenuation. Left ventricular cavity size is
increased.
Rest and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal septal akinesis with normal thickening,
consistent with ventricular pacing and or prior cardiac surgery.
There remaining segments are hypokinetic. The calculated left
ventricular ejection fraction is 35% with an EDV of 193 ml.
IMPRESSION:
1. Normal myocardial perfusion.
2. Increased left ventricular cavity size. Moderate systolic
dysfunction with global hypokinesis.
Echocardiogram ___
The left atrium is mildly dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is moderate regional
left ventricular systolic dysfunction with hypokinesis of the
septal, inferior, and inferolateral segments; the anterior and
anterolateral segments contract best. The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
[Due to acoustic shadowing, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Moderately depressed regional left ventricular
systolic function consistent with multivessel coronary artery
disease. Mildly hypokinetic right ventricle. At least moderate
tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension.
Brief Hospital Course:
___ with H/O CAD s/p CABG ___ (3 origins, 5 touchdowns), S/P
pacemaker for sick sinus syndrome, paroxysmal atrial
fibrillation on apixiban, ESRD on HD ___, presenting with
chest pressure, nausea, vomiting and stable elevation in
troponin-T.
# Chest pain: Patient reported chest and left arm pain in the
setting of history of CAD and CABG but also recent fall and left
upper extremity injury. His intermittent left arm pain was
sometimes provoked by movement and positioning of his arm, but
not consistently reproducible by palpation. His troponins were
not uptrending and thus were not consistent with ACS and more
likely due to impaired renal clearance given his ESRD.
Vasodilator nuclear stress test showed uniform perfusion,
consistent with either no significant ischemia or global
ischemia. His LVEF was depressed to 35% on both the MIBI and
echocardiogram. However, review of his ___ records from a year
ago showed LVEF 43% at that time on echocardiogram with patent
LIMA-LAD, SVG-OM2-OM3 and SVG-AM-RPDA. Given the anticipated
lifelong patency of his LIMA and relative stability of his LVEF,
the imaging was felt to be more consistent with no significant
ischemia rather than interval loss of all 3 bypass grafts
(including the previously patent LIMA). Given known native three
vessel CAD, he was started on atorvastatin 80 mg, aspirin, and
isosorbide mononitrate. He was briefly on clopidogrel for
presumptive ACS, but this was stopped when it was decided he
likely did not suffer a myocardial infarction and coronary
angiography with PCI was not anticipated. The recommendations
for medical therapy were reviewed with Dr. ___ he was in
agreement. Given documentation of left ventricular systolic
heart failure, his diltiazem was discontinued and his metoprolol
succinate increased.
# Hypertension: He was continued on losartan, increased beta
___ as above, and diltiazem was discontinued.
# Atrial fibrillation, paroxysmal: Patient bridged with heparin
gtt and restarted on apixiban. His metoprolol succinate was
increased.
# PPM for SSS: Patient's family noted patient to have HR 40's
prior to event. Pacemaker was interrogated by the
Electrophysiology Service, and no anomalies were seen. Of note,
the device's memory was purged during the interrogation, but the
programmer ran out of paper before all the findings could be
printed. The findings were saved to a flash drive, but as of the
time of this dictation, the EP Service had been unable to
recover useful data from the interrogation from the flash drive
and was awaiting further assistance from the manufacturer's
technical representative. The patient had intermittent
ventricular pacing, and it was unclear if the repolarization
abnormalities seen on his intervening non-paced QRS complexes
were cardiac memory vs. primary ischemic changes vs.
non-specific primary changes.
# Left ventricular systolic heart failure: LVEF now down to 35%.
The patient did not appear to be fluid overloaded, although
admission CXR showed mild vascular congestion but no overt
pulmonary edema. ___ CXR showed mild CHF with prominence
of the upper zone blood vessels. NT-Pro-BNP was not assayed.
Patient's fluid status was managed by hemodialysis.
CHRONIC ISSUES:
# ___ Disease: Patient was continued on home
cabidopa/levodopa ___ q4H when awake and neupro transdermal
patch
# ESRD: Patient continued hemodialysis on ___ and
___. He also continued Nephrocaps and Calcium Acetate
# COPD: Patient briefly on oxygen at admission which was quickly
weaned to room air. He was given duonebs.
# Gout: Patient was continued on allopurinol ___ mg daily
#Transitional issues
-New medications: aspirin, atorvastatin, Imdur, sublingual
nitroglycerin
-New doses: metoprolol increased to 150 XL daily
-TTE on admission showing EF 35% which will need to be followed
up by outpatient primary cardiologist
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 240 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Calcium Acetate 1334 mg PO TID W/MEALS
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Apixaban 5 mg PO BID
7. Carbidopa-Levodopa (___) 1 TAB PO 6X/DAY
8. Nephrocaps 1 CAP PO DAILY
9. Iron Polysaccharides Complex ___ mg PO DAILY
10. Allopurinol ___ mg PO DAILY
11. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pain
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
13. rotigotine 3 mg/24 hour transdermal DAILY
14. Senna 8.6 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Apixaban 5 mg PO BID
3. Calcium Acetate 1334 mg PO TID W/MEALS
4. Carbidopa-Levodopa (___) 1 TAB PO 6X/DAY
5. Losartan Potassium 100 mg PO DAILY
6. Metoprolol Succinate XL 150 mg PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. rotigotine 3 mg/24 hour transdermal DAILY
10. Senna 8.6 mg PO BID
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 80 mg PO QPM
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN pain
14. Iron Polysaccharides Complex ___ mg PO DAILY
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
16. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pain
17. Acetaminophen 650 mg PO Q6H:PRN pain, fever
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Chest pain
-Left upper extremity pain
-Coronary artery disease
-Abnormal troponin-T attributed to abnormal renal clearance due
to
-End stage renal disease, on hemodialysis
-Atrial fibrillation, on
-Low term use of oral anticoagulants
-Acute systolic and diastolic left ventricular heart failure
-Hypertension
-Gout
-Ventricular demand pacing
-Reactive airway disease
-___ Disease
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with arm pain and chest pain that was
concerning for a heart attack. You had a stress test which
showed no perfusion defects but did show worsened pump function.
You will need to follow up with your cardiologist in the next
two weeks. You were started on several new medications as
outlined below.
It was a pleasure to care for you
-Your ___ Team
Followup Instructions:
___
|
19739384-DS-25
| 19,739,384 | 26,638,931 |
DS
| 25 |
2141-01-20 00:00:00
|
2141-01-21 09:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lisinopril / Morphine / oxycodone-acetaminophen /
Shellfish Derived
Attending: ___.
Chief Complaint:
Word finding difficulty, hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old female with history of ESRD on
HD, diabetes, hemochromatosis, and cardiomyopathy who was
brought to the ___ (transferred from ___ today with
expressive aphasia, and right face/bilateral hand numbness and
tingling which started this morning at 5 am. She additionally
reported headache, nausea, and vomiting on arrival to the OSH
___. She was scheduled for dialysis today which she did not go to
. At the OSH head CT was without acute change but was
transferred to ___ with concern for acute stroke. On arrival
to the ___ she c/o ___ sharp abdominal pain and intermittent
chest pain. She was nauseated earlier, but reported resolution
of this after administration of ketorolac and zofran. Her
word-finding difficulties and numbness/tingling of her face have
improved, but not completely resolved. She denies any weakness.
No recent diarrhea. She reports having migraines in the past,
but not for the past ___ years. These were characterized by
unilateral pain and no symptoms associated with complex
migraines. Her current headache does not feel like her prior
migraines.
.
In the ___, initial VS: 98.2 77 179/97 20 97% RA. She was given
calcium gluconate, dextrose, and insulin. CT abd/pelvis was
negative preliminarily. Renal evaluated patient and recommended
2 hours of HD in her room tonight with full session tomorrow.
Neuro who recommended urgent MRI head/neck after HD session to
___ eval for stroke. Vitals prior to transfer 98.7 175/87 94
16 98 ra.
.
Currently, she is feeling well with no pain or discomfort. Has
nausea in her abdomen but no pain. She is still having some word
finding difficulties, although she reports that it is improved
since this AM. Only mild ___ headache at this time which is
bifrontal.
.
ROS: Denies fever, chills, night sweats, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- ESRD due to Hypertension, diabetes, HD since ___ MWF, left AV
fistula
- Hemochromatosis with grade 1 varices and cirrhosis.
- Diabetes type 2, on insulin.
- Osteoporosis.
- C. diff infection.
- Cardiomyopathy, followed by Dr. ___.
- Drop attacks and falls.
Social History:
___
Family History:
DM - in mother and 1 sisters. 2 sisters and mom passed away
young.
Physical Exam:
Admission exam:
VS - BP 173/68 HR 96 RR 16 SpO2 95/RA
___
GENERAL - comfortable, NAD
HEENT - NC/AT, pupils equal and symmetric, minimally reactive
NECK - plethoric, unable to assess JVP
LUNGS - CTA bilat, no r/rh/wh
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT, obese
EXTREMITIES - WWP, chronic venous stasis changes bilat, dry skin
and 1+ non-pitting edema of the ___
___ - awake, A&Ox3. Able to name simple objects. Has
non-fluent speech and some word finding difficulty. CNs II-XII
intact, muscle strength ___ throughout, sensation grossly intact
throughout. Finger-to-nose with mild dysmetria bilaterally, L>R.
Other cerebellar signs wnl.
Discharge exam - unchanged from above, except as below:
NEURO - word finding difficulties still present but somewhat
improved
Pertinent Results:
Admission labs:
___ 05:20PM BLOOD WBC-8.8 RBC-4.26 Hgb-10.6* Hct-35.9*
MCV-84 MCH-25.0* MCHC-29.7* RDW-16.4* Plt ___
___ 05:20PM BLOOD Neuts-85.6* Lymphs-7.6* Monos-4.9 Eos-1.5
Baso-0.4
___ 05:20PM BLOOD ___ PTT-29.8 ___
___ 01:25PM BLOOD Glucose-313* UreaN-48* Creat-7.0*#
Na-131* K-6.2* Cl-91* HCO3-23 AnGap-23*
___ 01:25PM BLOOD ALT-13 AST-23 CK(CPK)-98 AlkPhos-80
TotBili-0.3
___ 01:25PM BLOOD Lipase-81*
___ 01:25PM BLOOD CK-MB-3 cTropnT-0.09*
Discharge labs:
___ 09:45AM BLOOD WBC-7.2 RBC-4.17* Hgb-10.8* Hct-35.1*
MCV-84 MCH-25.8* MCHC-30.6* RDW-16.4* Plt ___
___ 09:45AM BLOOD Glucose-260* UreaN-40* Creat-6.2* Na-136
K-4.7 Cl-93* HCO3-28 AnGap-20
___ 09:45AM BLOOD Triglyc-152* HDL-23 CHOL/HD-5.6
LDLcalc-75
Micro:
-BCx (___): NGTD
Imaging:
-CXR (___): Mild cardiomegaly. No evidence of acute
disease.
-CT abd/pelvis (___):
1. No evidence of diverticulitis, colitis, or obstruction. No
findings to explain patient's symptoms.
2. Atrophic kidneys bilaterally.
MRI/MRA head/neck (___):
FINDINGS: A small focus of hyperintensity in the left centrum
semiovale
periventricular white matter on diffusion images is not
corresponding to any ADC abnormality and likely due to a
subacute infarct. There are moderate white matter changes seen.
Moderate brain atrophy identified. No midline shift or
hydrocephalus seen. There are no chronic microhemorrhages.
MRA of the head demonstrates normal flow signal in the arteries
of anterior and posterior circulation without stenosis,
occlusion or aneurysm greater than 3 mm in size.
IMPRESSION: Small subcortical signal abnormality in the left
periventricular white matter on diffusion images does not have
corresponding ADC abnormalities and is likely due to subacute
infarct. Moderate small vessel disease and brain atrophy.
Normal MRA.
Brief Hospital Course:
___ year-old female with history of ESRD on HD, diabetes,
hemochromatosis, and cardiomyopathy presenting to ___ with
expressive aphasia, R face/bilat hand numbness and tingling of
unclear etiology. Patient additionally has significant abdominal
pain, nausea, and chest pain.
# Subacute stroke and expressive aphasia: Patient initially
presented to the Miltol ___ where she had a head CT showing old
infarcts but no acute changes and no bleed. Given her ongoing
expressive aphasia, she was transferred to ___ for further
neuro evaluation. She was seen by neurology in the ___ who
initially felt that her symptoms were ___ a complex migraine,
however her headache was bifronatal and she hasn't had a
migraine in over ___ years. Additionally, her prior migraines
felt different from her current headache (unilateral, throbbing)
and she never had complex migraines in the past. No further
head imaging was obtained in the emergency room and the patient
was admitted to the floor where she had an urgent MRI/MRA of the
head/neck which showed a subacute stroke in the left
periventricular white matter which was thought to be many days
old. It was also thought that her concurrent metabolic
derangements contributed to her neurologic deficits from her
subacute stroke. Her symptoms had improved prior to discharge.
Her blood pressure was allowed to autoregulate and at discharge
she will continue her home antihypertensive regimen. She is
already on ASA and statin and lipid panel was sent at discharge
to assess for optimal medical management. She will follow-up
with her PCP after discharge.
# ESRD/HD and hyperkalemia: She was hyperkalemic to 7.0 in the
___ at admission and received insulin in the ___. No changes on
EKG consistent with hyperkalemia. She missed her HD session on
the day of admission because she came to the ___ for her
expressive aphasia. She received a 2 hour HD session on the
medical floor with improvement in her potassium to 4.7
# Abd pain: She had vague abdominal pain and nausea while in the
emergency department. For unclear reasons, she had a CT
abd/pelvis in the ___ which was unremarkable. Her pain resolved
by the time she arrived to the medical floor.
# Chest pain: She also had some vague chest pain in the
emergency room which had resolved by the time she arrived to the
floor. Her trop was at baseline given her ESRD and there were
no significant EKG changes.
--Inactive issues--
# Anemia: Hct remained at ___.
# Erythema over fistula site: She had been receiving vancomycin
at her outpatient ___ clinic which was continued during her
HD session this admission.
# Code status this admission: FULL (confirmed)
#Transitional issues:
-Follow-up lipid panel which is pending at discharge, adjust
statin dose as indicated
-F/u blood cultures pending at discharge
-Will follow-up with ___ clinic
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Nephrocaps 1 CAP PO DAILY
2. insulin glargine *NF* 30 units Subcutaneous At bedtime
3. Labetalol 300 mg PO BID
4. sevelamer HYDROCHLORIDE *NF* 800 mg Other Three times per day
5. Simvastatin 20 mg PO QHS
6. Acetaminophen 1000 mg PO DAILY:PRN pain
7. Aspirin 81 mg PO DAILY
8. Bisacodyl ___ mg PO DAILY:PRN constipation
9. Omeprazole 20 mg PO DAILY
10. Vancomycin Dose is Unknown IV HD PROTOCOL Duration: 7 Days
Per outpatient ___ clinic
Discharge Medications:
1. Acetaminophen 1000 mg PO WITH HD
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___ mg PO DAILY:PRN constipation
4. Nephrocaps 1 CAP PO DAILY
5. Omeprazole 20 mg PO DAILY
6. sevelamer HYDROCHLORIDE *NF* 800 mg Other Three times per day
7. Simvastatin 20 mg PO QHS
8. Vancomycin 1000 mg IV HD PROTOCOL Duration: 7 Days
Per outpatient ___ clinic
9. insulin glargine *NF* 30 units Subcutaneous At bedtime
10. Labetalol 300 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Subacute stroke
Secondary diagnoses:
End stage renal disease
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your admission to
___ for difficulty speaking. You were found to have an old
stroke on your brain MRI which is likely more than 30 days old.
Your electrolyte abnormalities related to your kidney failure
likely exacerbated the neurologic symptoms from your recent
stroke. Your symptoms had improved at discharge.
No changes were made to your medications.
Followup Instructions:
___
|
19739460-DS-12
| 19,739,460 | 27,449,085 |
DS
| 12 |
2178-03-14 00:00:00
|
2178-03-17 13:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
pedestrian struck by vehicle
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___, is a ___ male with history of left MCA
infarct in ___, who has hit by an SUV while walking in front of
his house, and was transferred to ___ from ___
due to a T9 vertebral body fracture and a 3.7 x 2.7 cm hypodense
right lobe liver lesion concerning for laceration.
Past Medical History:
PMH: HTN, previous stroke (difficulty with reading and writing),
alchohol abuse
PSH: toe surgery
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Oropharynx within normal limits
Chest: Clear to auscultation
Abdominal: Soft, + RUQ tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
___: No petechiae
Discharge Physical Exam:
VS: Temp: 98.2 HR: 90, BP: 134/77, RR: 18, O2: 99% RA
Gen: A+Ox3, MAE
CV: RRR
Resp: CTA b/l
Back: TLSO brace applied
Extremeties: no edema
Pertinent Results:
- RIGHT SHOULDER XR ___: There is bony irregularity along the
superior aspect of the humeral head which is concerning for a
___ lesion. No definite glenoid fracture identified
although there is a subtle lucency along the inferior aspect of
the glenoid. No evidence of dislocation.
- CT HEAD AND C-SPINE ___: Head: There is no evidence of
acute territorial infarction, hemorrhage or large mass. Large
area of encephalomalacia in the territory of the left MCA is
compatible with old infarction. The ventricles and sulci are
otherwise normal in size and configuration. No osseous
abnormalities seen. The paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The orbits are unremarkable.
C-spine: Alignment is normal. No fractures are identified.
There is no prevertebral edema. Degenerative changes are noted
with disc height loss and posterior osteophytes, specifically at
C3-4 and C6-C7. Disc bulge at C3-4 effaces the ventral CSF and
causes at least mild canal narrowing. There is a 4 mm hypodense
left thyroid nodule. The lung apices are unremarkable.
IMPRESSION: No acute intracranial abnormality. Degenerative
changes without acute fracture or traumatic malalignment in the
cervical spine.
- CT TORSO ___: CHEST: The heart is unremarkable. The
ascending aorta measures 5.4 cm at the root. At the level of the
main pulmonary artery, the aorta measures 5.0 cm. Coronary
artery calcifications are mild. There is no mediastinal
hematoma. There is no pericardial effusion. There is no
lymphadenopathy. The imaged thyroid is unremarkable. Right
middle lobe peripheral nodular opacity measuring 11 x 9 mm is
associated with volume loss and suggestive of scarring, but
follow up chest CT is recommended in 3 months unless prior
imaging is available to document stability. The lungs are
otherwise clear without worrisome consolidation. Airways are
patent to the subsegmental level. There is no evidence of
contusion or laceration. There is no pneumothorax or pleural
effusion. ABDOMEN: The liver is intact without focal lesion of
signs of acute injury. The spleen is intact and normal in size.
The gallbladder, pancreas, and adrenals are unremarkable. The
kidneys enhance symmetrically and excrete contrast promptly
without focal lesion or hydronephrosis. There is no evidence of
renal or collecting system injury. The abdominal aorta is normal
in course and caliber with widely patent major branches. No
lymphadenopathy, free air, or free fluid. Peripheral
wedge-shaped hypodense lesion in the right lobe of the liver
with peripheral hyperdense components is worrisome for
laceration. Hyperdense component at the inferior margin
measuring 8 x 11 mm could be contrast extravasation versus
pseudoaneurysm. The stomach and small bowel are unremarkable.
PELVIS: The small bowel is unremarkable, without ileus or
obstruction. There is no evidence or bowel or mesenteric injury.
The colon is unremarkable. The appendix is normal. The bladder
is unremarkable. There is no pelvic free fluid. BONES:
Horizontally oriented lucency through the T9 vertebral body with
surrounding soft tissue density is compatible with acute
fracture with surrounding paraspinal hematoma. Significant
degenerative chagnes. No suspicious osseous lesion. IMPRESSION:
Hypodense lesion in liver. T9 fracture. Nonurgent pleural based
nodule may be scarring. Aneurysmal dilation of aorta.
___ 05:16PM HCT-39.6*
___ 02:30PM WBC-6.5 RBC-4.12* HGB-13.2* HCT-39.6* MCV-96
MCH-32.0 MCHC-33.3 RDW-14.8 RDWSD-52.7*
___ 02:30PM PLT COUNT-203
___ 01:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 01:30PM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 01:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:30PM URINE RBC-5* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:30PM URINE MUCOUS-RARE
___ 08:20AM UREA N-14 CREAT-1.0 SODIUM-141 POTASSIUM-4.1
CHLORIDE-104 TOTAL CO2-21* ANION GAP-20
___ 08:20AM ALT(SGPT)-27 AST(SGOT)-29 ALK PHOS-58 TOT
BILI-0.6
___ 08:20AM ALBUMIN-4.2 CALCIUM-9.8 PHOSPHATE-4.4
MAGNESIUM-1.9
___ 08:20AM ASA-NEG ETHANOL-51* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 08:20AM WBC-5.0 RBC-4.19* HGB-13.7 HCT-40.8 MCV-97
MCH-32.7* MCHC-33.6 RDW-14.9 RDWSD-53.1*
___ 08:20AM PLT COUNT-248
___ 08:20AM ___ PTT-25.9 ___
Brief Hospital Course:
Mr. ___ is a ___ male with past history of a left MCA infarct
in ___ (on plavix), who presented to ___ on ___ as a
transfer from ___ after trauma, being hit by an
SUV while walking. Initial findings on his CT torso demonstrated
a hypodensity in the right lobe of the liver with pooling of
hyperdense material, thought to be a liver laceration. The
patient also sustained a T9 fracture. Upon arrival to ___ he
had a GCS of 15 and was hemodynamically stable. An ___ consult
was called for possible hepatic embolization, however, they felt
that given the lack of right upper quadrant pain, the stable
vital signs, and the indeterminate nature of the findings in the
liver (suggestive that this may be an atypical hemangioma),
there was no need for intervention. The Spine team was consulted
for his T9 vertebral body fracture and they recommended
nonoperative management with a TLSO brace x8 weeks. Mr. ___
was initially admitted to the ___ for close hemodynamic
monitoring and q6h Hct checks. His Plavix was held and he was
given no pharmacological DVT ppx due to concern for potential
bleeding. He had some complaints about right shoulder pain, so
plain films were obtained which revealed a ___ fracture.
Ortho was consulted for management, and they deemed his injury
to be nonoperative in nature, and recommended a sling for
comfort.
Mr. ___ remained completely stable the first 24 hours in the
hospital, so he was transferred from the TSICU to the floor on
hospital day 2. He was given a regular diet.
Since being on the step-down surgical floor, the patient
remained stable. He was ambulating independently and therefore
did not have require a session with the Physical Therapy team.
The patient was alert and oriented throughout hospitalization;
pain was managed with oral oxycodone. The patient remained
stable from a cardiovascular standpoint; vital signs were
routinely monitored. The patient remained stable from a
pulmonary standpoint. Good pulmonary toilet, early ambulation
and incentive spirometry were encouraged throughout
hospitalization.
The patient tolerated a regular diet. His 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's Plavix was held due to concern for risk of
bleeding, but the patient was instructed he may resume this home
medication one day following discharge. ___ 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:
Lisinopril 40 mg daily, Plavix 75 mg daily, Simvastatin 40 mg
daily, Sertraline 50 mg daily, Keppra 1000 QAM, 500 QPM,
Claritin 10 mg daily, Metoprolol ER 50 mg daily, Symbicort 1
puff BID, Naproxen 500 mg BID PRN pain
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Nicotine Patch 14 mg TD DAILY
4. Sertraline 50 mg PO DAILY
5. Simvastatin 40 mg PO QPM
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do NOT drive or drink alcohol while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
7. Lisinopril 40 mg PO DAILY
8. LeVETiracetam 1000 mg PO QAM
9. LeVETiracetam 500 mg PO QPM
10. Loratadine 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
T9 fracture, 4cm liver laceration, Right shoulder ___
fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You presented to ___ on ___ with complains of abdominal
pain after being struck by a car while walking. You were found
to have a liver laceration and a fracture of your spine at
___. You also complained of right shoulder pain
and had images which were negative for any acute injury.
You were admitted to the Trauma/Acute Care Surgery team for
further medical care. You were seen by the Orthopaedics team
for your right shoulder and no surgical intervention was needed.
If you still experience pain after discharge, you may call the
___ clinic for a follow-up appointment.
You were also seen by the Neurosurgery team and they recommended
that you continue to wear your TLSO brace at all times when
sitting up at higher than 45 degrees or while walking. You will
follow-up with the ___ clinic and will need CT scan of
your Thoracic Spine prior to this appointment. Please call the
___ clinic at ___ for any questions.
For your liver laceration, it is recommended you have an
oupatient MRI with and without contrast. You may schedule this
within the next 2 weeks. The phone number is: ___.
You are tolerating a regular diet, your pain is controlled with
oral medication and you are ambulating. You may resume your
home Plavix tomorrow (___). You are now medically cleared
to be discharged to 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:
___
|
19739825-DS-21
| 19,739,825 | 24,742,053 |
DS
| 21 |
2110-07-10 00:00:00
|
2110-07-10 17:02:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fever, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with h/o OSA (untreated) and
post-operative paroxysmal afib who p/w 5 days of ILI and
dizziness.
Patient reports that last week, his wife was quite ill and so on
___, he called out of a meeting to help take care of her. By
___, he was feeling quite poorly. On ___, he measured
a temperature of ___. He had significant headache and
productive cough. He endorses some myalgias. On ___, his
temperature persisted to 101.5. By ___, it seemed as though
his fever had broken. As his fever had gone, he felt confident
enough to try shoveling snow. He went to a job site and shoveled
snow with a snow blower and by hand. On ___ morning, he awoke
drenched in sweat. He tried to go stand to go to the bathroom
but felt extremely dizzy and felt as though he might faint. In
order to prevent this, he "dove" on the carpet in his bedroom.
He had another few episodes of dizziness while lying down on the
carpet. His wife then called ___ to come help him. Patient
denies any nausea or vomiting or diarrhea during these past few
days. He denies any chest pain or difficulty breathing. He
denies any palpitations.
In the ED, initial vitals were 97.4 129 ___ 18 99% RA
- On arrival to the ED, he was noted to be in rapid atrial
fibrillation in the 100s-140s. Labs significant for positive
influenza A. Patient was given 2L NS, 20mg IV dilt and then PO
dilt 30mg x 2 and admitted for further care. Per nursing report,
he converted to sinus at approximately 2pm.
On the floor, patient is feeling better, though continues to
feel a little weak. He denies any chest pain, shortness of
breath currently.
Past Medical History:
OSA - diagnosed but noncompliant with home CPAP
s/p bilateral total knee replacement
paroxysmal afib postoperatively
Social History:
___
Family History:
Father passed from stomach cancer. Mother passed at age ___ with
CHF.
Physical Exam:
Admission exam:
Vitals: T 99.4 BP 107/69 HR 61 RR 18 O2 sat 97 RA
General: well appearing elderly man, no acute distress
HEENT: PERRL, EOMI, oropharynx is clear, neck is supple
CV: distant heart sounds but appears to be regular, no murmurs
appreciated
Resp: CTA bilaterally without wheezing, rhonchi, or egophony
Abd: soft, nontender, nondistended, normoactive bowel sounds
Ext: wwp, no edema
Neuro: alert and oriented, no facial droop
Psych: mood and affect are appropriate
Pertinent Results:
Admission labs:
___ 08:16AM BLOOD WBC-4.8 RBC-5.66 Hgb-16.4 Hct-49.9 MCV-88
MCH-29.0 MCHC-32.9 RDW-13.0 RDWSD-42.5 Plt ___
___ 08:16AM BLOOD Neuts-53.1 ___ Monos-12.2 Eos-1.5
Baso-0.4 Im ___ AbsNeut-2.52# AbsLymp-1.54 AbsMono-0.58
AbsEos-0.07 AbsBaso-0.02
___ 08:16AM BLOOD Glucose-106* UreaN-17 Creat-1.1 Na-137
K-5.5* Cl-100 HCO3-23 AnGap-20
___ 08:16AM BLOOD ALT-35 AST-62* AlkPhos-58 TotBili-0.4
___ 08:16AM BLOOD Albumin-4.2
___ 10:04AM BLOOD K-4.9
Discharge labs:
___ 06:20AM BLOOD WBC-3.7* RBC-4.84 Hgb-14.4 Hct-42.6
MCV-88 MCH-29.8 MCHC-33.8 RDW-13.3 RDWSD-43.1 Plt ___
___ 06:20AM BLOOD Glucose-93 UreaN-16 Creat-0.9 Na-138
K-4.1 Cl-104 HCO3-23 AnGap-15
___ EKG - ED initial
irregular rate/rhythm, approx. rate 110s, likely AF, RBBB
ED EKG secondary
regular rate /rhythm, rate ___, some PACs, appears to be sinus
though no priors, RBBB
Imaging:
CXR ___
IMPRESSION:
No evidence of pneumonia.
TTE ___
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
low normal (LVEF 50-55%). 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 leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
Mr. ___ is a ___ man with h/o OSA and post-operative
paroxysmal afib who p/w 5 days of ILI and episode of
pre-syncope, found to have rapid AF and influenza A infection.
# Paroxysmal atrial fibrillation: Patient presented in AF with
rates into the 140s, which resolved with IVF and IV diltiazem.
He had 1 prior episode of AF in the post-op setting after his
bilateral knee replacements. He denies ever having had a holter
monitor to evaluate for AF burden. This episode is likely
precipitated by acute infectious process and hypovolemia. He may
have underlying paroxysmal AF, perhaps due to his OSA, which is
currently untreated. TTE did not show any valvular disorders or
structural heart disease. TSH was mildly elevated but T3/free T4
were within normal limits. CHADS2-vasc score of 1 for age and
thus, anticoagulation discussion was initiated, but patient
preferred to defer decision until he could read more information
and consider his options. He was monitored on telemetry without
any further episodes of AF. He was arranged for outpatient
cardiology follow-up.
# influenza A: Patient presented on day 4 of symptoms once
fevers and cough had resolved and he remained afebrile during
hospitalization. He declined Tamiflu as he was feeling better
and without fevers.
# elevated blood pressures: Patient's blood pressures were
initially low-normal in setting of rapid AF and hypovolemia,
which normalized after IVF. The day of discharge, he was noted
to have blood pressures in the 150-170 range, though he admitted
he was stressed from pressures at home and his current illness.
# OSA: Patient declined CPAP. TTE did show borderline elevated
PASP, which may be due to untreated OSA. Please continue to
encourage CPAP use.
TRANSITIONAL ISSUES:
- please continue to monitor hypertension as outpatient
- patient referred to cardiology as outpatient
- continue anticoagulation discussion
- continue encouraging CPAP use
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
paroxysmal atrial fibrillation
influenza A
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you during your stay at ___
___. You were admitted after feeling
light-headed at home. You were found to have the flu and an
irregular rapid heart rhythm, called "atrial fibrillation." This
resolved after you were treated with IV fluids.
You had an echocardiogram of your heart during your
hospitalization. We will contact you with the final results. You
should follow-up with your PCP and your new heart doctor as
listed below.
Take care,
Your ___ Team
Followup Instructions:
___
|
19739872-DS-13
| 19,739,872 | 23,023,377 |
DS
| 13 |
2140-11-03 00:00:00
|
2140-11-03 16:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
___ RIJ CVL insertion
___ ERCP, stent placement
History of Present Illness:
___ female with a history of atrial fibrillation on
Coumadin who presented initially to ___ with weakness,
transferred to ___ ___ with c/f GIB iso coagulopathy and
anemia.
Admitted to ___ for hypotension.
Patient was recently seen at ___ ___ after a
fall
with negative head/cspine CT. Since then, she has felt
increasingly weak, fatigued. She denies any fever, chills, black
or bloody stools, abdominal pain, chest pain, shortness of
breath. She presented this admission to ___, where she
was found to have an elevated INR (reported greater than assay),
creatinine 5.1 (prior baseline creatinine 1.3-1.6, most recently
1.6 in ___, hgb 10.2 (from prior baseline around 13 in ___,
elevated LFTs, and guaiac positive brown stools. BP documented
as
74/32 though also stable hemodynamically in note. Patient was
given Kcentra, 10mg vit K, and 1L LR prior to transfer. Ordered
for but unclear if received zosyn, vanc, fluconazole,
metronidazole "for potential for a descending
cholangitis."
Of note, at her last discharge on ___ INR was 3.5, pt was
told to hold Coumadin for a day.
Past Medical History:
HTN
CKD
severe COPD
Atrial fibrillation
Restless leg syndrome
left diaphragm paralysis
cataracts
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: reviewed in Metavision
GENERAL: Alert and interactive. In no acute distress.
HEENT: bruising over face
NECK: supple neck, JVD above clavicle at 45 deg
CARDIAC: irregular rhythm, normal rate. No murmurs/rubs/gallops.
LUNGS: relatively clear, No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, mildly TTP in
suprapubic area but otherwise no tenderness. No organomegaly.
EXTREMITIES: No ___.
SKIN: Warm.
NEUROLOGIC: alert, oriented x3, appropriate though tangential
DISCHARGE PHYSICAL EXAM:
Vitals: see Eflowsheets
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Central
line in the right neck dressed and in place
CV: Heart regular rate; normal perfusion, no appreciable JVD.
RESP: Symmetric breathing pattern with no stridor. Breathing is
non-labored
GI: Abdomen soft, non-distended, no hepatosplenomegaly
appreciated.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, normal muscle bulk and tone
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: normal thought content, logical thought process,
appropriate affect
Pertinent Results:
ADMISSION LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 05:23PM BLOOD WBC-12.6* RBC-2.91* Hgb-9.8* Hct-28.5*
MCV-98 MCH-33.7* MCHC-34.4 RDW-15.9* RDWSD-54.8* Plt ___
___ 05:23PM BLOOD Neuts-74.3* Lymphs-13.7* Monos-8.8
Eos-0.2* Baso-0.5 NRBC-0.9* Im ___ AbsNeut-9.33*
AbsLymp-1.72 AbsMono-1.10* AbsEos-0.03* AbsBaso-0.06
___ 08:00PM BLOOD ___ PTT-28.8 ___
___ 08:00PM BLOOD ___ 08:00PM BLOOD Glucose-99 UreaN-101* Creat-4.4* Na-134*
K-5.3 Cl-89* HCO3-23 AnGap-22*
___ 08:00PM BLOOD ALT-1571* AST-578* LD(LDH)-918*
AlkPhos-181* TotBili-7.1* DirBili-2.9* IndBili-4.2
___ 08:00PM BLOOD Lipase-71*
___ 08:00PM BLOOD cTropnT-<0.01
___ 08:00PM BLOOD Albumin-3.6 Calcium-9.0 Phos-4.0 Mg-1.5*
Iron-158
___ 08:00PM BLOOD calTIBC-229* ___ Ferritn-2405*
TRF-176*
___ 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:37AM BLOOD Lactate-2.1*
MICROBIOLOGY:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ URINE CULTURE
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ BLOOD CULTURE ***
___ BLOOD CULTURE ***
IMAGING:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ CT HEAD W/O CONTRAST
No acute intracranial process.
___ LIVER/GALLBLADDER US
1. The main portal vein is patent.
2. Echogenic liver consistent with hepatic steatosis. Other
forms of liver disease or advanced liver disease, including
significant hepatic fibrosis and cirrhosis, cannot be excluded
on this study.
3. 1.6 cm cyst at the pancreatic body/tail seen as seen on the
prior CT from the same day. Findings likely represent a side
branch IPMN. Further
evaluation with MRCP can be obtained.
4. Cholelithiasis without cholecystitis. Choledocholithiasis
identified on prior CT is not clearly delineated on this
ultrasound.
___ CHEST (PORTABLE AP)
The tip of the right internal jugular central venous catheter
projects over the mid SVC. There is unchanged elevation of the
left hemidiaphragm with left basilar atelectasis. There is no
focal consolidation, pleural effusion or pneumothorax
identified. The size of the cardiac silhouette is enlarged but
unchanged. Marked degenerative changes are present around the
left glenohumeral joint.
___ MRCP (MR ABD ___
1. 1.0 cm stone is identified in mid common bile duct and a
smaller one is
seen more distally, consistent with choledocholithiasis.
Cholelithiasis. No intra or extrahepatic biliary ductal
dilatation.
2. Multiple cystic lesions in the pancreas, measuring up to 2.8
cm, are likely IPMNs. Follow-up MRCP is recommended in 6
months.
3. Elevated left hemidiaphragm.
___ TTE
Suboptimal image quality. Mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global
biventricular systolic function. Mild mitral regurgitation. At
least mild tricuspid regurgitation. EF 70%.
OTHER DIAGNOSTIC:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ ERCP
Normal esophagus and stomach.
___ diverticulum.
Large filling defect in distal CBD. ___, 7cm plastic stent
placed.
Bile and small amount of purulent material drained after stent
placement.
DISCHARGE LABS:
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
___ 12:53PM BLOOD WBC-10.0 RBC-2.69* Hgb-9.1* Hct-27.9*
MCV-104* MCH-33.8* MCHC-32.6 RDW-20.4* RDWSD-69.3* Plt ___
___ 07:12AM BLOOD ___ PTT-30.3 ___
___ 07:12AM BLOOD Glucose-75 UreaN-23* Creat-1.3* Na-139
K-5.5* (hemolyzed) Cl-104 HCO3-22 AnGap-13
___ 07:12AM BLOOD ALT-166* AST-60* AlkPhos-119*
TotBili-2.3*
___ 07:12AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.1
Brief Hospital Course:
SUMMARY:
========
Ms. ___ is a ___ female with a history of atrial
fibrillation on Coumadin and CKD, who presented initially to ___
with weakness, with course c/b coagulopathy, hypotension,
elevated LFTs, and found to have choledocholithiasis. The
patient was supported with norepinephrine and treated
empirically with Zosyn for presumed sepsis ___ cholangitis. On
___ she underwent ERCP which revealed a large filling defect in
the CBD and she underwent successful stent placement with
subsequent bile drainage. Her LFTs progressively improved. She
was progressively weaned off Levophed. She required fluid
resuscitation for her ___
#Septic Shock
BPs in 70/30 on presentation to OSH. Etiology most likely septic
(from cholangitis) +/- hypovolemia (poor PO intake at home). TTE
___ with EF 70%, mild LVH, mild MR/TR. MRCP showing
choledocholithiasis and cholelithiasis with 1cm stone in CBD.
Now S/p ERCP ___ w/ stent placement, stone removal deferred to
outpatient setting. Received IVF, abx, and initially required
levophed for MAP >65, however weaned off on evening of ___. She
had been started on Zosyn ___ and completed a 5 day course for
cholangitis (___).
___ on CKD
Cr initially elevated at 5.1, down to 4.4 on ___ admission,
from prior baseline of 1.6 in ___. Downtrended after IVF
resuscitation, and urine lytes supported a pre-renal etiology.
Her home Lasix was held. Creatinine improved to 1.3 at time of
discharge.
# Acute liver injury
ALT/AST/ALP/Tb on admission to ___ were 1238/377, AP 172, and
total bilirubin of 7.2. Elevated LFTs thought to be secondary to
biliary obstruction. She underwent ERCP with stone removal, and
LFTs had significantly downtrended at time of discharge (ALT
166, AST 60 (hemolyzed), AP 119, and total bilirubin 2.3). Her
hepatitis panel and tox screen was negative. Serum iron panel
c/w inflammatory state vs. iron overload. Iron 167, Ferritin
1867. Found to have Positive anti-smooth muscle Ab(1:20) and
positive ___ (titer 1:640) with low IgG.
LFTs will need to be monitored at rehab to ensure that they are
fully normalized.
In addition, she should have SMA and ___ rechecked as an
outpatient and will need rheumatology referral if they remain
positive. Given continued improvement of LFTs (levels now nearly
within normal range) autoimmune hepatitis is clinically unlikely
at this time but she will require close monitoring as above.
Need for repeat ___ testing was discussed with patient's HCP.
# Anemia
Admitted with Hgb of 10, Baseline Hgb 13. Patient w/ guaiac
positive but had no overt melena or BRBPR. She had no other
evidence of dark/bloody stools. She underwent ERCP which
revealed a normal stomach and duodenum without signs of ulcers
or PUD. She was initially treated with a PPI which was stopped
given ERCP findings as above. She should have a colonoscopy as
an outpatient given positive FOBT. This was discussed with
patient and her HCP, though she reportedly has refused screening
colonoscopy in the past.
# Coagulopathy
On presentation to OSH had elevated INR (above assay) in the
setting of warfarin use and acute liver injury. Patient had been
on warfarin for AFib (CHADSVASC 4). Received vitamin K at OSH
with improvement. Her warfarin levels have been quite variable
as an outpatient.
# Atrial fibrillation: ___ 4. Had extensive discussion
with patient's niece and HCP about warfarin use. There is
concern because the patient has fallen quite a bit recently (5
times in the past several months) and lives alone. Her warfarin
levels are also extremely variable which patient's niece
believes is likely secondary to diet.
Restarted warfarin prior to discharge at 1mg daily (patient on
alternating ___ most recently but dose changes weekly). Did
discuss with patient's HCP that if patient returns to living
alone after rehab discharge, then I feel that warfarin would not
be a safe medication for her (given frequent falls and no one to
monitor her, though she likely should not be living alone and
family is considering the fact that she may require long term
care).
In terms of variable INR levels, unfortunately a NOAC is not an
option since patient does not have supplementary insurance and
NOACs are not covered by Medicare.
> 30 minutes spent on discharge coordination and planning
CORE MEASURES
=======================
#CODE STATUS: Full code
#CONTACT: ___)
TRANSITIONAL ISSUES
=====================
[] MRCP in 6mo to evaluate pancreas cyst, likely IPMN
[] repeat ERCP in ___ wks for outpt stone extraction
[] Hep B non-immune - recommend vaccination
[] 3 mm lung nodule in the peripheral left lower lobe. For
incidentally detected single solid pulmonary nodule smaller
than 6 mm, no CT follow-up is recommended in a low-risk patient,
and an optional CT in 12 months is recommended in a high-risk
patient. Patient has no smoking history so would be low risk
[] please follow up LFTs
[] needs SMA and ___ rechecked with rheumatology referral if
these remain elevated (SMA 1:20 here, ___ 1:640)
[] patient should have screening colonoscopy given her positive
FOBT
[] patient having frequent falls and lives alone. There is
concern about her safety and she may require placement in a long
term care facility. If patient does discharge home to live alone
then would likely discontinue warfarin (see above)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Furosemide 20 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Warfarin Dose is Unknown PO Frequency is Unknown
5. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Miconazole Powder 2% 1 Appl TP TID L groin rash
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
5. Warfarin 1 mg PO DAILY16
patient alternating 2mg and 3mg at home, will need to be dosed
pending INR
6. Allopurinol ___ mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Cholangitis
Septic Shock
Anemia
Acute Kidney Injury
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at ___
___.
You were admitted to ___ because you had low blood pressure
from an infection near your gallbladder and were also found to
have a liver injury.
What happened while you were in the hospital?
- You were given medications to help increase your blood
pressure
- You were given antibiotics to help with the infection
- A stent was placed to help open the tubes that drain your
gallbladder.
What should you do when you leave the hospital?
- Continue to take all of your medications as prescribed
- Please be sure to follow up with your health care providers to
follow up on your recent stent procedure and to monitor your
liver injury.
Followup Instructions:
___
|
19739929-DS-17
| 19,739,929 | 20,028,957 |
DS
| 17 |
2206-09-02 00:00:00
|
2206-09-03 07:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Nail ___ / Neosporin (neo-bac-polym)
Attending: ___
Chief Complaint:
fall with right arm and pelvic pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with HTN, HLD, asthma who
fell in her back yard this morning and landed on right hand,
right face. Denies LOC or neck pain. She remembers the entire
event. Denies any presyncopal symptoms prior to fall.
Past Medical History:
PMH: asthma, COPD, cataracts, GERD, HL, HTN, kidney stones, MGUS
?multiple myeloma, OA, ovarian cysts, hyperparathyroidism,
actinic keratoses
PSH: cholecystectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Physical Exam:
Gen: comfortable, no acute distress. Alert and oriented x 3
CV: RRR
Lungs: breathing room air comfortably.
Right upper extremity:
- small superificial skin tear over dorsal aspect of wrist.
Significant amount of ecchymosis and swelling about wrist
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Left upper extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender arm and forearm
- Full, painless AROM/PROM of shoulder, elbow, wrist, and digits
- EPL/FPL/DIO (index) fire
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse
Right lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Left lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Discharge Physical Exam:
vs: 97.3, 64, 135/58, 18, 99% RA
Gen: Awake, alert, sitting up in bed. Pleasant and interactive.
HEENT: No deformity. PERRL, EOMI. Neck supple. Trachea midline.
CV: bradycardic 55, regular rhythm. no murmur.
Resp: Clear to auscultation bilaterally.
Abd: Soft, non-tender, non-distended. Active bowel sounds x 4
quadrants.
Ext: Warm and dry. 2+ ___ pulses. no edema.
Neuro: A&Ox3. moves all extremities. able to moves lowers
laterally but not against gravity.
Pertinent Results:
___ 02:00AM BLOOD WBC-6.8 RBC-3.64* Hgb-10.9* Hct-34.6
MCV-95 MCH-29.9 MCHC-31.5* RDW-13.7 RDWSD-47.6* Plt ___
___ 05:25AM BLOOD Glucose-133* UreaN-37* Creat-0.9 Na-137
K-4.0 Cl-104 HCO3-23 AnGap-14
___ 07:25AM BLOOD Glucose-132* UreaN-33* Creat-0.9 Na-136
K-4.1 Cl-101 HCO3-23 AnGap-16
___ 02:00AM BLOOD Glucose-156* UreaN-31* Creat-0.9 Na-135
K-4.4 Cl-101 HCO3-22 AnGap-16
___ 05:25AM BLOOD Calcium-9.2 Phos-2.9 Mg-2.0
___ 02:42AM BLOOD Lactate-1.7
___ 03:44AM URINE Blood-TR Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 03:44AM URINE RBC-2 WBC->182* Bacteri-MANY Yeast-NONE
Epi-2 TransE-<1 RenalEp-<1
___ 03:44AM URINE Color-Yellow Appear-Hazy Sp ___
===============================================
RADIOLOGY:
___: Near anatomic alignment of the distal radius fracture
following reduction.
___ ECCHO:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild (non-obstructive) focal hypertrophy
of the basal septum. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened (?#). There is mild aortic valve stenosis
(valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
change.
Brief Hospital Course:
Ms. ___ is a ___ yo F who was admitted to the Acute Care
Trauma Surgery Service on ___ after a mechanical fall. She
was transferred from an outside hospital and found to have right
pelvic superior and inferior pubic rami fracture, right femoral
neck fracture, right distal radius fracture, and right ___ rib
fractures. She was noted to be bradycardic with heart rates in
the 50___s with occasional rates as low as 30's with blood
pressures within normal limits. She was admitted to the floor
for close respiratory and hemodynamic monitoring.
Orthopedic surgery was consulted and recommended no-operative
treatment for her pelvic and femoral neck fractures. She is
weight bearing as tolerated on the right lower extremity. Her
right arm was reduced at the bedside and splinted. She should
remain non-weight bearing on the right upper extremity.
Cardiology was consulted for her bradycardia and synocpal
episode on HD1. She was noted to have several episodes of
asymptomatic bradycardia with 1st degree AV delay and no
evidence of high grade AV block or infranodal disease as well as
pauses up to 1.7 seconds. They recommended discontinuing her
home amlodipine, taking her home losartan in the evening, and
obtaining a transthoracic echocardiogram. Her syncopal episode
was likely due to vasovagal response. She should follow up with
her primary care provider for further care.
On HD2 she was found to have a urinary tract infection and
started on a 5 day course of Macrobid to be completed on
___.
She was seen and evaluated by physical and occupational therapy
who recommended discharge to rehabilitation.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating with assistance, 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:
amlodipine 10mg daily, albuterol INH, atorvastatin 40mg daily,
losartan 100mg daily, advair INH, omega3FA, MVI daily
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID
4. Lidocaine 5% Patch 1 PTCH TD QAM
12 hours on; 12 hours off
5. Milk of Magnesia 30 mL PO Q6H:PRN constipation
6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 5
Days
Ends: ___
7. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
8. Senna 8.6 mg PO BID
as needed
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
10. Atorvastatin 40 mg PO QPM
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Losartan Potassium 100 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
1. right pelvic superior and inferior pubic rami fracture
2. right femoral neck fracture
3. right distal radius fracture
4. right ___ rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted for management of multiple injuries after a
fall including pelvic fracture, right femur fracture, right
forearm fracture, and four right rib fractures. Your pain
control was optimized and your right arm was splinted. You will
follow out with the orthopedic surgeons as an outpatient for
management of your pelvis, leg, and arm fractures.
You were seen and evaluated by the cardiologist for your slow
heart rate. They recommended discontinuing your amlodipine and
taking your losartan in the evening. Please continue to hold her
amlodipine medication until you follow up with your primary care
provider.
Please read the following directions:
Your right arm should be in a splint and non-weight-bearing. You
can move your fingers as much as you are able. You can bear
weight on your right leg as much you are able.
Keep in mind, these injuries are painful and will be for several
weeks.
For your rib fractures:
* Your injury caused several rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
19740429-DS-12
| 19,740,429 | 25,822,900 |
DS
| 12 |
2120-05-31 00:00:00
|
2120-05-31 13:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrocodone-acetaminophen
Attending: ___.
Chief Complaint:
acute encephalopathy
Major Surgical or Invasive Procedure:
Transesophageal echocardiography (TEE) ___
History of Present Illness:
___ with a history of CKD4, asthma, CHFpEF, and multiple recent
admission for GIB and PNA (___) presents with AMS. She
has had 1 week of confusion, increased forgetfulness,
depression, decreased PO intake. As per her daughter she has
been saying that " there were men in the ___ Her daughter
then found her outside in her slippers. She has been having
episodes of black stares. She denies fever, chills, burning
during urination. At bedside patient is alert and oriented X3
but answering questions
slowly, which is not baseline as per daughter. She lives alone
and has not been taking medications. She endorses cough. Denies
f/c/cp/sob/abd pain/urinary or bowel problems, bleeding. No
recent falls. She was recently admitted ___ for multifocal
pneumonia.
Past Medical History:
- HTN, HLD, CKD V
- Type 2 Diabetes Mellitus, with retinopathy, nephropathy
- Gout
- OSA not on CPAP
- Pulmonary Embolism - ___ years ago, s/p 6 months of coumadin
then stopped, no recurrence
- Osteoarthritis
- Goiter
- Asthma
- Right neck pain (? trigeminal neuralgia)
- Recent diagnosis of a lower GIB, diverticular bleed versus
ischemic colitis
Social History:
___
Family History:
Mother with DM.
Physical Exam:
-Vitals: reviewed
-GENERAL: sitting up in chair, NAD, pleasant
-HEENT: moist mucus membranes, PERRL, EOMi
-PULM: clear b/l, no wheezes
-GI: soft, mild abdominal tenderness, bowel sounds present
-GU: no foley
-MSK: PICC RUE, LUE fistula with palpable thrill; right calf
soft but tender and slightly larger than right
-NEURO: no focal neurological deficits, CN ___ grossly intact,
able to engage in appropriate conversation regarding hospital
course
-Psych: appropriate mood and affect
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS
___ 08:05PM BLOOD WBC-5.1 RBC-2.85* Hgb-8.6* Hct-27.4*
MCV-96 MCH-30.2 MCHC-31.4* RDW-13.5 RDWSD-48.0* Plt ___
___ 08:05PM BLOOD Neuts-61.4 ___ Monos-10.2 Eos-3.7
Baso-1.4* Im ___ AbsNeut-3.14 AbsLymp-1.18* AbsMono-0.52
AbsEos-0.19 AbsBaso-0.07
___ 06:00AM BLOOD ___ PTT-27.4 ___
___ 07:09PM BLOOD Glucose-95 UreaN-43* Creat-3.1* Na-145
K-4.4 Cl-106 HCO3-25 AnGap-14
___ 06:00AM BLOOD ALT-9 AST-15 AlkPhos-77 TotBili-0.5
___ 07:09PM BLOOD cTropnT-0.06*
___ 08:05PM BLOOD CK-MB-2 ___
___ 07:09PM BLOOD Calcium-9.4 Phos-4.1 Mg-2.0
___ 08:05PM BLOOD VitB12-1173*
___ 06:19AM BLOOD calTIBC-221* Ferritn-117 TRF-170*
___ 07:43AM BLOOD %HbA1c-5.7 eAG-117
___ 07:09PM BLOOD TSH-1.7
___ 07:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 03:13AM BLOOD ___ pO2-181* pCO2-40 pH-7.39
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
DISCHARGE LABS ***
IMAGING/STUDIES
-CT HEAD ___: 1. No acute intracranial abnormality. 2.
Age-related global atrophy and likely sequela of chronic
microvascular ischemic disease, similar to prior.
-ECHO ___: Normal global biventricular systolic function.
Grade II diastolic dysfunction with increased PCWP. Mild
pulmonary hypertension.
-MRI BRAIN ___: 1. No acute territorial infarct is
identified. 2. Millimetric focus of high signal on
diffusion-weighted images located in the paramedian left frontal
(302:21) is likely an artifact, please correlate. 3. Extensive
confluent periventricular white matter T2/FLAIR high-signal
intensity, which is a nonspecific finding and may reflect
chronic microvascular ischemic disease. 4. Major intracranial
arteries are patent without dissection.
-TEE ___: Good image quality. Mild aortic leaflet thickening
with small (0.3-0.4mm) mobile echodensity on the LVOT side c/w
but not diagnostic of a vegetation. No aortic regurgitation or
abscess seen. MIld mitral leaflet thickening with mild-moderate
mitral regurgitation. No discrete mitral valve vegetation or
abscess seen.
-B/L LOWER EXTREMITY VENOUS DUPLEX ___: 1. Nonocclusive deep
vein thrombosis in the right popliteal vein and one of the right
peroneal veins, some of which appears acute, and some of which
is
possibly chronic in nature. 2. No deep vein thrombosis in the
left lower extremity.
Brief Hospital Course:
___ h/o CKD stage V, chronic diastolic HF, HTN, DM II, and OSA
presented with subacute confusion with hallucinations found to
have S. epidermidis blood stream infection and aortic valve
endocarditis.
1. Aortic valve endocarditis w/ Staph epidermidis blood stream
infection
-Blood cultures ___ positive for S epidermis found to have
aortic vegetation consistent with endocarditis. There was no
clear source of infection or inoculation site. She was started
on vancomycin with all subsequent blood cultures negative. ID
will continue to manage her antibiotics at discharge
anticipating at least a ___s per OPAT weekly CBC
with differential, BUN, Cr, Vancomycin trough, CRP, AST, ALT.
Fax results to ATTN: ___ CLINIC -FAX: ___.
FOLLOW UP APPOINTMENTS: ___ 3:00 ___ with Dr. ___
___.
2. Acute encephalopathy w/ suspected mild cognitive impairment
-Likely in setting of acute illness/infection, which is
improving with only mild cognitive impairment at this time.
Daughter has concerns for gradual decline in cognitive function
and MRI suggestive of chronic microvascular disease concerning
for mild vascular dementia at baseline. Continue modifiable risk
factors including glycemic, lipids, and blood pressure control.
Recommend outpatient neurocognitive/geriatrics follow up.
3. RLE DVT h/o PE
-Patient reported right lower extremity calf pain found to have
DVT started on heparin drip as a bridge to coumadin. As per
chart she has a history of PE ___ years ago that was treated with
coumadin for 6 months. Given that this is her second lifetime
clot she will likely need to continue anticoagulation life long.
She will follow up with PCP at discharge from rehab. INR 3.1 on
day of discharge, will need more frequent monitoring until in
steady state, recommend INR be checked tomorrow (___).
4. HTN
-Poorly controlled. Labetalol uptitrated during admission and
continued on nifedipine. Consider ACEi given h/o DM although
defer to nephrology given h/o CKD V.
5. Hypomagnesemia - repleted.
-Replete and monitor.
6. Normocytic anemia - Suspect anemia of chronic disease plus
anemia of chronic kidney disease. She does not have any
evidence of bleeding although h/o GI bleeding in the past. She
remained hemodynamically stable. Hgb drifted down to 6.8 on ___.
Patient was offered blood transfusion however declined,
understood risks and benefits of declining blood transfusion.
Iron studies pending at time of discharge, may benefit from iron
repletion. She should also be continued on her Epo.
7. Hypoglycemia h/o DM II
-___ managing medications with the goal of minimizing the
number of injections per day questioning whether patient can
maintain that. ___ feels that HbA1C of 5.7% may be falsely
low given recent GI bleed. Aware of age, CKD V, and variable PO
intake ___ optimized her diabetic regimen to insulin (NPH).
Patient want to follow up with ___ at discharge.
CHRONIC/STABLE
1. Chronic diastolic heart failure: stable, clinically
euvolemic. Continued Lasix and imdur.
2. CKD IV/V, hyperphosphatemia: creatinine fluctuating up to 4.
Fistula in left arm not yet on HD. Cr 3.7 on discharge, no signs
or symptoms of fluid overload. Continued on PO Lasix.
3. Asthma: continue albuterol PRN
TRANSITIONAL ISSUES
- Refer to ___ clinic.
- Refer to ___ for DM management
- continue warfarin and INR monitoring
- monitor CBC to ensure Hgb not dropping further, patient
refused transfusion as she was minimally symptomatic and
hemodynamically stable however may need blood transfusion in
future.
- patient may benefit from iron supplementation, iron studies
pending at time of discharge.
>30 minutes spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. Senna 8.6 mg PO BID
4. insulin NPH isoph U-100 human 10 units subcutaneous BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Calcitriol 0.25 mcg PO EVERY OTHER DAY
8. Calcium Carbonate 650 mg PO TID:PRN dyspepsia
9. Cyclobenzaprine 10 mg PO TID:PRN muscle spams
10. Epoetin ___ ___ units SC 14 DAYS
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Furosemide 20 mg PO DAILY
13. GlipiZIDE 10 mg PO BID
14. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
15. Labetalol 300 mg PO DAILY
16. Labetalol 600 mg PO QPM
17. NIFEdipine (Extended Release) 60 mg PO DAILY
18. ProAir RespiClick (albuterol sulfate) 90 mcg/actuation
inhalation QID:PRN
19. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
Discharge Medications:
1. NPH 14 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
2. Ramelteon 8 mg PO QHS:PRN insomnia
3. Simethicone 40-80 mg PO QID bloating
4. Vancomycin 500 mg IV Q48H
5. Warfarin 4 mg PO DAILY16 DVT
6. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Calcitriol 0.25 mcg PO EVERY OTHER DAY
10. Calcium Carbonate 650 mg PO TID:PRN dyspepsia
11. Docusate Sodium 100 mg PO BID
12. Epoetin ___ ___ units SC 14 DAYS
13. Fluticasone Propionate NASAL 1 SPRY NU BID
14. Furosemide 20 mg PO DAILY
15. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
16. Labetalol 600 mg PO QPM
17. Labetalol 300 mg PO DAILY
18. NIFEdipine (Extended Release) 60 mg PO DAILY
19. ProAir RespiClick (albuterol sulfate) 90 mcg/actuation
inhalation QID:PRN
20. Senna 8.6 mg PO BID
21. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
22.Outpatient Lab Work
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
WEEKLY: CBC with differential, BUN, Cr, Vancomycin
trough, CRP, AST, ALT
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute GPC bloodstream infection
Acute metabolic encephalopathy
CKD stage IV
Chronic diastolic CHF
DM2 uncontrolled with retinopathy
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted with confusion found to have an infection in
your blood coming from your heart valve (endocarditis). You will
need to complete a ___ week course of antibiotics through your
IV. The outpatient infectious disease clinic will manage your
antibiotics.
You developed a blood clot in your right leg during your
hospitalization and will need to continue a medication called
coumadin (warfarin) for at least ___ months. Your PCP ___
determine how long to continue this for.
Your diabetes was managed by the endocrinologist specialists
from ___. You can continue following up with
them at discharge.
While most of your confusion was due to the infection you may
have some memory loss. You can follow up with the cognitive
neurology team.
Your blood counts were low over admission however you declined
blood transfusion. This was likely a result of infection and
chronic kidney disease. Please have your blood counts checked
periodically.
It was a pleasure taking care of you.
-Your ___ team
Patient was admitted with 2 weeks of confusion and inattention
and found to have a bloodstream infection and infection in your
heart (endocarditis). She will need to complete a course of
treatment and work with physical therapy.
Please have patient follow up with PCP and take all medications
as prescribed
Followup Instructions:
___
|
19740429-DS-13
| 19,740,429 | 21,089,660 |
DS
| 13 |
2120-07-18 00:00:00
|
2120-07-18 19:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrocodone-acetaminophen
Attending: ___.
Chief Complaint:
Shortness of breath and chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yoF with stage IV CKD, T2DM c/b retinopathy
and nephropathy, asthma, CHF, recent admissions for GIB
(___), PNA (___), and endocarditis
(___), who is presenting with worsening shortness of
breath and chest pain. Per history gathered from family, rehab
notes, and patient, patient has been having increasing wheezing
and shortness of breath over the past week and a half. She was
prescribed Lasix 80mg daily, but continued to have increased
swelling. Therefore, she presented to the ED.
During her previous hospitalization, she presented on ___ with
approximately 3 weeks of progressively worsening altered mental
status, subsequently found to have bacteremia with coag negative
staph growing from ___ bottles with 2 possible morphologies and
___ TEE showing possible aortic valve vegetation. Her hospital
course was also notable for development of DVT for which she is
now on AC. She was discharged on vancomycin, which she completed
on ___. She was then discharged from rehab ___),
and has been living at home with help of her daughter and a
visiting nurse.
In the ED, initial VS were: T 97.7, HR 59, BP 183/87, RR 16,
100% BiPap
Labs showed:
- CBC: WBC 5.6, Hgb 7.6, Hct 25, Plt 288
- Lytes:
144 / 107 / 57
--------------- 47
5.9 \ 19 \ 4.5
- coags: ___: 40.7, PTT: 43.6, INR: 3.8
- ___: ___
- Trop-T: 0.05
Imaging showed:
- CXR with:
1. Pulmonary vascular congestion and mild to moderate pulmonary
edema.
2. Patchy opacities at the lung bases for which superimposed
infection cannot be excluded in the appropriate clinical
setting.
Patient received:
___ 00:14 IM Glucagon 1 mg
___ 00:43 IV Dextrose 50% 25 gm
___ 02:00 IH Albuterol 0.083% Neb Soln 1 NEB
___ 02:00 IH Ipratropium Bromide Neb 1 NEB
___ 02:16 IV Furosemide 80 mg
___ 03:33 PO NIFEdipine (Extended Release) 90 mg
___ 03:33 PO Isosorbide Mononitrate (Extended Release)
30mg
___ 03:34 IH Albuterol 0.083% Neb Soln 1 NEB
___ 03:34 IH Ipratropium Bromide Neb 1 NEB
Transfer VS were: 98.3, HR 74, BP 155/68, RR 21, 100% RA
Past Medical History:
- HTN, HLD, CKD V
- Type 2 Diabetes Mellitus, with retinopathy, nephropathy
- Gout
- OSA not on CPAP
- Pulmonary Embolism - ___ years ago, s/p 6 months of coumadin
then stopped, no recurrence
- Osteoarthritis
- Goiter
- Asthma
- Right neck pain (? trigeminal neuralgia)
- Recent diagnosis of a lower GIB, diverticular bleed versus
ischemic colitis
Social History:
___
Family History:
Mother with DM.
Physical Exam:
==============================
ADMISSION PHYSICAL EXAMINATION
==============================
VS: 98.2, HR 70, BP 112/62, RR 18, 97% 3l
GENERAL: lying in bed, comfortable appearing, NAD
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, bilateral crackles at bases
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ edema to knees bilaterally, R>L
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
==============================
DISCHARGE PHYSICAL EXAMINATION
==============================
T:97.7 BP:137/54 HR:65 O2:99 Room Air
GENERAL: Sitting up in chair, no apparent distress.
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Clear bilaterally. No evidence of respiratory distress.
ABDOMEN: Nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: No lower extremity edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox2-3, moving all 4 extremities with purpose
PSYCH: flat affect, responsive to questions and appropriate but
subdued
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
==============
ADMISSION LABS
==============
CBC: WBC 5.6 Hgb 7.6 Hct 25.0 Plt 288
Trop 0.05 CMKB 3
BNP 31361
Lactate 1.4
Chem 10: Na 144 K 5.9 Ck 107 CO2 19 BUN 57 Cr 4.5 AG 18
==============
DISCHARGE LABS
==============
___ 06:54AM BLOOD ___ PTT-33.7 ___
___ 06:41AM BLOOD ___ PTT-85.8* ___
___ 09:00AM BLOOD ___ PTT-90.2* ___
___ 09:00AM BLOOD ___ PTT-27.8 ___
___ 06:54AM BLOOD Glucose-95 UreaN-86* Creat-4.8* Na-140
K-4.6 Cl-98 HCO3-24 AnGap-18
___ 06:54AM BLOOD Calcium-9.4 Phos-6.0* Mg-2.0
============
MICROBIOLOGY
============
___ 12:15 am BLOOD CULTURE
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
___ 10:52 am URINE Source: Catheter.
URINE CULTURE (Preliminary):
GRAM NEGATIVE ROD(S). >100,000 CFU/mL.
=========================
PERTINENT IMAGING/STUDIES
=========================
TTE ___
Mild LVH with normal LV systolic function > 55%. Mildly dilated
RV with normal systolic function. Mild mitral regurgitation.
Moderate pulmonary hypertension. Elevated PCWP.
Compared with the prior study (images reviewed) of ___ the
estimated PASP is higher in setting of higher estimated RAP. If
clinically indicated can consider TEE.
CXR ___
1. Pulmonary vascular congestion and mild to moderate pulmonary
edema.
2. Patchy opacities at the lung bases for which superimposed
infection cannot
be excluded in the appropriate clinical setting.
Brief Hospital Course:
Ms. ___ is a ___ yoF with stage IV CKD, T2DM c/b retinopathy
and nephropathy, asthma, CHF, recent admissions for GIB
(___), PNA (___), and endocarditis
(___), who is presenting with worsening shortness of
breath and chest pain.
ACUTE ISSUES
===============================================
# Shortness of breath
# Acute on chronic diastolic heart failure
Patient presented with several days of worsening shortness of
breath, associated with lower extremity swelling, elevated, and
CXR with vascular congestion. A TTE was done without evidence of
volume overload but with large volume LA and eleated PCWP. She
was maintained on a lasix drip initially. Her presenting weight
was 71.9kg and her discharge weight was 61.1kg. She was
eventually converted to torsemide. 60mg of torsemide daily
seemed to cause an ___, so she was converted to 40mg torsemide
daily on discharge. Her beta blockage is 600mg labetalol twice
daily, and afterload reduction is nifedipine which was decrease
from 90mg daily to 30mg daily.
# ___ on CKD
Recently baseline Cr ~3.5-4. Presenting with Cr 4.5. Her Cr
peaked at 6.0 on ___ and her new baseline appears to be 4.5 to
5. Renal was consulted and felt that it was likely ATN at this
point given recent hypotension. Received torsemide 60mg ___ and
___ and Cr increased to 5.5 with increasing phosphate. This was
thought to possibly be secondary to hypotension versus
overdiuresis, and her diuretic dose was decreased. For her
worsening phosphate, sevelamer was increased and she was started
on a low phosphorous diet. Of note, patient is not entertaining
the idea of dialysis at this time, stating that she does not
have physical symptoms from her renal failure and therefore does
not feel like dialysis would be indicated. We did encourage a
duplex ultrasound of her unused fistula, but the patient and
family declined, stating preference to complete this as an
outpatient.
#UTI
Urine culture from ___ (prior to cath) grew pan-sensitive
pseudomonas, repeat ___ growing E. Coli, pan-sensitive. Patient
did not endorse urinary symptoms. She was treated with a 10 day
course of ciprofloxacin ___ to ___.
# RLE DVT
During previous hospitalization, patient found to have RLE DVT.
Given that this was her second clot (previous PE) plan was for
likely lifelong anticoagulation. Discharged on warfarin but
admitted with INR 3.8. Warfarin regimen was titrated and she
became subtherapeutic on repeated doses of 4mg, requiring
heparin drip. She was therapeutic on discharge (goal INR ___
and discharged on 4mg warfarin daily.
# Hypertension and intermittent hypotension.
Presented with elevated SBP > 180, resumed home nifedipine and
nitrate with improvement in blood pressure. She did have
occasional drops in her blood ___ and ___ pressure requiring
continued titration of her antihypertensive regiment:
- Labetalol 600mg BID
- Nifedipine at reduced dose of 30mg daily
# Hypoglycemia h/o DM II
Found to be hypoglycemic in ED, improved. Was followed by ___
during last admission, and ultimately discharged on NPH. ___
was consulted on this admission and she was discharged on 70/30
insulin 20 units every morning with 2.5mg glipizide with dinner.
Patient will need continued exploration of the safest regiment
for insulin administration. After extensive discussion, decided
to switch patient to syringe administration of 70/30 insulin
every morning, to be drawn up by the ___ or daughter every
morning, and at least initially to be administered by either ___
or daughter.
CHRONIC ISSUES
========================
# Normocytic anemia - Suspect anemia of chronic disease as well
as anemia of chronic kidney disease. Stable from prior
admission.
TRANSITIONAL ISSUES
===========================
[ ] Needs close monitoring of phosphorus, which rose to 6 prior
to discharge due to worsening renal failure. Increased sevelamer
prior to discharge.
[ ] Patient will need duplex ultrasound of her fistula, which
she and her family preferred be completed as an outpatient.
[ ] Consider whether patient should continue on erythropoietin
therapy
[ ] Discharge INR 2.5. Follow up with INR in 2 days on ___
with goal ___ for DVT
[ ] Discharge weight 61.1kg (134.7 lb). Patient discharged with
diuresis regimen 40mg torsemide and will need follow-up BMP at
next PCP ___
[ ] Patient will need continued exploration of the safest
regiment for insulin administration. After extensive discussion,
decided to switch patient to syringe administration of 70/30
insulin every morning, to be drawn up by the ___ or daughter
every morning, and at least initially to be administered by
either ___ or daughter.
[ ] Discharge Cr 4.5. Recheck with BMP as above
[ ] Titrate anti-HTN medication regimen as needed. Patient
experienced both hypotension and hypertension during
hospitalization during medication titration.
[ ] Per our occupational therapists, Ms. ___ seemed to need
encouragement to eat and participate in self care. Should have
formal evaluation by psychiatry and neuropsychiatry in the
outpatient setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Calcitriol 0.25 mcg PO EVERY OTHER DAY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Furosemide 80 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Labetalol 1200 mg PO BID
9. NIFEdipine (Extended Release) 90 mg PO DAILY
10. Senna 17.2 mg PO BID:PRN Constipation - First Line
11. ProAir RespiClick (albuterol sulfate) 90 mcg/actuation
inhalation QID:PRN
12. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
13. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
14. Simethicone 40-80 mg PO QID bloating
15. Ramelteon 8 mg PO QHS:PRN insomnia
16. Warfarin 4 mg PO DAILY16 DVT
17. Regular 14 Units Breakfast
18. Ferrous Sulfate 325 mg PO DAILY
19. Epoetin Alfa 1 mL SC Q14DAYS
20. Bisacodyl 10 mg PR QHS:PRN constipation
Discharge Medications:
1. GlipiZIDE 2.5 mg PO DINNER
hold if not eating
RX *glipizide 5 mg 0.5 (One half) tablet(s) by mouth With Dinner
Disp #*30 Tablet Refills:*0
2. Insulin Syringe (insulin syringe-needle U-100) 0.5 mL 29
gauge x ___ miscellaneous QAM
RX *insulin syringe-needle U-100 31 gauge x ___ Every morning
Disp #*100 Syringe Refills:*0
3. Lancets,Ultra Thin (lancets) 26 gauge miscellaneous DAILY
RX *lancets [Safety Lancets] 28 gauge Twice Daily Disp #*4 Each
Refills:*0
4. sevelamer CARBONATE 1600 mg PO TID W/MEALS
RX *sevelamer carbonate 800 mg 3 tablet(s) by mouth Three times
daily WITH MEALS Disp #*270 Tablet Refills:*0
5. Torsemide 40 mg PO DAILY
RX *torsemide 10 mg 4 tablet(s) by mouth Daily Disp #*120 Tablet
Refills:*0
6. 70/30 20 Units Breakfast
RX *insulin NPH and regular human [Novolin 70/30 U-100 Insulin]
100 unit/mL (70-30) AS DIR 20 SQ 20 Units before BKFT; Disp #*1
Package Refills:*0
7. Labetalol 600 mg PO BID
RX *labetalol 200 mg 3 tablet(s) by mouth Twice Daily Disp #*180
Tablet Refills:*0
8. NIFEdipine (Extended Release) 30 mg PO DAILY
RX *nifedipine 30 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 40 mg PO QPM
12. Bisacodyl 10 mg PR QHS:PRN constipation
13. Calcitriol 0.25 mcg PO EVERY OTHER DAY
14. Docusate Sodium 100 mg PO BID:PRN constipation
15. Epoetin Alfa 1 mL SC Q14DAYS
16. Ferrous Sulfate 325 mg PO DAILY
17. Fluticasone Propionate NASAL 1 SPRY NU BID
18. ProAir RespiClick (albuterol sulfate) 90 mcg/actuation
inhalation QID:PRN
19. Ramelteon 8 mg PO QHS:PRN insomnia
20. Senna 17.2 mg PO BID:PRN Constipation - First Line
21. Simethicone 40-80 mg PO QID bloating
22. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
23. Warfarin 4 mg PO DAILY16
24.Outpatient Lab Work
ICD 9 = 428.0; ___, PTT, CBC, Na, K, Cl, CO2, BUN, Cr, Ca, Mg,
Phos drawn on ___ and faxed to PCP, ___ at
___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
======================
Acute on chronic diastolic heart failure
SECONDARY DIAGNOSIS:
======================
Stage IV Chronic Kidney Disease
Left Deep Vein Thrombosis
History of endocarditis
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!
Why were you admitted?
- You were admitted from your rehab for shortness of breath
What happened while you were in the hospital?
- You were found to be in worsening of your heart failure, which
resulted in too much fluid retention in your body
- We gave you some IV medications to help get fluids out of your
body
- We changed around your blood pressure medications to make sure
you blood pressures were not too high or too low
- We treated you for a urinary tract infection
- We changed the type of insulin you will get for your diabetes
- We worked with the kidney doctors to ___ to preserve the
function of your kidneys
What should you do when you leave the hospital?
- Closely review the attached medication list as we made several
changes to your medications.
- Weigh yourself every morning, and call MD if weight goes up
more than 3 lbs.
- If you develop worsening shortness of breath, please present
to the ER immediately
- You should continue to take your blood thinner for your clot
in your leg
Thank you for allowing us to participate in your care!
- Your ___ Team
Followup Instructions:
___
|
19740429-DS-14
| 19,740,429 | 26,139,470 |
DS
| 14 |
2120-10-15 00:00:00
|
2120-10-15 21:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrocodone-acetaminophen
Attending: ___.
Chief Complaint:
Worsening renal function
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with a history of chronic kidney disease stage
V with a functioning left upper extremity fistula, not on
dialysis, Who presents for evaluation of worsening renal
function.
She was in her usual health until ___, when she presented to the
___ emergency department with knee pain. Her knee was
aspirated, and blood was withdrawn, but this was not sent for
culture. She went to an orthopedic surgeon who later diagnosed
her as having gout as well as hemarthrosis. However, due to
persistent knee pain, the patient is unable to arise from bed to
go to the bathroom. Thus, over the weekend, she has been
drinking less than usual because she cannot get someone to
assist her to the bathroom. On that background, they have been
measuring her renal function tests at rehab, and noticed her
kidney function getting worse. They spoke to her nephrologist,
who therefore referred her to our hospital for further
evaluation today. The patient herself denies any complaints.
Specifically, there are no fevers or chills. No chest pain. No
difficulty with breathing, no worsening peripheral edema. No
abdominal pain, nausea, or vomiting. Her most recent
BUN/creatinine from the rehab paperwork showed BUN 133,
creatinine 5.9 (last measurements in our system 60/3.9). She
continues to urinate.
Of note, her nursing home is been holding her warfarin, which
she is taking for right lower extremity DVT. This is because of
the hemarthrosis in the left lower extremity. They are awaiting
clearance from her orthopedic surgeon to restart it.
In the ED:
97.2 65 146/59 16 100% RA
Labs showed:
Na:134
K:4.7
Cl:101
TCO2:24
Glu:130
Hgb:9.3
CalcHCT:28
U/A: unremarkable
WBC 5.2
H/H 8.9/___.8
Plt 238
___: 11.4 PTT: 25.3 INR: 1.1
138 98 132
-------------<147 AGap=16
5.0 24 5.2 ___
Ca: 9.1 Mg: 2.0 P: 5.2
CXR showed:
Mild pulmonary vascular congestion, improved from prior.
Patient received:
___ 01:28 IVF NS Started
___ 01:33 IVF NS 10 mL Stopped (___)
___ 06:17 IVF NS Restarted
___ 07:34 PO/NG Acetaminophen 650 mg
___ 08:34 IVF NS 450 mL Stopped (7h ___
___ 09:00 SC Insulin Not Given
___ 09:20 SC Insulin Not Given per Sliding Scale
___ 09:26 PO NIFEdipine (Extended Release) 60 mg
___ 09:26 PO/NG Labetalol 200 mg
___ 09:38 SC Insulin 8 UNIT
___ 10:15 PO sevelamer CARBONATE 800 mg
___ 10:15 IH Fluticasone-Salmeterol Diskus (250/50) 1 INH
Vitals at transfer:
98.0 81 177/71 17 99% RA
On the floor:
She was recently went from the ED to rehab for pain in her knee.
She went to clinic to have her knee evaluated, and had an
aspiration from her knee joint.
She was subsequently sent back to rehab (this happened last
___
She reports she has been trying to drink more to hydrate her
kidneys She denies dysuria. Denies fevers or chills. Reports
some mild abdominal discomfort in abdomen last week.
She reports her knee pain is "about the same."
She has been taking Tylenol for knee pain.
She says she was not taking her blood thinners because her rehab
did not have them.
Denies n/v, denies CP, SOB, dizziness, HA. Denies blood in stool
or urine.
Per review of recent ED note:
Seen ___
"Pt and daughter state that she has been experiencing some
discomfort in her left knee for the past few weeks while working
with ___ at home, however yesterday the pain became much worse
and she developed significant swelling. She now states she is
unable to bear weight on the leg. She denies any trauma to the
knee, redness or fevers. She does report a brief episode of pain
and tingling in her left toes this morning which has since
resolved. Her problem list includes gout, however the patient
and daughter deny any history of gout or swollen joints.
On review of chart, pt has history of OA in left knee, has
received intraarticular steroid injections
Diagnosis: osteoarthritis
ED Course (labs, imaging, interventions, consults):
- IV morphine 2mg
- knee tapped."
at that time, she was discharged to Rehab.
She was seen by Ortho at ___ on ___ for follow up.
At that time, 60 mL of bloody fluid was aspirated. She did
receive L knee steroid injection.
Per report, test were positive for gout, and X ray showed severe
OA.
There is documentation of multiple calls from MD to ___
providers.
Per last ___ note on ___, OK to restart anticoagulation.
Past Medical History:
- HTN, HLD, CKD V
- Type 2 Diabetes Mellitus, with retinopathy, nephropathy
- Gout
- OSA not on CPAP
- Pulmonary Embolism - ___ years ago, s/p 6 months of coumadin
then stopped, no recurrence
- Osteoarthritis
- Goiter
- Asthma
- Right neck pain (? trigeminal neuralgia)
- Recent diagnosis of a lower GIB, diverticular bleed versus
ischemic colitis
- hemarthrosis, L knee
Social History:
___
Family History:
Mother with DM.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: per OMR
GENERAL: lying in bed, comfortable appearing, NAD
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, bilateral crackles at bases
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 1+ edema to knees bilaterally. L knee with limited
ROM ___ pain, L knee wrapped with ace bandage. Some L knee joint
space tenderness to palpation medially/laterally
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE PHYSICAL EXAM
VITALS: T 98.3 BP 122/62 HR 67 RR 16 O2SAT 94% RA
GENERAL: lying in bed, alert, interactive, comfortable
appearing, NAD
HEART: ___, RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABDOMEN: nondistended, nontender in all quadrants, no rebound or
guarding, no hepatosplenomegaly
EXTREMITIES: no peripheral edema. mild tenderness on palpation
in L knee in bilateral joint spaces, no warmth, erythema, or
swelling.
NEURO: moving all 4 extremities with purpose, L knee strength
___, symmetric smile, raised eyebrows, shut eyes
Pertinent Results:
ADMISSION LABS
___ 01:30PM GLUCOSE-176* UREA N-115* CREAT-4.7*
SODIUM-141 POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
___ 01:30PM estGFR-Using this
___ 01:30PM CALCIUM-9.1 PHOSPHATE-4.7* MAGNESIUM-2.1
___ 05:04AM ___ PTT-25.3 ___
___ 03:04AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:04AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:04AM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:09AM GLUCOSE-130* NA+-134 K+-4.7 CL--101 TCO2-24
___ 01:09AM HGB-9.3* calcHCT-28
___ 12:09AM GLUCOSE-147* UREA N-132* CREAT-5.2*#
SODIUM-138 POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-24 ANION GAP-16
___ 12:09AM CALCIUM-9.1 PHOSPHATE-5.2* MAGNESIUM-2.0
___ 12:09AM WBC-5.2 RBC-2.98* HGB-8.9* HCT-27.8* MCV-93
MCH-29.9 MCHC-32.0 RDW-13.9 RDWSD-46.9*
___ 12:09AM NEUTS-66.1 LYMPHS-16.5* MONOS-11.7 EOS-4.5
BASOS-0.8 IM ___ AbsNeut-3.41 AbsLymp-0.85* AbsMono-0.60
AbsEos-0.23 AbsBaso-0.04
___ 12:09AM PLT COUNT-236
DISCHARGE LABS
___ 07:20AM BLOOD WBC-5.3 RBC-2.82* Hgb-8.6* Hct-27.0*
MCV-96 MCH-30.5 MCHC-31.9* RDW-14.0 RDWSD-49.2* Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD ___ PTT-26.3 ___
___ 07:20AM BLOOD Glucose-150* UreaN-100* Creat-4.3*
Na-148* K-5.0 Cl-109* HCO3-19* AnGap-20*
___ 07:20AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.0
___ 06:50AM BLOOD ___ PTT-26.3 ___
___ 06:50AM BLOOD Glucose-144* UreaN-94* Creat-4.3* Na-141
K-4.7 Cl-103 HCO3-23 AnGap-15
___ 06:50AM BLOOD Calcium-9.7 Phos-4.1 Mg-1.8
IMAGING
CXR ___
FINDINGS:
Lungs are adequately inflated and clear of consolidation. There
is mild pulmonary vascular congestion, without interstitial
edema. The cardiomediastinal and hilar silhouettes are within
normal limits. No pleural effusion. No pneumothorax.
IMPRESSION:
Mild pulmonary vascular congestion, improved from prior.
MICROBIOLOGY
___ 3:04 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 12:09 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
Brief Hospital Course:
ASSESSMENT/PLAN:
Ms. ___ is a ___ yo F with a past medical history of of HTN,
HLD, CKD stage V, T2DM (with retinopathy, nephropathy), gout,
OSA not on CPAP, PE ___ years ago), DVT (on Coumadin, though
recently held in setting of recent hemarthrosis), asthma, and
recent lower GIB who presents to the hospital for worsening Cr
at rehab in setting of poor PO intake due to limited mobility
from recently diagnosed L knee pain/gout.
=============
ACUTE ISSUES
=============
___ on CKD
The patient presented with ___, Cr to 5 from baseline ~3.3. Per
report of patient and daughter, she has had poor PO intake at
rehab over the past ___ weeks after recent hemarthrosis/knee
pain in setting of inability to move herself to the bathroom.
She appeared euvolemic on admission with no signs of volume
overload or severe dehydration. She was given 450cc NS in the ED
with a mild improvement of Cr from 5.2 to 4.7. Renal was
consulted and stated there was no indication for RRI. Home
torsemide was held from admission on ___ until the AM of ___,
when it was restarted, however after some hypotension to the
90/___, this was ___ on ___. Home sevelamer 1600 TID and
calcitriol QOD were continued. On the morning of discharge, Cr
was 4.3.
#HFpEF
The patient was euvolemic on presentation with an EKG that is
overall unchanged from priors in ___. CXR in the ED
showed some pulmonary vascular congestion. The patient was
asymptomatic in regard to cardiovascular complaints and remained
on room air during the course of her stay. Torsemide was held as
above initially but restarted on ___. However, subsequently the
patient experienced hypotension to the 90/50s with dizziness
symptoms the ___ of ___ this improved quickly after increased
PO intake to 130s systolic. We felt that given her clinical
examination it was reasonable to hold this medication, and to
consider restarting at rehabilitation facility at a reduced dose
(likely 10 mg or 20 mg daily) once her PO intake remained
stable.
#Recent ___ DVT
The patient was started on warfarin for ___ DVT in ___. This
was held in early ___ for an episode of knee hemarthrosis,
though reportedly it was recently restarted at rehab per ___
notes. INR was subtherapeutic at 1.1 on admission. Warfarin 2 mg
qd was continued. It was increased to 3 mg on ___, but lowered
back to 2 mg daily on ___, with 3 mg give ___ of ___. INR at
the time of discharge was 1.1. The patient and her daughter had
many concerns about warfarin during the course of her stay; it
was discussed that they could further discuss her indications
for continuing anticoagulation and the duration of AC needed
(along with the risks and benefits) with her PCP at discharge.
#Hemarthrosis
#Gout flare
The patient had a recent diagnosis of hemarthrosis/gout in the L
knee ___ weeks prior to admission). At ___, her knee tap was
bloody with monosodium urate crystals. She was given a steroid
shot and knee aspiration was performed at that time. On
admission, the patient had some limited ROM on exam, but she
reported that her pain is overall improving. Tylenol was given
as needed and warfarin was restarted as above. She was seen by
___ who recommended ongoing rehabilitation. She complained of L
toe pain, which was evaluated; her toe was not red and inflamed,
and X ray showed fracture; it was felt this was ___ altered gait
from L knee injury.
===============
CHRONIC ISSUES
===============
#DM2: continued home insulin 70/30 8U QAM with additional HISS.
Home ASA and statin were continued. Per her daughter, she is on
home ___; this was held during admission as it is non
formulary. Discussed with patient that she should continue on
HISS and 70/30 during her rehabilitation stay, but likely could
transition back to ___ when she leaves rehab.
#HTN: patient presented with elevated blood pressures, maximum
SBPs in 200s with significant lability through the day (SBPs
from 100s after BP medication administration to 200s in the
hours prior to medication administration). Recommend staggering
the timing of home nifedipine and labetalol as such: labetalol
BID (qAM, qPM) and nifedipine (midday). Her torsemide was held
as per above (though was given once on ___, with resultant low
BPs). Please monitor patient's volume status daily and consider
adding torsemide at reduced dose (possibly 10 mg or 20 mg to
start) as her PO intake increases.
#Asthma: continued her albuterol inhaler PRN. Initiated
Fluticasone-Salmeterol Diskus (250/50) while in house in lieu of
home symbicort and fluticasone spray. Will continue home regimen
at discharge.
#Poor PO intake
Patient overall had poor PO intake prior to her arrival at
___. Nutrition saw her during her hospital stay, and
recommended Glucerna supplementation. Patient should have
ongoing monitoring of PO intake, and consideration of switch
from Glucerna to Nepro given CKD/ESRD with preparation for HD.
====================
TRANSITIONAL ISSUES
====================
HELD torsemide 40 mg qd - please monitor weight daily and volume
status daily, and consider titrating up slowly, perhaps at
reduced dose of 10 mg or 20 mg dose on ___ or ___
Restarted: warfarin 3 mg daily ; should be dosed according to
INR level
Next INR: ___
Next Basic Metabolic Panel: please draw on ___ for
monitoring of Na, K, Mag, Phos, and BUN Creatinine
[ ] Follow up on two pending blood cultures from ___ (no
growth to date)
[ ] Continue monitoring INR daily and uptitrate warfarin with
goal INR ___ (upon discharge, patient's INR was only 1.1). Next
INR on ___. Per daughter's report, patient previously taking 4
mg 5x per week and 5 mg on 2 days per week.
[ ] Please encourage PO intake as acute kidney injury likely
occurred in the setting of poor PO intake. Consider nutrition
eval at rehab. Please consider switching patient from Glucerna
to Nepro (as she is ___
[ ] Follow up with nephrologist Dr. ___ kidney
function, plan for future dialysis
[ ] Follow up with vascular surgeon Dr. ___ as scheduled to
verify fistula on LEFT extremity is functioning
[ ] Please schedule appointment with patient's primary care
doctor within ___ weeks of discharge from rehabilitation
facility
[ ] Please continue to monitor patient's L knee and foot pain.
She may need additional visit with Orthopedics or Rheumatology
if worsening L knee pain with concern for ongoing gout or OA
[ ] Consider restarting torsemide as tolerated by kidney
function. Her home dose is 40 mg qd, however as noted above this
was held during her hospitalization for labile blood pressures
and concern for ___ and ___ PO intake. Please monitor patient's
weight daily and volume status. Please consider initiating low
dose (10 mg or 20 mg on ___ or ___ and slowly titrating up.
Torsemide was held during admission due to stabilizing kidney
function and labile blood pressure; however due to her history
of heart failure, she likely should not be kept off of this
medication entirely for too long.
[ ] Please continue to monitor labile blood pressures. Recommend
staggering administration of blood pressure medication:
labetalol (qAM, qPM), and nifedipine (midday, around noon).
[ ] Anticoagulation plan: Warfarin was restarted at this
hospitalization given patient's history of remote PE and recent
DVT; per prior notes without clear provocation, with plan for
lifelong anticoagulation. Patient and her daughter had many
concerns about this during the course of her stay; it was
discussed that they could further discuss her indications for
continuing anticoagulation and the duration of AC needed(along
with the risks and benefits) with her PCP at discharge.
[ ] diabetes: home ___ held during hospitalization as non
formulary; however continued on 70/30 and put on HISS while
inpatient. Discussed with patient that she should consider
continuing HISS and 70/30 while inpatient and at rehab, with
reinitiation of ___ once she leaves rehab
FULL CODE
Name of health care proxy: ___
Relationship: daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. 70/30 8 Units Breakfast
2. Torsemide 40 mg PO DAILY
3. sevelamer CARBONATE 1600 mg PO TID W/MEALS
4. Labetalol 600 mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. NIFEdipine (Extended Release) 60 mg PO DAILY
8. Calcitriol 0.25 mcg PO EVERY OTHER DAY
9. Bisacodyl 10 mg PO QHS:PRN Constipation - First Line
10. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
11. Epoetin Alfa 1 mL SC Q14 DAYS
12. Ferrous Sulfate 325 mg PO DAILY
13. Fluticasone Propionate NASAL 1 SPRY NU BID
14. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing, SOB
15. Ramelteon 8 mg PO QHS:PRN insomnia
16. Simethicone 40-80 mg PO QID:PRN upset stomach, bloating
17. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
18. FLUoxetine 20 mg PO DAILY
19. Warfarin 4 mg PO 5X/WEEK (___)
20. Omeprazole 20 mg PO DAILY
21. Toujeo Max SoloStar (insulin glargine) 6 units subcutaneous
QAM
22. Warfarin 5 mg PO 2X/WEEK (___)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. 70/30 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Warfarin 3 mg PO DAILY16
4. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing, SOB
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Bisacodyl 10 mg PO QHS:PRN Constipation - First Line
8. Calcitriol 0.25 mcg PO EVERY OTHER DAY
9. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
10. Epoetin Alfa 1 mL SC Q14 DAYS
11. Ferrous Sulfate 325 mg PO DAILY
12. FLUoxetine 20 mg PO DAILY
13. Fluticasone Propionate NASAL 1 SPRY NU BID
14. Labetalol 600 mg PO BID
15. NIFEdipine (Extended Release) 60 mg PO DAILY
recommend giving at noon to prevent midday hypotension
16. Omeprazole 20 mg PO DAILY
17. Ramelteon 8 mg PO QHS:PRN insomnia
18. sevelamer CARBONATE 1600 mg PO TID W/MEALS
19. Simethicone 40-80 mg PO QID:PRN upset stomach, bloating
20. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
21. HELD- Torsemide 40 mg PO DAILY This medication was held. Do
not restart Torsemide until discuss it with the doctors at
rehab. you may have to start on a slightly lower dose.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute kidney injury (prerenal azotemia)
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 the hospital because of worsening kidney
function. We think this may have happened because you were not
eating or drinking enough at rehab.
You also had some knee pain from your previously diagnosed gout.
While in the hospital, you were treated with IV fluids, and your
kidney function improved with increased eating and drinking. Our
team of kidney doctors ___ Dr. ___ saw you here and
felt that at this time, despite the Creatinine number going up
and down a little bit, the kidney function was overall about the
same. However, they did not feel that you need to start dialysis
at this time.
We restarted your warfarin while you were in the hospital.
Please discuss with your PCP about how long you should continue
to be on warfarin (Coumadin).
Please continue to monitor your weight daily and eat a low
sodium diet. We held your torsemide diuretic while you were here
in the hospital, but will recommend that your rehab facility
consider restarting it at a lower dose once you start eating and
drinking more normally. Please watch out for more leg swelling
or shortness of breath.
You have a follow up appointment with your vascular surgeon to
examine the fistula in your left arm.
Please continue to drink plenty of fluids and maintain a healthy
diet. Continue to take all your medicines and keep your
appointments.
It was a pleasure caring for you at ___
___. We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19740429-DS-5
| 19,740,429 | 28,708,627 |
DS
| 5 |
2114-05-10 00:00:00
|
2114-05-11 14:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrocodone-acetaminophen
Attending: ___.
Chief Complaint:
bloody stools
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year-old woman presenting with dark red stools since the day
prior to presentation. Patient reports two instances of passing
dark red stool and once again the day of presentation. Denies
abominal pain, although it did have one episode of cramping
across her abdomen once earlier today which lasted seconds. She
denies fevers, chills, nausea, vomiting but endorsed 1 week ago
history of nausea vomiting and loose stools which she called
"stomach virus".
.
In the ED, her initial VS were 98.5 76 153/64 18 96%. Labs in
the ED were notable for Cr 2.2, BUN 34 and HCT 29.8. Rectal exam
in the ED identified guiaic positive dark red stool. She was
given pantoprazole IV and received 1L of NS IV. Vitals on
transfer were 98.1 82 21 167/75 97% RA.
.
Past Medical History:
1. Hypertension
2. Type 2 Diabetes Mellitus, with retinopathy, npehropathy, A1C
___
3. Gout
4. Hyperlipidemia
5. Chronic Renal Failure, baseline cr 1.6 but per ___ note last
serum crt ___
6. Obstructive Sleep Apnea - unable to tolerate cpap
7. Pulmonary Embolism - ___ years ago, s/p 6 months of coumadin
then stopped, no recurrence
8. Osteoarthritis
9. Goiter
10. Asthma
11. Right neck pain (? trigeminal neuralgia)
Social History:
___
Family History:
Breast cancer in 2 sisters, DM in father, mother, sister, htn in
mother.
Physical Exam:
VS - Temp 99.2F, BP 144/92, HR 88, R 22, O2-sat 100% RA
Gen: Well appearing woman in NAD
Eye: extra-occular movements intact, pupils equal round,
reactive to light, sclera anicteric, not injected, no exudates
ENT: mucus membranes moist, no ulcerations or exudates
Neck: no thyromegally, JVD: flat
Cardiovascular: regular rate and rhythm, normal s1, s2, no
murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non-tender without rebound or guarding, non
distended, no
heptosplenomegally, bowel sounds present
Extremities: trace pitting lower extremity edema, no cyanosis,
clubbing, joint swelling
Neurological: Alert and oriented x3, CN II-XII intact, normal
attention, sensation normal, speech fluent
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Hematologic: no cervical or supraclavicular LAD
Pertinent Results:
LABS:
=====
___ BLOOD WBC-7.6 RBC-3.24* Hgb-9.6* Hct-29.8* MCV-92
MCH-29.8 MCHC-32.3 RDW-13.8 Plt ___
___ 07:00AM BLOOD Hct-28.0*
___ BLOOD ___ PTT-28.3 ___
.
Blood chemistry:
================
___ BLOOD Glucose-125* UreaN-34* Creat-2.2* Na-144 K-4.1
Cl-106 HCO3-27 AnGap-15
___ BLOOD Creat-1.7* Na-145 K-3.9 Cl-107
___ Glucose-127* UreaN-31* Creat-2.1* Na-142 K-4.4 Cl-106
HCO3-26 AnGap-14
___ BLOOD Calcium-9.9 Phos-3.6 Mg-2.6
.
IMAGING:
========
CT abdomen-pelvis without contrast:
IMPRESSION:
1. Extensive diverticulosis throughout the descending and
sigmoid colon.There is minimal fat stranding surrounding few
diverticula at the level of the descending colon representing
mild uncomplicated diverticulitis.
2. Normal appearance of the stomach and small bowel without CT
evidence of
mass lesion or inflammation. Normal appendix.
3. Markedly enlarged uterus with multiple large calcified fundal
fibroids.
.
MICROBIOLOGY:
=============
___ 12:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
___ year old woman presented with frequent bloody stools, right
and left lower quadrant tenderness, found to have diverticulosis
and mild diverticulitis on CT scan. Antibiotics were initiated
after CT findings. Her Hct and vital signs remained stable
throughout her stay. She was discharged home in stable
condition.
# GI Bleed: Lower GI bleed is most likely secondary to
diverticulosis seen on CT. Upper GI bleed was unlikely given
stable Hct throughout her stay with stable vital signs. Given
lower abdominal cramps and mild tenderness in the lower
quadrants on admission, infectious etiologies were considered.
Stool studies for infections was negative. CT abdomen showed
diverticulosis (please see result section) with findings
suggestive of mild diverticulitis. Initially she was placed on
IV ciprofloxacin and IV flagyl, which was switched to augmentin
on discharge to be taken for total of 7 days through ___.
Increasing fiber in her diet was encouraged to ensure soft
stools.
.
# Acute on chronic renal failure: Patient has CKD with baseline
Cr 1.6-1.8. Cr on admission was 2.2 likely in the setting of GI
Bleed. Patient received 2L NS since admission and Cr slightly
improved down to 1.7. Upon discharge her Cr was back to 2.1-2.2
and remained stable. Good oral fluid intake was encouraged.
.
# DM: Held oral agents while inpatient and placed on insulin
sliding scale. Discharged back on home regimen.
.
# COPD: Continued albuterol inhaler as needed.
.
# HTN: Initially held lisinopril and nifedipine in concern of
possible profuse lower GI Bleed, however she remained stable and
these medications were restarted.
.
# HLD: Continued atorvastatin.
.
# Trigeminal neuralgia: Continued topiramate.
.
.
Transitional issues:
- consider repeat renal function
- follow up on diverticulitis and bowel movements
Medications on Admission:
- Topiramate 50mg daily
- Glipizide 10 mg BID
- Calcitriol 0.25 mcg daily
- Omeprazole 20 mg daily
- Lisinopril 40 mg daily
- Furosemide 20 mg daily
- Nifedipine ER 90 mg daily
- NPH 7 units AM and ___
- Epoetin alfa 5000 units weekly
- Ketoconazole 2 % Topical Cream BID
- ProAir HFA 2 Puffs QID
- ___ 325 mg (65 mg iron) BID
- One Daily Multivitamin daily
- Calcium carbonate 650 mg calcium (1,625 mg) daily
- Aspirin 81 mg daily
- Atorvastatin 20 mg daily
Discharge Medications:
1. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
3. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day.
6. NPH insulin human recomb 100 unit/mL Suspension Sig: One (1)
inj Subcutaneous twice a day: 7unit in morning, 7unit in
evening.
7. epoetin alfa 10,000 unit/mL Solution Sig: 0.5 inj Injection
once a week.
8. ketoconazole 2 % Cream Sig: One (1) application Topical twice
a day.
9. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2)
puff Inhalation every six (6) hours as needed for shortness of
breath or wheezing.
10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
11. multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
14. calcium carbonate 650 mg calcium (1,625 mg) Tablet Sig: One
(1) Tablet PO once a day.
15. topiramate 50 mg Tablet Sig: One (1) Tablet PO once a day.
16. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
17. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 7 days: through ___.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Lower GI bleed
Diverticulosis
Mild Diverticulitis
Hypertension
.
Secondary Diagnoses:
Hyperlipidemia
Chronic Kidney Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a great pleasure taking care of you as your doctor. As
you know you were admitted to ___ for having bloody stools. We
have checked your blood levels serially which was stable. You
were stable during your stay. We did abdominal scan with
contrast which showed diverticulosis (outpouching of the colon
wall lining) in addition to mild inflammation. We initiated
antibiotics for the inflammation.
GI doctors were following with us in your care. You did not
require blood transfusions during your stay. Your lower
abdominal pain on exam resolved on your discharge day.
We did the following changs in your medication list.
Please START augmentin 875 mg twice daily for total of 7 days
through ___
Please continue taking the rest of your home medications the way
you were taking prior to admission.
Please follow with your appointments as illustrated below.
Followup Instructions:
___
|
19740429-DS-7
| 19,740,429 | 20,033,338 |
DS
| 7 |
2118-04-04 00:00:00
|
2118-04-04 17:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrocodone-acetaminophen
Attending: ___
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old female with a PMHx of diastolic heart
failure, T2DM on insulin, CKD, and hypertension presenting for
evaluation of dyspnea.
She has had worsening breathing for several days and then 2 days
ago she had wheezing without any improvement from the inhaler.
Her shortness of breath is exertional. This morning, she woke up
very dyspneic. No chest pain. Mild ___ swelling which happens off
and on. +Orthopnea. +PND. As the evening progressed, she became
more worried and came to the hospital.
No URI symptoms. Some chills last night. No fevers. No N/V/D.
In the ED, initial VS were 99.0 84 174/70 24 94% RA.
Past Medical History:
- Hypertension
- Type 2 Diabetes Mellitus, with retinopathy, nephropathy
- Hyperlipidemia
- Chronic Kidney Disease Baseline ~2.5
- Gout
- Obstructive Sleep Apnea not on CPAP
- Pulmonary Embolism - ___ years ago, s/p 6 months of coumadin
then stopped, no recurrence
- Osteoarthritis
- Goiter
- Asthma
- Right neck pain (? trigeminal neuralgia)
Social History:
___
Family History:
Breast cancer in 2 sisters, DM in father, mother, sister, htn in
mother.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T 98.5, BP 181/71, HR 91, RR 20, O2 94/RA
WEIGHT: 74.5 kg
GENERAL: NAD, well appearing
HEENT: Anicteric sclera, pink conjunctiva, MMM
NECK: JVP to earlobe at 45 degrees
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Crackles about half-way up bilaterally, otherwise clear,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: L wrist fistula with palpable thrill, warm and well
perfused, 1+ edema in b/l ___
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.6 ___ 93% RA
WEIGHT: 69.9 <- 70.9 <- 71.4 <- 73 <- 74.5 kg
I/O ___
GENERAL: NAD, well appearing
HEENT: Anicteric sclera, pink conjunctiva, MMM
NECK: JVP non-elevated
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Lungs CTAB, breathing comfortably without use of accessory
muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: L wrist fistula with palpable thrill, warm and well
perfused, trace pedal edema in b/l ___
Pertinent Results:
ADMISSION LABS
==============
___ 08:20PM BLOOD WBC-7.5 RBC-2.78* Hgb-8.3* Hct-26.7*
MCV-96 MCH-29.9 MCHC-31.1* RDW-12.5 RDWSD-43.8 Plt ___
___ 08:20PM BLOOD Neuts-76.5* Lymphs-12.4* Monos-7.6
Eos-2.3 Baso-0.9 Im ___ AbsNeut-5.71 AbsLymp-0.93*
AbsMono-0.57 AbsEos-0.17 AbsBaso-0.07
___ 08:20PM BLOOD Plt ___
___ 08:20PM BLOOD Glucose-186* UreaN-42* Creat-2.5* Na-140
K-4.0 Cl-102 HCO3-27 AnGap-15
___ 08:20PM BLOOD cTropnT-0.01 proBNP-3443*
___ 05:53AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.9
___ 08:27PM BLOOD Lactate-1.1
DISCHARGE AND PERTINENT LABS
============================
___ 05:05AM BLOOD WBC-6.3 RBC-2.93* Hgb-8.6* Hct-27.9*
MCV-95 MCH-29.4 MCHC-30.8* RDW-12.5 RDWSD-43.2 Plt ___
___ 06:35AM BLOOD ___ PTT-27.5 ___
___ 05:05AM BLOOD Glucose-130* UreaN-69* Creat-3.5* Na-141
K-3.7 Cl-98 HCO3-30 AnGap-17
___ 06:35AM BLOOD ALT-12 AST-18 LD(LDH)-233 AlkPhos-99
TotBili-0.5
___ 05:05AM BLOOD Calcium-9.8 Phos-4.8* Mg-2.1
IMAGING
=======
___ ECG
Sinus rhythm. Non-specific ST-T wave changes. Compared to the
previous
tracing of ___ no change.
___ Chest CXR, portable
FINDINGS:
Cardiac silhouette size is borderline enlarged. Mediastinal
contour is
unchanged. Mild pulmonary vascular congestion is noted. Patchy
atelectasis is seen in the lung bases. No pleural effusion or
pneumothorax is identified. No acute osseous abnormalities seen.
IMPRESSION:
Mild pulmonary vascular congestion and bibasilar atelectasis.
___
Conclusions
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. Normal left ventricular wall thickness,
cavity size, and regional/global systolic function (biplane LVEF
= 62 %). The estimated cardiac index is normal (>=2.5L/min/m2).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. [The severity of
mitral regurgitatiaon may be UNDERestimated due to acoustic
shadowing.] There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mild
pulmonary artery systolic hypertension.
MICROBIOLOGY
============
___ 8:20 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Patient is a ___ with PMHx of T2DM on insulin, CKD IV, HTN, and
dCHF presenting with dyspnea.
# Diastolic Heart Failure Exacerbation: Patient with elevated
BNP 3443, ___ edema, elevated JVP, and bibasilar crackles. There
was low concern for ACS with negative troponin x 1 and no
concerning EKG changes. Patient admitted to eating lots of salty
ham over the holidays which could have caused the exacerbation.
Patient diuresed with IV Lasix during the hospital course - 40mg
QD to BID and achieved euvolemia by time of discharge. TTE on
___ showed normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mild
pulmonary artery systolic hypertension which was most likely due
to hypervolemia. Prior to discharge she was started on torsemide
40mg daily. Her home Lasix 40mg BID was discontinued on
admission. She was counseled on cardiac healthy low sodium diet
to help prevent future exacerbations. Discharge weight 69.9 kg.
#Hypertension: On admission patient was hypertensive to
160s-170s. Patient's home regiment was: nifedipine extended
release 90mg, labetalol 300 QAM and 600 QPM. Her nifedipine was
increased to 120mg but she remained hypertensive. She was
started on hydralazine 10mg TID and isosorbide dinitrate 10mg
TID with improvement of SBPs to 110s to 120s however the patient
felt lightheaded with ambulation. The hydralazine was
discontinued and nifedipine lowered to 60mg qd. Her SBPs were in
the 120s-130s and she was no longer lightheaded. Discharge blood
pressure medications were: nifedipine extended release 60mg,
labetalol 300 QAM and 600 QPM, isosorbide mononitrate extended
release 30mg daily. Her blood pressure should be monitored and
medications adjusted as necessary.
# Chronic Kidney Disease: Patient with stage IV CKD. Baseline
appears to range from 2.5-3.3. Creatinine on admission was 2.5
and worsened to 3.5 by time of discharge. However, patient's
electrolytes were normal and she maintained good urine output.
She needs to follow up with nephrology as an outpatient to
discuss initiating dialysis as she already has an AV fistula in
place.
# Anemia: Patient receives Epo Q10days. Likely secondary to CKD
but possible there is an acute on chronic component given her
baseline Hgb is ___. Stable during hospitalization. No dark of
bloody stools were reported and stool guiacs negative. Hb was
stable throughout hospitalization and 8.6 on day of discharge.
Patient recently had outpatient Fe studies and is on iron
supplementation. Should be followed as outpatient and epopoeitin
redosed as necessary.
# Type 2 Diabetes on Insulin: Held home glipizide during
admission and continued NPH 8U QAM and QPM with insulin sliding
scale. Restarted home medications on discharge.
- HISS
# Hyperlipidemia: Continued home atorvastatin 40 mg
# Asthma/Obstructive lung disease: Unclear etiology. Patient
reports only having "asthma" for the last several years. Never
smoker. Continued home albuterol inhaler.
TRANSITIONAL ISSUES
====================
Discharge Weight: 69.9kg
[] started on isosorbide mononitrate(extended release) 30mg QD
[] nifedipine decreased to 60mg qd
[] started torsemide 40mg and stopped home furosemide 40mg BID
[] recheck CBC
[] recheck renal panel and assess creatinine/lytes
[] follow up blood pressure and titrate medicines as needed
[] encourage patient to eat a low salt cardiac diet given heart
failure/ CKD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Epoetin ___ ___ U/ml SC Q10D
3. Ferrous Sulfate 325 mg PO BID
4. Furosemide 40 mg PO BID
5. GlipiZIDE 10 mg PO BID
6. Labetalol 600 mg PO QPM
7. Labetalol 300 mg PO QAM
8. NPH 8 Units Breakfast
NPH 8 Units Bedtime
9. NIFEdipine CR 90 mg PO QHS
10. Calcitriol 0.25 mcg PO 3X/WEEK (___)
11. Omeprazole 20 mg PO DAILY:PRN heartburn
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
13. Multivitamins 1 TAB PO DAILY
14. Calcium Carbonate 500 mg PO TID
15. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Calcitriol 0.25 mcg PO 3X/WEEK (___)
5. Calcium Carbonate 500 mg PO TID
6. NPH 8 Units Breakfast
NPH 8 Units Bedtime
7. Labetalol 600 mg PO QPM
8. Labetalol 300 mg PO QAM
9. Multivitamins 1 TAB PO DAILY
10. NIFEdipine CR 60 mg PO QHS
RX *nifedipine 60 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
11. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
12. Epoetin ___ ___ U/ml SC Q10D
13. Ferrous Sulfate 325 mg PO BID
14. GlipiZIDE 10 mg PO BID
15. Omeprazole 20 mg PO DAILY:PRN heartburn
16. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Acute on chronic diastolic heart failure exacerbation
SECONDARY DIAGNOSIS
===================
Hypertension
Chronic Kidney Disease
Anemia
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were admitted to the hospital
after you developed worsening shortness of breath. On evaluation
here, it was found that you had too much fluid in your body most
likely from a condition called congestive heart failure. You
were given medications to help you pee out extra fluid in your
body. We started you on a medication called torsemide which will
help keep fluid from collecting in your body and causing
problems. It is important that you eat a low salt diet to
prevent fluid from accumulating in your body again.
We also found that you blood pressure was very high and have
made changes to your blood pressure medications. We started a
medication called isosorbide mononitrate and decreased your
nifedipine to 60mg daily.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you the best of health,
Your ___ care team!
Followup Instructions:
___
|
19740429-DS-8
| 19,740,429 | 21,118,175 |
DS
| 8 |
2119-01-04 00:00:00
|
2119-01-04 23:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrocodone-acetaminophen
Attending: ___
Chief Complaint:
Palpitations, chest pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a PMHx of diastolic heart failure, T2DM
on insulin, CKD, and hypertension who presents with palpitations
and chest pressure.
Patient awoke this morning at 4 AM and had the sensation of
palpitations, which lasted approximately 30 minutes. She went
back to sleep and awoke at around 6 AM it with another episode
of palpitations lasting 30 mins. Starting with the second
episode of palpitations, she has had pressure in her lower left
anterior chest wall, constant, lasting 2 hours, with no
alleviating or aggravating factors, which went away on its own.
Pressure radiates towards her upper back. CP does not change
with movement, no exertional component. Has never had CP like
this with exertion or otherwise before. Denies SOB or
diaphoresis. Reports the pain is worse when she palpates the
site. Experienced some lightheadedness, but associated with
taking AM BP meds which is relatively common. No headache. Has
chronic orthopnea and intermittent ankle edema, hasn't been
worse recently. Has chronic cough. Denies fevers, chills,
abdominal pain, nausea/vomiting/diarrhea, dysuria. Has chronic
constipation.
At urgent care, BP 151/67 Pulse 78 Temp 97.5 °F Resp 16, SpO2
97% EKG showed T wave inversion lateral precordial leads V4, V5,
V6. She received ASA 325.
In the ED initial vitals were: 97.7 164/68 73 14 99/RA
EKG: NSR, TWI V4 V5 V6
Labs/studies notable for:
5.0>9.4/___.9<212
141 | 100 | 51
--------------<127
3.5 | 31 | 3.0
Trop 0.02 MB 2
BNP 3318
UA benign
#CXR: The lungs are clear. Right hilum remains prominent within
appearance that is unchanged compared with ___. Given
stability over time, likely represents a prominent vascular
structure. No focal consolidation, large effusion or
pneumothorax. The cardiomediastinal silhouette is stable. Bony
structures are intact. No free air is seen below the right
hemidiaphragm.
Patient given 600mg labetalol in the ED
On the floor, patient is tired but reports resolution of chest
pressure and palpitations. Is otherwise asymptomatic
Past Medical History:
- Hypertension
- Type 2 Diabetes Mellitus, with retinopathy, nephropathy
- Hyperlipidemia
- Chronic Kidney Disease Baseline ~2.5
- Gout
- Obstructive Sleep Apnea not on CPAP
- Pulmonary Embolism - ___ years ago, s/p 6 months of coumadin
then stopped, no recurrence
- Osteoarthritis
- Goiter
- Asthma
- Right neck pain (? trigeminal neuralgia)
Social History:
___
Family History:
Breast cancer in 2 sisters, DM in father, mother, sister, htn in
mother.
Physical Exam:
ADMISSION EXAM:
VS: 98.6 189 / 95 72 18 98 RA
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 7 cm.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No
thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, obese, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pretibial edema. No c/c. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses 3+ and symmetric
DISCHARGE EXAM:
VS: 98.6 ___ 72 18 98% on RA
GENERAL: Pleasant elderly woman in NAD
HEENT: NCAT. MMM
NECK: Supple with JVP just above clavicle at 45 degrees
CARDIAC: RRR, no m/r/g
LUNGS: CTAB
ABDOMEN: Soft, NT/ND, BS+
EXTREMITIES: WWP, no c/c/e
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: DP pulses present and symmetric
Pertinent Results:
ADMISSION/DISCHARGE LABS:
___ 07:30PM BLOOD WBC-5.0 RBC-3.12* Hgb-9.4* Hct-29.6*
MCV-95 MCH-30.1 MCHC-31.8* RDW-12.2 RDWSD-42.3 Plt ___
___ 07:35AM BLOOD WBC-5.0 RBC-2.94* Hgb-8.8* Hct-28.1*
MCV-96 MCH-29.9 MCHC-31.3* RDW-12.1 RDWSD-42.3 Plt ___
___ 07:30PM BLOOD Neuts-63.9 ___ Monos-7.3 Eos-2.6
Baso-0.6 Im ___ AbsNeut-3.22 AbsLymp-1.28 AbsMono-0.37
AbsEos-0.13 AbsBaso-0.03
___ 07:30PM BLOOD ___ PTT-29.7 ___
___ 07:30PM BLOOD Plt ___
___ 07:35AM BLOOD ___ PTT-28.4 ___
___ 07:35AM BLOOD Plt ___
___ 07:30PM BLOOD Glucose-127* UreaN-51* Creat-3.0* Na-141
K-3.5 Cl-100 HCO3-31 AnGap-14
___ 07:35AM BLOOD Glucose-137* UreaN-50* Creat-2.9* Na-141
K-3.3 Cl-100 HCO3-24 AnGap-20
___ 07:30PM BLOOD CK(CPK)-168
___ 07:30PM BLOOD CK-MB-2 proBNP-331___*
___ 07:30PM BLOOD cTropnT-0.02*
___ 01:50AM BLOOD cTropnT-0.02*
___ 07:35AM BLOOD CK-MB-2 cTropnT-0.02*
___ 07:30PM BLOOD Calcium-9.5 Phos-3.8 Mg-1.7
___ 07:35AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.6
___ 04:35PM URINE Color-Straw Appear-Clear Sp ___
___ 04:35PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:35PM URINE RBC-0 WBC-0 Bacteri-FEW Yeast-NONE Epi-<1
___ 04:35PM URINE CastHy-1*
___ 04:35PM URINE Mucous-RARE
IMAGING:
CXR ___:
FINDINGS:
PA and lateral views of the chest provided. The lungs are
clear. Right
hilum remains prominent within appearance that is unchanged
compared with ___. Given stability over time, likely represents a
prominent vascular
structure. No focal consolidation, large effusion or
pneumothorax. The
cardiomediastinal silhouette is stable. Bony structures are
intact. No free
air is seen below the right hemidiaphragm.
IMPRESSION:
As above.
BILAT LOWER EXT VEINS U/S ___:
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 left posterior tibial
and peroneal
veins and right posterior tibial veins. The right peroneal
veins were not
well visualized.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
The right peroneal veins were not well visualized. Otherwise no
evidence of deep venous thrombosis in the right or left lower
extremity veins.
Brief Hospital Course:
___ year old female with a PMHx of diastolic heart failure, T2DM
on insulin, CKD, and hypertension who presents with palpitations
and chest pressure. Patient was awoken from sleep multiple times
prior to presentation by palpitations which she had never
experienced before. Upon presentation she had TWI in V4-V6 and
an otherwise unremarkable EKG. She had no known history of
a-fib, and no a-fib was captured on tele during this admission.
Trop 0.02 x2 ISO CKD, MB 2. Pt had hx of PE, CTA not done for
evaluation of PE possible inciting factor given renal disease.
___ negative for DVT. She was hypertensive w/ SBPs in 170-180s
and was started on hydral. She had no episodes of palpitations
while in the hospital and will be discharged with close
cardiology follow up with Dr. ___.
TRANSITIONAL ISSUES:
DISCHARGE WEIGHT: 62.6 kg
DISCHARGE Cr: 2.9
DISCHARGE DIURETIC: Torsemide 20 mg PO/NG DAILY
MEDICATIONS STARTED: Hydralazine 25 mg PO TID
- Patient to have close follow up with her cardiologist, Dr.
___
- Dr. ___ to set up patient with ACT monitor that she will
pick up as an outpatient
- Please follow up on blood pressure as patient was started on
hydralazine prior to discharge
- Consider outpatient nuclear stress test
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 20 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. NIFEdipine CR 60 mg PO QPM
4. Labetalol 600 mg PO BID
5. GlipiZIDE 10 mg PO BID
6. Calcitriol 0.25 mcg PO 3X/WEEK (___)
7. Ketoconazole 2% 1 Appl TP BID
8. Epoetin ___ ___ units SC EVERY 7 DAYS (THURS)
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Ferrous Sulfate 325 mg PO BID
12. ciclopirox 0.77 % topical BID
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
14. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain
15. Ketoconazole Shampoo 1 Appl TP ASDIR
16. Multivitamins 1 TAB PO DAILY
17. Calcium Carbonate 1250 mg PO DAILY
18. Aspirin 81 mg PO DAILY
19. NPH 8 Units Breakfast
NPH 8 Units Dinner
Discharge Medications:
1. HydrALAZINE 25 mg PO TID
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*1
2. NPH 8 Units Breakfast
NPH 8 Units Dinner
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Calcitriol 0.25 mcg PO 3X/WEEK (___)
7. Calcium Carbonate 1250 mg PO DAILY
8. ciclopirox 0.77 % topical BID
9. Epoetin ___ ___ units SC EVERY 7 DAYS (THURS)
10. Ferrous Sulfate 325 mg PO BID
11. GlipiZIDE 10 mg PO BID
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Ketoconazole 2% 1 Appl TP BID
14. Ketoconazole Shampoo 1 Appl TP ASDIR
15. Labetalol 600 mg PO BID
16. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain
17. Multivitamins 1 TAB PO DAILY
18. NIFEdipine CR 60 mg PO QPM
19. Omeprazole 20 mg PO DAILY
20. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Palpitations
Chronic diastolic heart failure
Hypertension
SECONDARY DIAGNOSES:
Chronic kidney disease stage IV
Chronic normocytic anemia
Hyperlipidemia
Asthma
Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you. You were admitted to the
hospital because you were feeling some palpitations while at
home. Your heart was in a normal rhythm while you were in the
hospital, and all of your other testing was reassuring. We
watched you overnight, and you did not have any more of these
episodes.
You also had high blood pressure while you were in the hospital,
and we started you on hydralazine 10 mg three times per day.
This is a new medication to help bring your blood pressure down.
We are also setting you up to get a monitor early next week that
you will wear to see if you are experiencing any abnormal
rhythms that could be causing you to feel these palpitations.
If you experience any chest pain, shortness of breath, or
lightheadedness, you should return to the hospital to be
evaluated.
When you are discharged, it is important for you to take all of
your medications as directed. Weigh yourself daily and get in
touch with your doctor if your weight goes up more than 3 lbs.
You will have close follow up with your cardiologist, Dr.
___.
All our best,
Your ___ Care Team
Followup Instructions:
___
|
19740429-DS-9
| 19,740,429 | 24,846,722 |
DS
| 9 |
2119-08-11 00:00:00
|
2119-08-12 09:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
hydrocodone-acetaminophen
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ year old female with a PMHx of diastolic heart failure, T2DM
on insulin, CKD (b/l Cr 2.9-3.0)(left wrist fistula but not on
HD, asthma, remote PE and hypertension p/w dyspnea and wheezing.
Patient has worsening shortness of breath over the last two
days. She has been needing her albuterol inhaler every two hours
with some improvement in her symptoms. She is becoming very
short of breath with exertion and is only able to walk as far as
the bathroom, which is off from her baseline. She has slight
non-productive cough. Symptoms are worse when lying flat. Trace
lower extremity edema. No recent viral infection- denies fevers,
chills, nasal congestion. She is reporting chronic pain in her R
shoulder and upper back.
Of note patient has a history of remote PE, was on
anticoagulation for 6 months and is no longer on
anticoagulation.
In the ED, initial vitals were: 98.2 83 142/93 14 97% RA
- Exam notable for:
O2 sat 97% on room air
CV: Irregularly irregular, no murmurs
Resp: Faint wheezing, decreased air movement.
Ext: Trace lower extremity edema
- Labs notable for:
BNP 25682
TROP 0.03
Cr 3.1
WBC 7.3, crit 30
- Imaging was notable for:
CXR with mild cardiomegaly and bilateral pulmonary edema.
Small bilateral pleural effusions.
- Patient was given:
___ 01:30 IH Albuterol 0.083% Neb Soln 1 NEB
___ 01:30 IH Ipratropium Bromide Neb 1 NEB
___ 02:39 IV Furosemide 80 mg
___ 04:57 PO NIFEdipine CR 60 mg
___ 04:57 PO/NG HydrALAZINE 25 mg
___ 04:57 IV Labetalol 10 mg
___ 05:35 PO/NG Labetalol 600 mg
___ 08:24 PO Isosorbide Mononitrate (Extended Release)
30 mg
___ 08:24 PO Omeprazole 20 mg
___ 11:09 IV Furosemide 80 mg
Upon arrival to the floor, patient reports that she is still
having shortness of breath and wheezing.
She also reports constipation for three days.
- ECG: Irregularly irregular rhythm, rate 84, possibly frequent
PACs versus wandering pacemaker. No acute ischemic changes.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- Hypertension
- Type 2 Diabetes Mellitus, with retinopathy, nephropathy
- Hyperlipidemia
- Chronic Kidney Disease Baseline ~2.5
- Gout
- Obstructive Sleep Apnea not on CPAP
- Pulmonary Embolism - ___ years ago, s/p 6 months of coumadin
then stopped, no recurrence
- Osteoarthritis
- Goiter
- Asthma
- Right neck pain (? trigeminal neuralgia)
Social History:
___
Family History:
Breast cancer in 2 sisters, DM in father, mother, sister, htn in
mother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: T 98 BP 134/69 HR 71 SPO2 94% on 2L
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP elevated to mandible at 45deg
CV: Irregularly irregular. Normal rate, 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: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM:
========================
- VITALS: afebrile, BP 100's-150's/60-80's HR 60-80's RR 18 O2
sat 95% RA
- I/Os: 120/75(8hrs), 1030/750 (24hrs)
- WEIGHT: 67.2 from 66.2 kg
- WEIGHT ON ADMISSION: 69.3kg
- TELEMETRY: NSR with ongoing PACs
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM
Neck: Supple. JVP not elevated
CV: irregular. Normal rate, 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
Thorax: no CVA tenderness.
MSK: no ttp to paraspinal muscles. full ROM.
Ext: Warm, well perfused, no clubbing, cyanosis, trace edema.
Palpable thrill to LUE fistula
Neuro: strength and sensation grossly intact
Pertinent Results:
ADMISSION LABS:
===============
___ 03:47PM GLUCOSE-323* UREA N-59* CREAT-3.5* SODIUM-141
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-24 ANION GAP-19
___ 03:47PM CK-MB-2 cTropnT-0.03*
___ 03:47PM CALCIUM-9.3 PHOSPHATE-4.7* MAGNESIUM-2.0
___ 01:20AM GLUCOSE-172* UREA N-53* CREAT-3.1* SODIUM-141
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-22 ANION GAP-22*
___ 01:20AM estGFR-Using this
___ 01:20AM cTropnT-0.03*
___ 01:20AM ___
___ 01:20AM WBC-7.3 RBC-3.13* HGB-9.6* HCT-30.0* MCV-96
MCH-30.7 MCHC-32.0 RDW-13.2 RDWSD-46.2
___ 01:20AM NEUTS-82.2* LYMPHS-7.7* MONOS-7.0 EOS-2.1
BASOS-0.7 IM ___ AbsNeut-6.00# AbsLymp-0.56* AbsMono-0.51
AbsEos-0.15 AbsBaso-0.05
___ 01:20AM PLT COUNT-209
PERTINENT LABS:
===============
___ 06:45AM BLOOD WBC-4.3 RBC-3.26* Hgb-9.9* Hct-31.6*
MCV-97 MCH-30.4 MCHC-31.3* RDW-12.5 RDWSD-44.4 Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-103* UreaN-77* Creat-4.8* Na-141
K-4.2 Cl-100 HCO3-25 AnGap-20
___ 06:45AM BLOOD Calcium-10.0 Phos-5.5* Mg-2.2
IMAGING:
========
___ CXR:
Mild cardiomegaly and bilateral pulmonary edema.
Small bilateral pleural effusions.
___ TTE:
The left atrial volume index is mildly increased. No atrial
septal defect is seen by 2D or color Doppler. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (bipolane LVEF 53%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Mild to moderate (___) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and low normal global biventricular systolic function.
Mild-moderate mitral regurgitation. Mild pulmonary artery
systolic hypertension. Incresaed PCWP.
Compared with the prior study (images reviewed) of ___,
global left ventricular systolic function is slightly less
vigorous and mild-moderate mitral regurgitation is now seen.
Increasedd PCWP is also now suggested.
Brief Hospital Course:
___ year old female with a PMHx of diastolic heart failure, T2DM
on insulin, CKD IV (b/l Cr 2.9-3.0, left wrist fistula but not
on HD) asthma, remote PE and hypertension p/w dyspnea and
wheezing. Profound BNP elevation, mild tropenemia consistent
with acute exacerbation of diastolic heart failure, diuresed
with some improvement. Changed her over from 120 IV Lasix BID to
40 torsemide. Discharged without torsemide given ___. Nifedepine
was also held and should be restarted at discretion of outpt
cardiologist. BPs 130s-150s on discharge.
___ on CKD: renal consulted. Held diuresis ___. Work up
consistent with pre renal ___ ___ initial diuresis. Will be seen
by renal as outpt for ___ and diuretic titration.
Torsemide held on discharge. Nifedipine also held on discharge.
Discharged with sevelamer 800 tid with meals for hyperphos of
5.5 on discharge.
DM: Had few episodes of hypoglycemia so bedtime NPH decreased
from 10u to 6u with good effect.
TRANSITIONAL ISSUES:
-Torsemide held given ___. to be restarted as outpt. Nifedipine
also held.
-Discharge Cr 4.8, baseline around 3s. Please recheck at
nephrology appointment on ___ and can restart home torsemide 20
mg po daily if back to baseline.
-Started on sevelamer 800 TID w meals for hyperphos, please
titrate as necessary
-Bedtime NPH decreased from 10u to 6u, please monitor patient's
blood sugars
- Full code
- HCP: ___ daughter ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 10 mg PO BID
2. Labetalol 300 mg PO QAM
3. Labetalol 600 mg PO QPM
4. Torsemide 20 mg PO DAILY
5. Atorvastatin 40 mg PO DAILY
6. NPH 8 Units Breakfast
NPH 10 Units Bedtime
7. NIFEdipine CR 60 mg PO DAILY
8. Epoetin ___ ___ units SC WEEKLY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. HydrALAZINE 25 mg PO TID
11. Ferrous Sulfate 325 mg PO DAILY
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
13. Aspirin 81 mg PO DAILY
14. Calcium Carbonate 650 mg PO DAILY
15. Calcitriol 0.25 mcg PO EVERY OTHER DAY
16. Fluticasone Propionate NASAL Dose is Unknown NU Frequency
is Unknown
17. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
tid with meals Disp #*30 Tablet Refills:*0
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. HydrALAZINE 37.5 mg PO TID
RX *hydralazine 25 mg 1.5 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
4. NPH 8 Units Breakfast
NPH 6 Units Bedtime
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO DAILY
8. Calcitriol 0.25 mcg PO EVERY OTHER DAY
9. Calcium Carbonate 650 mg PO DAILY
10. Epoetin ___ ___ u SC WEEKLY
11. Ferrous Sulfate 325 mg PO DAILY
12. GlipiZIDE 10 mg PO BID
13. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
14. Labetalol 300 mg PO QAM
15. Labetalol 600 mg PO QPM
16. Multivitamins 1 TAB PO DAILY
17. HELD- NIFEdipine CR 60 mg PO DAILY This medication was
held. Do not restart NIFEdipine CR until you see your
cardiologist
18. HELD- Torsemide 20 mg PO DAILY This medication was held. Do
not restart Torsemide until you see your kidney doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute exacerbation of chronic diastolic heart failure
Acute on Chronic Kidney Disease
Demand NSTEMI from CHF/CKD
DM2 with hyper/hypoglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had shortness of breath
What happened while I was in the hospital?
- Your home water pill was not strong enough to work with your
kidney function, so we gave you medications to help your kidneys
get the fluid off your lungs that was causing your shortness of
breath
- Your kidneys became too dry and you will need to see your
kidney doctors in ___.
STOP THESE MEDICATIONS:
- stop torsemide
- stop nifedipine
You should discuss with your cardiologist Dr. ___ your
renal doctor Dr. ___ restarting these medications.
What should I do after leaving the hospital?
- Take all of your medications as described in this discharge
summary.
- Go to your follow up appointments.
- If you experience any of the danger signs listed below call
your primary care physician or come to the emergency department
immediately.
- Your discharge weight is 66.9 kg
-Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19740506-DS-15
| 19,740,506 | 20,458,231 |
DS
| 15 |
2169-04-17 00:00:00
|
2169-04-18 16:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine-Iodine Containing / Naproxen / Codeine /
Demerol / Latex / Nsaids / Novolog Flexpen
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ h/o DM, HTN, CKD, disc herniation presents with worsening of
chronic back pain x 1 week. In the ED, she reported ___ pain
in her lower back radiating down her left leg. She is followed
at ___ for her back pain and most recently had an MRI in
___ showing a herniated disc. She reports that she is
currently only on tylenol for pain. She reports significant
worsening in her pain over the past week, with new paresthesias
and weakness in her left leg as well. She reports "blacking out"
on ___, and today. She further characterizes
these episodes as feeling lightheaded due to pain and losing
consciousness; she denies chest pain, palpitations, post-ictal
confusion, loss of bowel or bladder control; the episodes were
unwitnessed. The first two episodes occured while in bed, and
the most recent occured while she was in the bathroom. She
lowered herself to the ground; denies headstrike/fall. Her pain
became so severe today that she called EMS to bring her to the
hospital. She denies CP, SOB, palpitations, n/v, f/c, abd pain,
diarrhea, bowel/bladder incontinence.
In the ED, initial VS were 10 97.7 59 137/67 16 100% RA
Exam notable for normal rectal tone, ___ lower extremity
strength, intact sensation, normal reflexes, downgoing toes.
Labs notable for absence of leukocytosis; Cr 2.4 (at baseline);
Hgb 11.5 (at baseline).
Imaging (MRI records from ___ showed spondylosis from
L3-S1, foraminal disc protrusion at L4-L5 on left side. ECG with
SR NA NI, no STTW changes.
Received morphine 5 mg IV x3.
Transfer VS were 97.0 49 141/63 16 99% RA
Ortho spine was consulted and recommended: "No need for urgent
MRI; recommend pain control and follow up with her provider at
___ for further work up of this chronic problem."
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports nausea and ___ back
pain.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
-C5 radiculopathy; cervical/lumbar radiculopathy
-Chronic lower back pain
-Osteoarthritis
-Type 2 diabetes, followed at ___, A1c 6.7
-Hx of gastritis (normal EGD ___ colonoscopy with: Internal hemorrhoids, Diverticulosis;
Rectal Polyps; Melanosis in the whole colon
-Hx of pancreatic ductal dilation
-Sickle cell trait
-Myelopathy
-Hypercholesterolemia
-Adrenal adenoma
-Glaucoma.
-Status post appendectomy in ___.
-Status post bilateral cataract surgery.
-Status post hysterectomy in ___
Social History:
___
Family History:
Early CAD. One brother with lung cancer; one brother with colon
cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Afebrile HR 50 BP 159/71 (223/104 rechecked) RR 20 o2
100%ra
GENERAL: uncomfortable appearing, lying in bed, spits up into
emesis basis several times
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM, good
dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: LLL inspiratory crackles noted
ABDOMEN: nondistended, +BS, +LLQ tenderness, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, lower extremity exam limited by pain,
fluent speech
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS - 98.1 50 18 143/70 100RA
Tele: NSR @ 50s, frequent PACs
BG ___ 238 89 120
I/O 440/900 // ___
GENERAL: Pleasant, non-toxic
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM, good
dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: LLL inspiratroy crackles noted
ABDOMEN: nondistended, +BS, no tenderness, no rebound/guarding,
no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, lower extremity exam limited by pain,
fluent speech
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ON ADMISSION
___ 02:00PM BLOOD WBC-6.2 RBC-3.61* Hgb-11.5* Hct-33.5*
MCV-93 MCH-31.8 MCHC-34.3 RDW-14.0 Plt ___
___ 02:00PM BLOOD Neuts-59.0 ___ Monos-7.1 Eos-5.9*
Baso-0.4
___ 02:00PM BLOOD Plt ___
___ 02:00PM BLOOD Glucose-104* UreaN-34* Creat-2.4* Na-141
K-4.4 Cl-106 HCO3-25 AnGap-14
ON DISCHARGE
as above
MICRO
none
IMAGING
MR ___ SPINE W/O CONTRAST Study Date of ___
Final read:
IMPRESSION:
1. Multilevel multifactorial lumbar spondylosis, most prominent
at L3-L4 where there is moderate spinal canal narrowing, severe
right neural foraminal narrowing and moderate left neural
foraminal narrowing and at L4-L5 where there is moderate severe
spinal canal narrowing, severe left neural foraminal narrowing
and moderate to severe right neural foraminal narrowing. These
findings are significant worsened since ___.
2. 1.4 cm T2 hypointense left inferior renal pole incompletely
characterized lesion, not definitively seen on prior exams.
This may represent a hemorrhagic cyst although neoplasm is not
excluded.
3. STIR hyperintense signal of the L3-L4 and L4-L5 discs, most
compatible with degenerative changes. However, very early
diskitis may appear in this fashion and clinical correlation
with infectious markers is recommended.
4. Interval increased prominence of a 4 mm cystic structure
contiguous with the pancreatic duct. This may represent a
prominent side branch or IPMN.
5. Unchanged appearance of previously described left adrenal
adenoma. Nodular focus of the right adrenal gland is unchanged
and likely represents adrenal adenoma or nodular hyperplasia.
RECOMMENDATION(S): Regarding point 2: Further evaluation with
renal mass mass MRI if there no contraindications is recommended
if clinically indicated.
Regarding point 3: STIR hyperintense signal of the L3-L4 and
L4-L5 discs, most compatible with degenerative changes.
However, very early discitis may appear in this fashion and
clinical correlation with infectious markers is recommended.
Regarding Point 4: The apparent increased prominence of the
pancreatic cystic focus may be secondary to technical
differences, however dedicated examination is recommended to
exclude interval increase size.
Brief Hospital Course:
Hospital course: Ms. ___ is a ___ year old woman with a
history of DM2, HTN, CKD, lower back pain, presenting with
worsening back pain with radiation of pain to the left lower
extremity, consistent with radiculopathy. MRI showed Multilevel
multifactorial lumbar spondylosis and spinal stenosis. She was
treated with acetaminophen and gabapentin and discharged home
with plans for outpatient follow up. She also reported syncope,
of which partial work-up was negative.
Active issues:
#Back pain: Patient with chronic progressively worsening LBP
with radicular symptoms to left leg. Prior MRI with L3-L5
spondlosis and L4-5 foraminal stenosis on L side; MRI at ___
showed multilevel multifactorial lumbar spondylosis and spinal
stenosis. No bowel or bladder symptoms or sudden weakness or
change in neurological status. Her pain was treated with
standing tylenol, lidocaine patch, and gabapentin. She was
encouraged to follow up with her PCP and her orthopedics
specialist at ___
#Syncope: Per pt's initial description of closing her eyes in
the setting of pain, vasovagal syncope was thought most likely,
which was treated as above. Admission ECG was without signs of
ischemia and she denied CP or palpitations and endorsed
preceding lightheadedness. She later described a history of
falls with traumatic loss of teeth, which raised concern for
arrythmia as a contributor to her syncope, so she was monitored
on telemetry which showed no arrhythmias. She denied post-ictal
confusion or loss of bowel/bladder control to suggest seizures.
Orthostatic vitals were negative. Patient was scheduled to get
TTE, however, wanted to be discharged prior to this being
obtained. She understood the risks of not obtaining this study
prior to discharge. She was instructed to go to the emergency
room if she syncopizes again. PCP informed of this.
#Nausea: Associated with pain. No fevers, chills, or diarrhea to
suggest infection; no leukocytosis. She was treated with zofran
prn nausea with good effect.
Chronic issues:
#Diabetes, type 2: Recent A1c 6.7 indicates good control. She
was treated with
ISS in the hospital and home glargine 32 units.
#CKD: Cr at recent baseline. 2.4 on admission
#Anemia: Normocytic anemia, likely of chronic disease. Recent
EGD/colonoscopy ___ notable for internal hemorrhoids,
diverticulosis; rectal polyps; and melanosis coli.
#HTN: Continued home labetolol, hctz
#HLD: Continued home statin, aspirin
#Glaucoma: Continued home dorzolamide-timolol drops
EMERGENCY CONTACT HCP: ___, ___,
___
CODE: Full (confirmed)
Transitional issues:
- TTE was recommended to evaluate for valvular pathology as
cause of syncope, however, she declined remaining inpatient for
this test. She understood the risks of not obtaining this study
prior to discharge. She was instructed to go to the emergency
room if she syncopizes again. PCP informed of this.
-Incidental imaging findings as follows:
[ ]1.4 cm T2 hypointense left inferior renal pole
[ ]Interval increased prominence of a 4 mm cystic structure
contiguous with the pancreatic duct. This may represent a
prominent side branch or IPMN
-Given current GFR, HCTZ may not be efficacious and could
consider discontinuing this, per inpatient pharmacy
recommendations.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 200 mg PO BID
2. Calcitriol 0.25 mcg PO DAILY
3. Rosuvastatin Calcium 10 mg PO QPM
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
5. Aspirin 81 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Acetaminophen Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Glargine 32 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Labetalol 200 mg PO BID
8. Rosuvastatin Calcium 10 mg PO QPM
9. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
10. Gabapentin 200 mg PO DAILY
RX *gabapentin 100 mg 2 capsule(s) by mouth daily Disp #*60
Capsule Refills:*0
11. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % (700 mg/patch) apply 1 patch to lower back
daily Disp #*30 Patch Refills:*0
12. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 2 capsule by mouth daily Disp #*60
Capsule Refills:*0
13. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Q6H PRN
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnoses:
lumbar spondylosis
spinal stenosis
radiculopathy
syncope
secondary diagnoses:
diabetes
chronic kidney disease
hypertension
anemia
glaucoma
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___! You were admitted
with back pain and left leg pain. We found that this is due to
degenerative changes in your lower back and narrowing of the
canal that spinal nerves pass through. We treated your pain with
medications and recommend that you follow up with your
orthopedic specialist. Our spine specialists did not think that
any urgent surgery was needed, however, they did recommend
orthopedics follow up.
We also investigated the cause of your loss of consciousness at
home. We think it may have been due to pain. We would have liked
to obtain an ultrasound of your heart, or echocardiogram,
however, you opted to be discharged from the hospital prior to
obtaining this test. We explained to you the risks of leaving
prior to getting this test, such as missing a dangerous heart
valve condition. It is very important that if you experience
another fainting episode that you come to the emergency for
evaluation.
Best wishes in your recovery!
Your ___ Medicine Team
Followup Instructions:
___
|
19740874-DS-20
| 19,740,874 | 24,016,222 |
DS
| 20 |
2138-02-25 00:00:00
|
2138-03-04 19:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / doxycycline / Thorazine
Attending: ___.
Chief Complaint:
GI Illness, Hypotension
Major Surgical or Invasive Procedure:
None performed
History of Present Illness:
___ with history of breast cancer and hypothyroidism presenting
with hypotension in the setting of 5 days of
chills/fevers/diarrhea.
She was hiking in ___ 3 weeks ago, and then on the ___ in
___ areas 2 weeks ago. On ___ she had increased fatigue and
went to bed early. She woke up early on ___ with a sore throat
requiring regularly scheduled ibuprofen to control the pain and
tolerate PO intake. She had concomitant diarrhea at this time.
She subsequently developed chills and N/V late ___ and all
throughout ___. She saw her PCP ___ who thought this was ___
viral illness and provided PO APAP as well as miconazole for
suspected ___ esophagitis. As she subsequently vomited the
Tylenol she was instructed to go to ___, where she
received IVF, Tylenol, and toradol. She was sent home with
instructions to alternate tylenol and ibuprofen. Yesterday she
continued to have symptoms despite the above treatment, and went
back to ___ for evaluation. Notes no recent observed
tick bites. Endorses sick contact with a friend with URI
symptoms ___ while playing ___.
She was found to be hypotensive to SBP's in the 90's (baseline
100-110's). She had hyponatremia and ___ iso elevated lactate.
She was started on cefepime, azithryomycin, and doxycycline.
She
was given 3.5L of fluid for resuscitation. Plan was then for
transfer to ___ for further evaluation and management.
In the ED she was noted to be hypotensive to SBP's in the 70's.
She was given an additional litre of NS and was started on
norepinephrine. CXR c/f RLL PNA. Her antibiotic coverage was
broadened to include Vancomycin and she was transferred to the
MICU for further management.
Past Medical History:
-Left ER+ DCIS and LCIS s/p breast conserving surgery and
adjuvant radiation therapy, unable to tolerate tamoxifen due to
postmenopausal bleeding
- Hypothyroidism
- Seasonal Allergies
Social History:
___
Family History:
Father: ___ cancer: deceased
Mother: ___
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
VS: ___, 108, 90/50, 19, 96% on RA
GEN: Woman laying in NAD, pleasant
HEENT: PERRL, dry mucous membranes
NECK: RIJ in place, c/d/i
CV: Tachycardia with no m/g/r
RESP: Bronchial breath sounds at ___ posterior apices R>>L, ___
posterior inspiratory crackles at the bases
GI: Soft, NTND.
MSK: 1+ ___ edema, pitting
SKIN: Erythematous silky rash across abdomen and thighs,
non-purulent.
NEURO: AAOx3
DISCHARGE PHYSICAL EXAM:
=========================
___ 0412 Temp: 98.6 PO BP: 105/62 HR: 64 RR: 18 O2 sat: 92%
O2 delivery: Rq
GEN: sitting up and eating breakfast, pleasant
HEENT: large pupils bilaterally, no evidence of chelitis. Trace
thrush evident on roof of mouth (much improved from day prior).
NECK: RIJ site is well healed
CV: RRR no murmurs or pre-mature beats noted today
RESP: lungs clear to auscultation bilaterally
GI: soft, non-distended, no tenderness to light or deep
palpation
EXT: 1+ pitting edema from mid-calf down to feet
SKIN: No new rashes noted
NEURO: AAOx3, CN intact, ___ in all extr.
Pertinent Results:
ADMISSION LABS
==============
___ 02:30AM BLOOD WBC-3.2* RBC-4.02 Hgb-11.6 Hct-36.1
MCV-90 MCH-28.9 MCHC-32.1 RDW-13.2 RDWSD-44.1 Plt Ct-18*
___ 02:30AM BLOOD Neuts-78* Bands-2 Lymphs-6* Monos-8 Eos-5
Baso-1 AbsNeut-2.56 AbsLymp-0.19* AbsMono-0.26 AbsEos-0.16
AbsBaso-0.03
___ 07:51AM BLOOD ___ PTT-33.5 ___
___ 02:30AM BLOOD Glucose-107* UreaN-39* Creat-2.1* Na-130*
K-3.8 Cl-100 HCO3-18* AnGap-12
___ 02:30AM BLOOD ALT-154* AST-45* AlkPhos-66 TotBili-1.7*
___ 02:30AM BLOOD Albumin-2.2* Calcium-6.7* Phos-2.9
Mg-1.0*
___ 02:55AM BLOOD ___ pO2-62* pCO2-32* pH-7.36
calTCO2-19* Base XS--6 Comment-GREEN TOP
___ 06:05AM BLOOD Type-CENTRAL VE Temp-38.3 pO2-44* pCO2-36
pH-7.33* calTCO2-20* Base XS--6
___ 02:55AM BLOOD Lactate-4.4*
DISCHARGE LABS
=================
___ 06:10AM BLOOD WBC-8.4 RBC-3.77* Hgb-10.9* Hct-33.3*
MCV-88 MCH-28.9 MCHC-32.7 RDW-13.4 RDWSD-43.0 Plt Ct-79*
___ 06:35AM BLOOD Neuts-63.9 ___ Monos-6.3 Eos-0.0*
Baso-0.1 NRBC-0.4* AbsNeut-4.28 AbsLymp-1.73 AbsMono-0.42
AbsEos-0.00* AbsBaso-0.01
___ 06:10AM BLOOD Plt Ct-79*
___ 06:10AM BLOOD Glucose-76 UreaN-26* Creat-0.9 Na-140
K-3.9 Cl-104 HCO3-26 AnGap-10
___ 06:35AM BLOOD ALT-74* AST-16 AlkPhos-254*
___ 06:10AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.1
___ 06:05PM BLOOD CMV IgG-NEG CMV IgM-NEG CMVI-There is n
EBV IgG-POS* EBNA-POS* EBV IgM-NEG EBVI-Results in
MICROBIOLOGY
=============
___ 12:13 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___:
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
___ 9:31 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 6:04 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
___ 6:11 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
ADAMSTS 13: 55
Test Result Reference
Range/Units
RMSF IGG Not Detected Not Detected
RMSF IGM Not Detected Not Detected
Test Result Reference
Range/Units
BABESIA MICROTI DNA, REAL Not Detected Not Detected
TIME PCR
Test Result Reference
Range/Units
SOURCE Serum
PARVOVIRUS B19 DNA, QL REAL Not Detected Not Detected
TIME PCR
Test Result Reference
Range/Units
ANAPLASMA PHAGOCYTOPHILUM Not Detected Not Detected
DNA, QL REAL TIME PCR
Test Result Reference
Range/Units
SOURCE Whole Blood
EBV DNA, QN PCR <200 <200 copies/mL
Test Result Reference
Range/Units
BABESIA MICROTI DNA, REAL Not Detected Not Detected
TIME PCR
Test Result Reference
Range/Units
LEGIONELLA PNEUMOPHILA <1:256
ANTIBODY (IGM), IFA
IMAGING
=========
LIVER/GALLBLADDER US
IMPRESSION:
1. New, moderate bilateral pleural effusions. Trace perihepatic
and
perisplenic ascites.
2. Echogenic material within the gallbladder lumen, consistent
with sludge.
Moderate thickening of the gallbladder wall, likely due to third
spacing.
3. Dilated IVC and hepatic veins suggests possibility of
underlying heart
failure.
4. Normal spleen size.
CT HEAD W/O CONTRAST
IMPRESSION:
1. No evidence of acute intracranial hemorrhage.
2. Paranasal sinus disease with findings suggestive of acute
and chronic
sinusitis, as described.
TTE
IMPRESSION: Normal left ventricular wall thickness and
biventricular cavity sizes and regional/
global biventricular systolic function. Mild pulmonary artery
systolic hypertension. Mild mitral
regurgitation with normal valve morphology.
CXR
IMPRESSION:
1. The right central venous catheter tip terminates in the mid
to lower SVC.
No pneumothorax or mediastinal widening.
2. Redemonstrated opacity within the right lower lung.
3. Left retrocardiac atelectasis.
4. Possible trace left pleural effusion.
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of breast
cancer and hypothyroidism presenting with hypotension in the
setting of 5 days of chills, fevers, diarrhea, who was found to
be in shock with acute kidney injury, transaminitis, and severe
thrombocytopenia, all concerning for tick-borne illness or GI
infection and secondary ITP.
ACUTE/ACTIVE ISSUES
====================
#Thrombocytopenia - On admission, her platelet count was 18,
however downtrended to 5, requiring 6 platelet transfusions in
the MICU. Large platelets noticed on smear raised concern for
secondary ITP for which she was treated with IVIG x1 and 5 day
course of dexamethasone. However, cause of ITP remained unclear,
possibly secondary to GI illness or tick-borne illness. Stool
cultures and C.diff remained negative. Serologies for Lyme,
Anaplasma, and Babesia negative as well. ADAMTS-13 was mildly
decreased at 58. Platelets uptrending following treatment. No
evidence of bleed noticed on head CT or CT abdomen/pelvis.
Ophthalmology assessment for retinal hemorrhages negative. Work
up negative for: CMV, UTI, MRSA, EBV, parvovirus, Lyme.
#Septic Shock - Patient with initial shock in the setting of
likely tick-borne illness. Stabilized with pressors and fluids
in the ICU, then transferred to the general medicine floor.
Blood cultures with no growth to date. Also noted to have RLL
infiltrate on chest x-ray and was treated for community acquired
pneumonia. Initially started on broad spectrum antibiotics
including linezolid, ceftriaxone, and
azithromycin/atovaquone/doxycycline. Narrowed following
microbiology studies to doxycycline 100mg twice a day for
empiric tick-borne illness coverage for 14 days (till ___.
#Diarrhea - She had persistent non-bloody diarrhea on initial
presentation and through her hospitalization. Stool cultures
negative for E. coli, campylobacter, salmonella, and shigella.
C. diff negative. Likely secondary to antibiotic treatment or
possibly tick-borne illness.
#Oral Thrush - Following course of dexamethasone, she developed
white plaques that could be scraped. It resolved following
treatment with oral fluconazole.
#Transminitis - LFTs elevated with ALT at 154 and AST at 45 on
admission, raising concern for tick-born illness. Downtrended
over the course of hospitalization. RUQUS with evidence of
hepatic congestion secondary to fluid overload after ICU course
with fluid boluses and pressors. Patient was subsequently
diuresed for three days with IV furosemide to improve fluid
status. ALT 74 and AST 16 on discharge, down-trend suggestive of
congestive hepatopathy that improved with diuresis. Work up
negative for Babesia, HCV, HBV, and HIV.
#Anemia - Hemoglobin 11.6 on admission, stable at ___ for
several days. Likely related to suppression iso acute infectious
proccess and possibly dilutional given multiple transfusions.
CHRONIC/STABLE ISSUES:
======================
#Tachyarrhythmia - ICU rhythm strips with evidence of PAC
without atrial fibrillation while on pressors. She was noted to
have PVC on the floor without symptoms. Bradycardic throughout
admission, which is patient's baseline. Transthoracic
echocardiogram did not demonstrate any vegetations. EKG did not
demonstrate any evidence of complete heart block.
#Hyponatremia - Sodium 130 on admission, likely in setting of
hypovolemia secondary to diarrhea and distributive shock.
Resolved during her course.
#Acute Kidney Injury - Creatinine elevated at 2.1 on admission.
Initial insult likely due to hypoperfusion secondary to diarrhea
and also secondary to pressors in the ICU. Downtrended to 1 and
remained stable for the rest of admission.
#Hypothyroidism - Continued on home levothyroxine.
#Asthma - Continued on home ___.
Transitional Issues
====================
[] Will continue doxycycline 100mg twice a day till ___
[] Please check repeat CBC within one week to monitor platelet
counts and LFTs to monitor transaminitis
[] Please check repeat CMP in one week to monitor kidney
function given autodiuresis and ongoing diarrhea
[] If patient continues to have diarrhea after finishing
doxycycline, would recommend repeat stool studies given long
hospital course
[] If patient's weight does not continue to decrease on its own
due to autodiuresis, could consider PO Lasix to assist with
fluid overload
[] Very mild 1+ mitral regurgitation noted on TTE (thought to be
secondary to fluid overload), however if symptoms develop, could
consider follow up with cardiology
# CODE: Full
# CONTACT: ___ (husband): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Montelukast 10 mg PO DAILY
2. Levothyroxine Sodium 112 mcg PO DAILY
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice per
day Disp #*13 Tablet Refills:*0
2. Levothyroxine Sodium 112 mcg PO DAILY
3. Montelukast 10 mg PO DAILY
4.Outpatient Lab Work
LABS: CBC, LFTs, CMP
ICD-9: R74.0, ___
___. ___
___: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
Secondary Immune Thrombocytopenia due to unknown trigger
Septic Shock
Transaminitis
Diarrhea
Anemia
Oral Thrush
SECONDARY DIAGNOSES
=====================
Tachyarrythmia
Acute Kidney Injury
Hypothyroidism
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you here at ___!
What happened during my hospitalization?
=============================================
You were hospitalized after several days of diarrhea and fever.
Due to your low blood pressure, you were initially taken care of
in the ICU. Your platelet counts were very low so you received
multiple transfusions of platelets. After a course of IVIG and
steroids, your platelet count started to increase. We are unsure
what exactly caused this initial decrease in your platelets, but
we suspect you had some form of infection. You are being treated
with doxycycline just in case you may have had exposure to a
tick borne disease that caused your acute illness.
We also gave you some medicine to help remove some of the fluid
that had collected on your body. Over the next few weeks, your
body will naturally urinate this extra water till you reach your
baseline weight. In addition, your diarrhea should resolve
within a week of finishing your antibiotics. If it does not,
then please let your PCP ___.
What should I make sure to do when I get home?
==================================================
Please make sure to get your blood counts checked in the next
four days and follow up with your PCP in the next week. You have
received a lab requisition for labs. Also, please remember that
you should not take your doxycycline with any dairy products. It
can also make you more sensitive to the sun, so we encourage you
to wear sun protection.
We wish you all the best as you recover!
-Your ___ team
Followup Instructions:
___
|
19741821-DS-9
| 19,741,821 | 22,778,644 |
DS
| 9 |
2115-06-17 00:00:00
|
2115-06-18 08:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with FT dementia and possible ALS here with FTT. Per her
partner of ___ years and daughter, she has been having more falls
at home. Worsening dysphagia, has no cough reflex. Has lost
30lbs over past 6 mos. Is incontinent of urine. No
F/C/CP/SOB/Vom/Diarrhea.
.
In the ED:
- Initial Vitals: 97.2, 84, 166/82, 16
- EKG: SR @66, LAD, no ischemic changes
- Labs: WBC 16.5
- UA: +UTI
- CXR: calcified granuloma/LN in R apex with, potentially, an
aspiration pna in retrocardiac space
- Meds: 500mg cipro, 0.5mg lorazepam, nicotine patch
- Access: PIV
- Admit Vitals: 97.5, 88, 111/65, 96 RA, 16
.
On the floor she is nonverbal and gesturing the middle-finger.
Her partner speaks for her and tells me that she communicates
with writing. When asked what she wants, she requests "the
pills", which he takes to mean her sleeping regimen
.
Past Medical History:
Pick's Encephalopathy
? ALS
MI at ___
no hx of UTIs
Social History:
___
Family History:
nc
Physical Exam:
Vitals: 97.5, 88, 111/65, 96 RA, 16
GEN: No acute distress, moaning unintellibly.
HEENT: Mucous membranes moist, no lesions noted. Sclerae
anicteric. No conjunctival pallor noted.
NECK: JVP not elevated. No lympadenopathy.
CV: Regular rate and rhythm, no murmurs, rubs ___
PULM: Clear to auscultation bilaterally, no wheezes, rales or
rhonchi.
ABD: Soft, non-tender, non distended, bowel sounds present. No
hepatosplenomegaly
EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally.
NEURO: Alert and oriented x3.
SKIN: No ulcerations or rashes noted.
Pertinent Results:
BLOOD
___ 12:00PM BLOOD WBC-16.5* RBC-5.47* Hgb-16.3* Hct-48.9*
MCV-89 MCH-29.7 MCHC-33.3 RDW-13.3 Plt ___
___ 12:00PM BLOOD Neuts-80.0* Lymphs-16.4* Monos-2.3
Eos-1.0 Baso-0.4
___ 12:00PM BLOOD Glucose-89 UreaN-26* Creat-0.6 Na-145
K-4.1 Cl-106 HCO3-23 AnGap-20
URINE
___ 01:45PM URINE RBC-2 WBC-37* Bacteri-MANY Yeast-NONE
Epi-1
___ 01:45PM URINE Blood-SM Nitrite-POS Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 01:45PM URINE Color-Yellow Appear-Hazy Sp ___
MICRO
___ URINE URINE CULTURE-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
CXR
Focal left basilar opacification could reflect atelectasis,
aspiration or infectious pneumonia
Brief Hospital Course:
___ woman with FTD/ALS here with inability to be cared for at
home and progressive decline. Found to have a UTI and discharged
to a rehab where goals of care can be further defined with
transfer to nursing home/hospice as goal
.
# Frontotemporal Dementia - unable to be cared for at home.
Exacerbated, perhaps, by UTI. Continued seroquel, ativan,
remeron.
# UTI - risk factor is incontinence. Plan is ceftriaxone x 7
days or equivalent based on urine culture. Please call ___
MICROBIOLOGY (___) to learn of final culture results
# "Aspiration" on CXR - fair Video swall previously but in the
setting of UTI could be worsened. No clinical indication of PNA
and ceftriaxone covers most causes anyhow. Recommend a speech
and swallow consult. Healthcare proxy is focused on securing her
comfort and she seems to love eating and drinking, especially
diet coke. We had her on nectar thick liquids and crushed pills
for now
.
# Nicotine abuse - voracious smoker. patch and lozenges
provided
# HTN, CAD - continued metoprolol, amlodipine
TRANSITIONAL ISSUES
1. Urine culture results NOT finalized. Please call in ___
hours to learn of results ___, ask for micro lab)
2. Palliative care and transfer to nursing home
3. Consider speech and swallow
Medications on Admission:
Remeron 15
Ativan 0.5
Megace 625 qd
Amlodipine 5
Omeprazole 20
Folic 1
MVI
Seroquel 200
Metoprolol 25 BID
Discharge Medications:
1. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. quetiapine 200 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
8. nicotine (polacrilex) 4 mg Lozenge Sig: One (1) Lozenge
Buccal Q1H (every hour) as needed for craving, agitation.
9. Lorazepam 0.5-1 mg IV Q8H:PRN insomnia, agitation, anxiety
10. ceftriaxone 1 gram Recon Soln Sig: One (1) gm Injection once
a day for 6 days.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Frontotemporal Dementia
ALS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted for failure to thrive at home and a urinary
tract infection.
ANTIBIOTICS
Ceftriaxone - will need for 6 more day
Followup Instructions:
___
|
19742008-DS-12
| 19,742,008 | 21,395,967 |
DS
| 12 |
2162-05-13 00:00:00
|
2162-05-12 10:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
status post pedestrian struck
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y.o. female s/p pedestrian struck. Per report
patient was found down on the street after being struck by a
car,
+ LOC. EMS arrived at scene and patient had signs of TBI and
agitation, as a result patient was sedated/chemically paralyzed
and intubated for airway protection. Unknown GCS scale at the
scene.
On arrival, patient was GCS 3T, pan-scanned and head CT showed
bilateral traumatic SAH. Neurosurgery consulted for further
management.
Past Medical History:
Unknown
Social History:
___
Family History:
Unknown
Physical Exam:
Vitals: T: 98.2 146/81 72 12 100% 50%FIO2
Gen: WD/WN, intubated/sedated with propofol/versed, no battle
sign or racoon eyes
HEENT: head: traumatic left head laceration/abrasion, eyes: left
upper lid with laceration and bleeding Pupils: PERRL 1mm and
sluggish ears: blood in left ear canal, TM intact, no
gross otorrhea of CSF, right clear,
Neck: Cervical collar in place
Lungs: CTA bilaterally, overbreathing the vent
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. no deformities
Neuro:
GCS:7T, E:1 ___ M:5 secondary to sedation/intubation,
no battle sign, no racoon eyes
localizes to pain in all extremities, does not open eyes, ?
tremors in the right hand
No clonus
Toes downgoing bilaterally
Pertinent Results:
___ 11:54PM TYPE-ART RATES-/20 TIDAL VOL-400 PEEP-5 O2-30
PO2-115* PCO2-36 PH-7.48* TOTAL CO2-28 BASE XS-4
___ 09:53PM GLUCOSE-120* UREA N-12 CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-26 ANION GAP-15
___ 09:53PM ALT(SGPT)-19 AST(SGOT)-41* ALK PHOS-45 TOT
BILI-0.3
___ 09:53PM ALBUMIN-4.1 CALCIUM-8.6 PHOSPHATE-3.1
MAGNESIUM-1.9
___ 09:53PM WBC-8.0# RBC-3.87* HGB-13.2 HCT-37.5 MCV-97
MCH-34.2* MCHC-35.3* RDW-11.8
___ 09:53PM NEUTS-79.3* LYMPHS-13.3* MONOS-6.6 EOS-0.6
BASOS-0.2
___ 09:53PM PLT COUNT-212
___ 09:53PM ___ PTT-22.0* ___
___ 08:00PM TYPE-ART TEMP-37.2 RATES-14/ TIDAL VOL-500
PEEP-5 O2-100 PO2-472* PCO2-40 PH-7.42 TOTAL CO2-27 BASE XS-1
AADO2-207 REQ O2-43 -ASSIST/CON INTUBATED-INTUBATED
___ 05:40PM COMMENTS-GREEN TOP
___ 05:40PM GLUCOSE-101 NA+-139 K+-3.9 CL--102 TCO2-24
___ 05:16PM UREA N-14 CREAT-0.7
___ 05:16PM estGFR-Using this
___ 05:16PM LIPASE-25
___ 05:16PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:16PM URINE HOURS-RANDOM
___ 05:16PM URINE UCG-NEGATIVE
___ 05:16PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 05:16PM WBC-5.3 RBC-4.08* HGB-13.8 HCT-39.5 MCV-97
MCH-33.7* MCHC-34.9 RDW-12.1
___ 05:16PM PLT COUNT-252
___ 05:16PM ___ PTT-26.4 ___
___ 05:16PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
CT Spine: ___
No cervical spine fracture or malalignment.
CT Head without Contrast: ___
1. Small volume of subarachnoid hemorrhage mostly in the left
frontal lobe, and also involving the right frontal and temporal
lobes.
2. Partial left mastoid air cell opacification with
subcutaneous emphysema about the left styloid process. No
definite evidence of left temporal bone fracture. If there is
continued clinical concern for a temporal bone fracture, then a
dedicated temporal bone CT is recommended.
3. Hyperdense focus in the left frontal subcutaneous tissues
may represent embedded foreign body vs. scalp calcification.
Correlate with physical exam.
CT Abdomen and Pelvis with Contrast: ___
1) No traumatic injury to the chest, abdomen or pelvis.
2) Multiple uterine fibroids.
3) 4-mm left upper lobe pulmonary nodule. If there are risk
factors for lung cancer, a ___ follow up chest CT is
recommended; otherwise, no further follow up is needed.
4) Right groin stranding and hematoma about the right common
femoral artery likely related to recent intervention.
CT Chest with Contrast: ___
1) No traumatic injury to the chest, abdomen or pelvis.
2) Multiple uterine fibroids.
3) 4-mm left upper lobe pulmonary nodule. If there are risk
factors for lung cancer, a ___ follow up chest CT is
recommended; otherwise, no further follow up is needed.
4) Right groin stranding and hematoma about the right common
femoral artery likely related to recent intervention.
Chest X-ray: ___
Lung volumes are slightly improved, but whatever diffuse process
was present previously has resolved and left lower lobe
atelectasis is almost entirely cleared. An upper enteric tube
ends in the region of the pylorus, nevertheless the stomach is
severely distended with air and fluid. ET tube is in standard
position. There is no pneumothorax.
Head CT: ___
Motion-limited study with redistribution of, but otherwise no
significant change in the scattered foci of bilateral
subarachnoid hemorrhage at the vertex. Persistent partial
opacification of the left mastoid air cells and middle ear.
Assessment for fractures is limited on the present study.
MRI Cervical Spine: ___
IMPRESSION:
1. Moderately motion-degraded study.
2. Increased C7-T1 disc signal with focal disruption of the
ligamentum flavum at the corresponding level. Concern is also
raised for interspinous ligamentous injury. Consider repeat
imaging when the patient is able to stay still in the scanner.
3. Mild cord encroachment from multilevel degenerative changes,
but without evidence of cord compression or cord signal
abnormality.
MRI BRAIN ___ -
IMPRESSION:
1. Scattered foci of subarachnoid hemorrhage as described above
along with small amount of hemorrhage in the left occipital horn
and possible component of subdural hemorrhage overlying the
right posterior parietal region. No mass effect.
2. Small foci of increased FLAIR and DWI signal with slightly
decreased ADC signal in the brain parenchyma in the white
matter, subcortical and centrum semiovale and in the right
sublentiform location extending into the cerebral peduncle and
the posterior aspect of the right side of the ponto-midbrain
junction. Some of these demonstrate negative susceptibility and
some do not. Possibilities include diffuse axonal injury versus
small acute-subacute infarcts. A followup study ( pre and post
contrast) can be considered as clinically
indicated to assess stability.
___:
Portable abdomen: IMPRESSION: Persistence of feeding tube tip
within stomach.
___
Liver ultrasound
IMPRESSION:
Normal abdomen ultrasound.
___ Chest xray
FINDINGS: In comparison with the study of ___, there is
little change in the appearance of the heart and lungs. No
vascular congestion or pleural effusion. Calcified granuloma is
seen in the right mid zone.
The Dobbhoff tube has been removed.
___
ENZYMES & BILIRUBIN
ALT AST LD(LDH) CK(CPK) AlkPhos Tbili
186* 117* ___ 0.3
Brief Hospital Course:
Ms. ___ was admitted to the trauma ICU on the day of
admission, ___ with bilateral traumatic
subarachnoid hematomas. She underwent a CT of the cervical spine
which was negative for any fractures. She underwent a CT of the
abdomen, pelvis and chest which was negative for any traumatic
injuries but revealed multiple uterine fibroids and a 4-mm left
upper love pulmonary nodule. On ___, she was extubated and
following commands. Repeat head CT on ___ which was unchanged.
On examination she moved all four extremities yet was
non-verbal. ACS completed a secondary survey and cleared her
thoracic and lumbar spine. After demonstrating continued
clinical stability she was transferred to the neuro step-down
unit. MRI of her c-spine was concerning for ligamentous injury
so she was maintained in the hard cervical collar at all times.
She was initially not safe to take PO, so a dobhoff NG tube was
placed to allow for enteric feedings.
On ___, the she had a decrease in her mental status. Her
Dilantin was bolused, she got an EEG and a brain MRI. A Dobhoff
tube for nutrition was placed. The EEG was negative and
discontinued.
___ she had a positive urine culture for which she was
started on Bactrim. She pulled out her own dobhoff. Throughout
the day she became more interactive on ___ and was able to
follow commands readily, state her name and the year.
On ___ she had a seizure witnessed by nursing during which her
lips turned blue and she had eye deviation. Her Dilantin was
increased and Keppra was added.
She failed multiple speech and swallow trials, so it nutrition
recommended that she continue tube feeds. Surgery was consulted
for a PEG placement. The dobhoff tube was replaced.
___ Due to continuously elevated liver enzymes, hepatology
was consulted and her Dilantin was stopped. A liver ultrasound
was ordered as well as a KUB. The NGT became clogged and was
removed.
___ OR for PEG tube placement. Tube feeds were started
post op. She tolerated tubefeeds and moved bowels without
issues
Now dod, she is afebrile, VSS and neuro stable. she is set for
discharge to rehabe in stable condition
Medications on Admission:
unknown
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Diazepam 5 mg PO Q6H:PRN agitation
3. Docusate Sodium (Liquid) 100 mg PO BID
4. Heparin 5000 UNIT SC TID
5. LeVETiracetam 1000 mg PO BID
6. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
7. Famotidine 20 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
bilateral traumatic subarachnoid hemorrhage
subdural hematoma
diffuse axonal injury
hypertension
confusion
urinary tract infection
elevated liver enzymes
malnutrition
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:
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 have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
Followup Instructions:
___
|
19742279-DS-8
| 19,742,279 | 21,622,954 |
DS
| 8 |
2147-07-16 00:00:00
|
2147-07-16 13:29:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___, leukocytosis
Major Surgical or Invasive Procedure:
Psoas biospy
History of Present Illness:
___ year old woman with recently diagnosed Stage IV endometrial
cancer s/p ex-lap / TAH and BSO/ tumor debulking on ___
followed ___ x 6 cycles ___
currently
on q4wk zometa as only active therapy, who was referred to the
ED
after discovery on routine labs of creatinine of 2.5 (b/l 1.0)
and leukocytosis (WBC 17.8). THe patient herself does note
decreased urination over the past several weeks but no dysuria,
hematuria, fevers, abdominal pain. She states a week ago urine
started coming out as only a dribble and she felt she had to
urinate frequently. She had some mild suprapubic discomfort but
really didn't think much of it. Today she noted some left
back/flank pain. No nausea/vomiting. No fevers. No dyspnea or
leg
swelling. No chest pain or headaches. She reports her usual PO
intake.
ED COURSE:
v/s 97.4 118 113/59 18 99% RA
Labs: creatinine up to 3.3. K of 5.4. UA with pyuria, renal US
with bilateral hydro (left> right). Urology was consulted for
hydronephrosis. EKG reassuring. K is stable at 5.4 currently.
SHe
received total 4l NS. APAP. 2g IV CTX.
On the floor she is calm and comfortable. She reports 3 liters
of
urine came out after foley was placed and she had resolution of
the vague abdominal discomfort.
Past Medical History:
ONC HISTORY:
Ms. ___ is a lovely ___ old woman with recently diagnosed
stage IV endometrial cancer, grade 3 endometrioid. Key events
are
as summarized below:
- ___ pt presented with postmenopausal bleeding
- ___ endometrial and vaginal biopsies (CHA) reviewed at
___: high grade carcinoma most consistent with endometrial
adenocarcinoma, endometrioid type; FIGO grade 3 of 3.
- ___ exploratory laparotomy, TAH/BSO, tumor debulking.
Intraoperative findings included a 12 cm enlarged uterus, most
notably dilated in lower uterine segment. There appeared to be
tumor invading the uterine serosa and adherent to the bladder
serosa. The parametria and cervix as well as upper ___ of the
vagina were grossly abnormal with infiltration of tumor. There
was no significant ascites or peritoneal implants. Pathology
showed a 13 cm grade 3 endometrial adenocarcinoma, myometrial
invasion almost 100% with cervical stromal invasion. LVSI was
seen. Serosa, ovaries and fallopian tubes were negative. Lymph
nodes were not submitted.
- ___ PET/CT notable for FDG-avid mass involving the vaginal
cuff and vagina consistent with remnant primary malignancy; FDG
avid lymphadenopathy involving lymph nodes in the left external
iliac, left para-aortic, aortocaval, and bilateral inguinal
regions; multiple pulmonary metastases scattered throughout both
lungs; osseous metastasis involving the left inferior pubic
ramus/ischium.
- ___ ___ x 6 cycles
- ___ start monthly ZA for bone mets
PAST MEDICAL HISTORY:
- T2DM, diet-controlled
- HTN
- Hyperlipidemia
Social History:
___
Family History:
Mother BC, and ?brain cancer (vs. metastatic disease)
Physical Exam:
Tc 98.7 100/52 85 18 94%RA
General: NAD
HEENT: MMM
CV: RR, NL S1S2
PULM: CTAB, nonlabored
GI: mod distended, no palpable mass, nontender w/ deep
palpation, soft.
Ext: No edema, full ROM all ext, non tender over spine or bil
hips or w/ active hip flexion on L
SKIN: No rashes or skin breakdown, port site c/d/i, foley in
place.
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
ADMISSION LABS:
___ 12:00PM BLOOD WBC-17.8* RBC-2.50* Hgb-8.1* Hct-25.1*
MCV-100* MCH-32.4* MCHC-32.3 RDW-15.3 RDWSD-57.0* Plt ___
___ 10:45PM BLOOD Neuts-87.2* Lymphs-5.4* Monos-6.5
Eos-0.3* Baso-0.1 Im ___ AbsNeut-12.81* AbsLymp-0.80*
AbsMono-0.96* AbsEos-0.05 AbsBaso-0.02
___ 10:45PM BLOOD ___ PTT-41.5* ___
___ 10:45PM BLOOD Glucose-118* UreaN-55* Creat-3.3* Na-131*
K-5.4* Cl-95* HCO3-21* AnGap-20
___ 10:45PM BLOOD Calcium-8.7 Phos-2.6* Mg-2.7*
DISCHARGE LABS:
****
PERTINENT IMAGING:
CT Pelvis (___):
1. Slight asymmetrical enlargement and surrounding fat
stranding of the left psoas muscle appears new from ___. This may represent a subacute or small retroperitoneal
bleed, alternatively abscess or tumor infiltration could also be
considered, given adjacent para-aortic lymphadenopathy. It is
notable that the degree of left psoas enlargement is not
expected to be sufficient to
cause a drop in hemoglobin level.
2. Persistent mild right and moderate left hydronephrosis and
moderate proximal left hydroureter. No stones identified.
3. Unchanged appearance of the mass at the introitus abutting
the base of the bladder, which may be causing mass effect on the
base of the bladder and urethra. As before, evaluation is
limited given lack of intravenous contrast.
4. Left adrenal myelolipoma.
IMPRESSION:
1. Large, rim-enhancing, centrally hypodense lesion within the
proximal left psoas muscle with surrounding inflammatory fat
stranding. Findings appear atypical for retroperitoneal
hematoma, with metastatic disease versus abscess felt more
likely. However, if this is a small retroperitoneal bleed, its
small size would not explain the patient's hematocrit drop.
Abdominal interventional radiology can be consulted for
drainage/biopsy as indicated.
2. Large heterogeneous enhancing mass at the introitus/labia,
which is
difficult to measure but appears grossly larger as compared to
the prior
contrast enhanced examination dated ___. This
lesion causes mass effect on the adjacent bladder base and
ureter, as before.
3. Persistent moderate left hydronephrosis and proximal
hydroureter. No
discrete obstructing calculus is identified, and findings may be
secondary to the inflammatory changes surrounding the adjacent
left psoas muscle, as
described above. Urology consultation is recommended for
further management.
4. Stable left adrenal myelolipoma.
5. For description of the intrathoracic findings, please see
the separate
dedicated CT chest examination.
RECOMMENDATION(S): 1. Abdominal interventional radiology can
be consulted
for drainage/biopsy of left psoas lesion/collection.
2. Advise urologic consulation for management of left
hydronephrosis and
hydroureter.
MICRO:
urine culture ___ all negative
blood culture ___ NGTD
psoas culture ___ NGTD
Brief Hospital Course:
___ year old woman with recently diagnosed Stage IV endometrial
cancer s/p ex-lap / TAH and BSO/ tumor debulking on ___
followed ___ x 6 cycles ___ who was
admitted w/ ___ and leukocytosis on routine labs and found
to have bilateral hydronephrosis and sepsis of presumed urinary
origin.
# Urinary sepsis
- Treated with a 7 day course of cetriaxone and IV fluids as
well as relief of bladder outlet obstruction.
#Fever
- She developed a fever and there was concern on a CT done about
a possible psoas abscess. This was bopsied. All cultures have
remained negative and her fever resolved without intervention.
# ___ obstruction
- She had an elevated creatinine on admission and a renal
ultrasound demonstrating bilateral hydronephrosis with a mass
compressing the base if the bladder. Nephrology and urology were
consulted. A foley was placed which relieved the obstruction and
improved her labwork. Electrolytes were repleated as needed. Of
note she also had anemia on admission likely due to a
combination of hematuria and anemia of chronic disease which did
improve with transfusion. Per urology she will have the foley
for one month and then will follow up with them in the office
for a voiding trial.
#Endometrial Cancer
- Recieved cycle 7 ___ while inpatient as cause of
bladder outlet obstruction likely due to mass. She tolerated the
treatment well. The patient was going to get neulasta however
was an inpatient so this was not possible. Her counts remained
stable. She will have her bloodwork checked after discharge and
was sent home with a prescription for neulasta. Her primary
oncologist office will call her to instruct her if she needs to
start it. Her home oxycodone was continued for pain as needed.
# Constipation
- Started senna and colace and PRN miralax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Ibuprofen 600 mg PO Q6H:PRN pain
3. Acetaminophen ___ mg PO Q6H:PRN pain
4. Lisinopril 10 mg PO DAILY
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Medications:
1. Calcium Carbonate 500 mg PO QID:PRN acid reflux
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
4. Senna 8.6 mg PO BID Constipation
5. Polyethylene Glycol 17 g PO BID:PRN Constipation
6. Acetaminophen ___ mg PO Q6H:PRN pain
7. Filgrastim 300 mcg SC Q24H
to be started at home if instructed by your oncologist
RX *filgrastim [Neupogen] 300 mcg/0.5 mL ___aily Disp
#*10 Syringe Refills:*0
8. Outpatient Lab Work
CBC with differential on ___
ICD-9 182.0
please fax to ___, NP at ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute kidney injury
Hydronephrosis (Blocked urine flow)
Anemia
Endometrial cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___ it was a pleasure caring for you during your stay at
___. You were admitted with abnormal labs including kidney
injury. You were found to have a mass in the pelvis blocking
urine flow from the bladder. A foley catheter was placed with
good urine drainage and your kidney function has returned to
normal. You also received blood transfusions for anemia and
antibiotics for a urine infection. You were restarted on
chemotherapy for your endometrial cancer. You then had fevers
and further evaluation showed a lesion in the psoas muscle. THis
was biopsied and thus far there is no sign of infection, it is
most likely a tumor which we are treating with chemotherapy.
Please have your labs checked early next week at your local
clinic. If your WBC is too low we will instruct you to start
neupogen.
Your appointments at ___ are listed below with oncology and
urology for determining removal of the catheter.
Followup Instructions:
___
|
19742279-DS-9
| 19,742,279 | 25,512,021 |
DS
| 9 |
2147-09-07 00:00:00
|
2147-09-08 06:35:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
Foley (inserted ___ - to continue as outpatient until
urology follow up
History of Present Illness:
Ms. ___ is a very pleasant ___ year0old woman with
history of endometrial cancer on chemotherapy with AMS found to
have a UTI. She was in her prior state of health until earlier
today when she came for chemo with ___. She had a UTI
and received Bactrim DS. Then she was confused lost in the
parking lot. She couldn't remember the floor in the garage where
she had parked. ___ MD contacted family realized she had not
driven (or drives) and had taken the ride. She was taken to the
ED for further evaluation. She does not recall the episode.
She reports several days of dysuria, hematuia. Denies fever,
chills, nausea, vomiting. Denies chest pain or shortness of
breath. Denies cough, abdominal pain, nausea, vomiting.
In the ED, initial VS were: 99.9, 110, 133/83, 16, 98% RA. Exam
was non-focal. Labs were notable for: WBC 17.1, HGB 9.2, PLT
217, Na 133, K 3.9, Cl 96, CO2 26, BUN 22, Cr 1.1, CA125 146,
ALT 8, AST 11, AP 93, TB 0.3, UA showed >182 WBC, few bacteria,
no EPI and positive nitrates. She received 1L NS and CTX 1g.
Past Medical History:
PAST ONCOLOGIC HISTORY
- ___ pt presented with postmenopausal bleeding
- ___ endometrial and vaginal biopsies (CHA) reviewed at
___: high grade carcinoma most consistent with endometrial
adenocarcinoma, endometrioid type; FIGO grade 3 of 3.
- ___ exploratory laparotomy, TAH/BSO, tumor debulking.
Intraoperative findings included a 12 cm enlarged uterus, most
notably dilated in lower uterine segment. There appeared to be
tumor invading the uterine serosa and adherent to the bladder
serosa. The parametria and cervix as well as upper ___ of the
vagina were grossly abnormal with infiltration of tumor. There
was no significant ascites or peritoneal implants. Pathology
showed a 13 cm grade 3 endometrial adenocarcinoma, myometrial
invasion almost 100% with cervical stromal invasion. LVSI was
seen. Serosa, ovaries and fallopian tubes were negative. Lymph
nodes were not submitted.
- ___ PET/CT notable for FDG-avid mass involving the vaginal
cuff and vagina consistent with remnant primary malignancy; FDG
avid lymphadenopathy involving lymph nodes in the left external
iliac, left para-aortic, aortocaval, and bilateral inguinal
regions; multiple pulmonary metastases scattered throughout both
lungs; osseous metastasis involving the left inferior pubic
ramus/ischium.
- ___ ___ x 6 cycles
- ___ start monthly ZA for bone mets
- ___ PET/CT substantial decrease across all sites of
disease
- ___ pt admitted with ___, found to have enlarging pelvic
mass causing bladder outlet obstruction, Foley placed with
normalization of kidney function, also treated for urinary
sepsis
- ___ resumed ___
PAST MEDICAL HISTORY:
- T2DM, diet-controlled
- HTN
- Hyperlipidemia
Social History:
___
Family History:
Mother BC, and ?brain cancer (vs. metastatic disease)
Physical Exam:
VITAL SIGNS: 98 100/58 (SBP dips to ___ while asleep) 86
General: NAD, resting in bed comfortably, frail appearing
HEENT: OMM
LUNGS CTA B/L
S1S2 NL, no M/R/G
ABD: BS+, soft, NTND
LIMBS: No ___
SKIN: No rashes on extremities
GU: Foley draining clear yellow urine
NEURO: Grossly WNL, oriented X 3
Pertinent Results:
___ 05:02AM BLOOD WBC-6.7# RBC-2.49* Hgb-7.8* Hct-23.9*
MCV-96 MCH-31.3 MCHC-32.6 RDW-16.7* RDWSD-58.8* Plt Ct-38*
___ 05:02AM BLOOD Glucose-91 UreaN-13 Creat-1.4* Na-135
K-3.7 Cl-106 HCO3-22 AnGap-11
___ 05:02AM BLOOD Calcium-6.4* Phos-1.9* Mg-1.9
___ 05:56AM BLOOD 25VitD-28*
___ 04:33AM BLOOD CRP-209.6*
___ 09:45AM BLOOD CA125-145*
Brief Hospital Course:
___ w/ endometrial cancer on C3D7 Paclitaxel and Carboplatin who
p/w AMS found to have MRSA pyelonephritis, left renal
obstruction and potentially superinfected enlarging tumor
extending into the spinal cord. Course c/b C dif.
# Pyelonephritis
# L hydroureteronephrosis
# Acute Kidney Injury
Urine culture grew MRSA however this was not entirely clear if
this was colonization or true infection. She improved on
Ceftriaxone but she continued to have low grade fevers hence CT
abdomen was done. The pyelonephritis was related to extrinsic
obstruction from mets/psoas mass and ureteral obstruction from
tumor. Urology was consulted and we performed a renal nuclear
study to evaluate the function of the left kidney. It did not
have much meaningful function worthy of surgical intervention
(such as PCN or stenting)
-- she will complete a 14 day course with tetracycline on
___.
-- cont Foley (inserted ___ until outpatient urology
appointment and then can review intermittent catheterization
# Psoas Mass:
CT of the abdomen revealed a left psoas muscle tumor with areas
of central hypodensity and rim enhancement and mass effect on
the left proximal ureter and new extension into the lateral
recesses at the L2-L3 and L3-L4 levels is likely tumor with
necrosis and superinfection rather than simply an abscess. MRI
of the L spine revealed left para-aortic soft tissue mass
involving the left psoas muscle invading the L2 vertebral body,
extending into the left paracentral epidural space at the level
of L2 and extending into L1-L2 and L2-L3 left neural foramen
causing narrowing of the spinal canal and Obstructive moderate
left hydroureteronephrosis, secondary to the encasement of left
ureter by the left para-aortic mass. ___ was consulted to
drain/biopsy psoas tumor/mass however due to TCP and extension
of mass into spinal cord, risks of procedure are high and this
was deferred. ID did not feel we need to treat this with
antibiotics as we do not have a culture from this mass, and the
last time it was biopsied, it was confirmed malignancy. If she
continues to have fevers of undetermined etiology, she will need
a biopsy.
# Endometrial Ca:
Metastatic and progressive. She had completed C3 of
taxol/carboplatin. She was seen by her NP ___, Dr.
___ now her new oncologist Dr. ___. She received
neupogen starting ___ to help avoid a neutropenic nadir and
this was discontinued once her WBC improved. The plan is now to
complete five fractions of radiation (she received 2 inpatient)
and then follow up in clinic with oncology to start chemotherapy
if her functional status continues to improve and her infections
controlled. She had minimal amount of vaginal bleeding despite
the thrombocytopenia.
# Spinal Mass:
Left endometrial tumor extending into spinal foramina. She had
no neurological deficits. Radiation Oncology started palliative
XRT on ___.
# Hyponatremia: Most likely volume depletion as she had poor po
intake and diarrhea. This improved with IVF
# C dif
She developed C.diff while inpatient. Her loose stools improved
on oral vancomycin. Day 1 = ___, to continue for 14 days.
# Pain
- Cont home-dose oxycodone.
# Pancytopenia: this is most likely due to her chemotherapy as
expected. She received 2U PRBC.
# Deconditioning: She worked with ___ and improved quickly. She
refused SNF and was discharged to her HCP's home (cousin ___.
CODE: Full
HCP: ___ (Cousin)
BILLING: ___ ___ spent coordinating care for discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
3. Acetaminophen ___ mg PO Q6H:PRN pain
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Sulfameth/Trimethoprim DS 1 TAB PO BID
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*40 Capsule Refills:*0
2. Tetracycline 250 mg PO Q12H Duration: 6 Doses
Start first dose on ___. always take 2 hours before or
after calcium or magnesium
RX *tetracycline 250 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*12 Capsule Refills:*0
3. Acetaminophen ___ mg PO Q6H:PRN pain
4. Docusate Sodium 100 mg PO BID
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Calcium Carbonate 1000 mg PO DAILY
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth Daily Disp #*30 Tablet Refills:*0
9. Magnesium Oxide 400 mg PO DAILY
RX *magnesium oxide 400 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Neutra-Phos 1 PKT PO TID Duration: 7 Days
RX *potassium & sodium phosphates [Phos-NaK] 280 mg-160 mg-250
mg 1 PKT by mouth three times a day Disp #*21 Packet Refills:*0
11. 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 With Service
Facility:
___
Discharge Diagnosis:
primary: pyelonephritis, MRSA
Endometrial Cancer causing hydroureteronephrosis
C dif Diarrhea, Severe
Pancytopenia, likely from anti-neoplastic therapy
Acute Urinary Retention
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was so lovely to meet you and a pleasure to take care of you
in the hospital.
You were admitted to the hospital with a urinary infection. You
were treated with IV antibiotics and were found to have a germ
called MRSA in your urine. You were seen by the ID team because
even though your UTI improved, you still had low grade fevers.
You will continue a 14 day course of antibiotics, and the last
day will be ___.
You had a CT scan of your belly, because of the low grade fevers
and the low back pain, and it showed that your tumor is getting
larger and possibly infected. We cannot biopsy it because it is
too deep into your spine and your platelets are low. We are not
too convinced that it is infected but should you have fevers in
the future, you may need this biopsied.
You received Radiation Therapy to your tumor on ___ and ___.
You will need to return back daily for three more fractions.
Your oncology team saw you in the hospital and felt you needed
some time to recuperate from the last chemo and the radiation
before thinking of a new chemotherapy regimen for you.
You were also found to have a left kidney that isnt working
well. Thats ok because your right kidney is still working well
and it is too late to fix it. However it is important you do not
take medications that can harm the kidneys, such as Ibuprofen,
Motrin, Advil, and other non-steroidal anti-inflammatory drugs.
While you were in the hospital, you developed a very large
bladder, with over a liter of urine inside. We spoke with your
urologist and the urology team. You had a foley placed and you
will need to continue this until you see your urologist. They
may do a voiding study and discuss intermittent catheterization.
Unfortunately while you were in the hospital, you developed
diarrhea and were found to have C.Diff diarrhea. You improved
on antibiotics and you will need to continue oral Vancomycin for
a total of 14 days, with the last day on ___.
We did feel it was best that you go to a SNF but you preferred
going home. ___ recommended going to ___ home with physical
therapy. We helped establish ___ for you.
It was a pleasure and best wishes,
Dr ___ your ___ Team
Dear Ms. ___,
It was so lovely to meet you and a pleasure to take care of you
in the hospital.
You were admitted to the hospital with a urinary infection. You
were treated with IV antibiotics and were found to have a germ
called MRSA in your urine. You were seen by the ID team because
even though your UTI improved, you still had low grade fevers.
You will continue a 14 day course of antibiotics, and the last
day will be ___.
You had a CT scan of your belly, because of the low grade fevers
and the low back pain, and it showed that your tumor is getting
larger and possibly infected. We cannot biopsy it because it is
too deep into your spine and your platelets are low. We are not
too convinced that it is infected but should you have fevers in
the future, you may need this biopsied.
You received Radiation Therapy to your tumor on ___ and ___.
You will need to return back daily for three more fractions.
Your oncology team saw you in the hospital and felt you needed
some time to recuperate from the last chemo and the radiation
before thinking of a new chemotherapy regimen for you.
You were also found to have a left kidney that isnt working
well. Thats ok because your right kidney is still working well
and it is too late to fix it. However it is important you do not
take medications that can harm the kidneys, such as Ibuprofen,
Motrin, Advil, and other non-steroidal anti-inflammatory drugs.
While you were in the hospital, you developed a very large
bladder, with over a liter of urine inside. We spoke with your
urologist and the urology team. You had a foley placed and you
will need to continue this until you see your urologist. They
may do a voiding study and discuss intermittent catheterization.
Unfortunately while you were in the hospital, you developed
diarrhea and were found to have C.Diff diarrhea. You improved
on antibiotics and you will need to continue oral Vancomycin for
a total of 14 days, with the last day on ___.
We did feel it was best that you go to a SNF but you preferred
going home. ___ recommended going to ___ home with physical
therapy. We helped establish ___ for you.
It was a pleasure and best wishes,
Dr ___ your ___ Team
Followup Instructions:
___
|
19742427-DS-20
| 19,742,427 | 20,543,706 |
DS
| 20 |
2182-06-17 00:00:00
|
2182-06-18 16:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anorexia, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ old woman with with suboptimally
debulked stage IVB,grade 3 endometrial adenocarcinoma who
presents with persistent abdominal pain, nausea, vomiting. She
is followed by Dr. ___ and is status post 6 cycles ___
ending ___ with progression disease. She was put on a new
chemotherapy regimen, everolimus, in ___. Three weeks ago
she noted onset of anorexia and decreasing ability to eat. Two
weeks ago she noted "spitting up" when she ate; mostly what she
had just eaten but sometimes progressing to bilious emesis.
Currently, she really only tolerates water. Continues to have
normal BM, last on the day of admission. She thinks she has
lost 20 pounds since the beginning of ___. She denies
diarrhea, CP, SOB, fevers or chills. She has been having regular
bowel movements every ___ days. She has had no sudden change in
symptoms over the past week, but over several weeks is having
increased abdominal distention, increased difficulty swallowing
food. She saw her PCP on the day of admission, and was sent to
the ED for evaluation due to symptoms concerning for a partial
small bowel obstruction.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___: Presented with postmenopausal bleeding. Pap smear:
atypical glandular cells, and an endometrial biopsy showed
likely adenocarcinoma.
___ Ultrasound at ___ prior
to surgery, showing a uterus measuring 5.9 x 45 x 5.7 cm with a
very thick endometrium and a significant amount of internal
fluid as well as a polypoid lesion. There was no obvious adnexal
disease.
___ ___ Dr. ___ a laparoscopic procedure,
and it immediately became apparent that there was disease
outside the uterus. An omental biopsy confirmed metastatic
disease by frozen section, and then he went to an exploratory
laparotomy with a total abdominal hysterectomy, bilateral
salpingo-oophorectomy, right pelvic lymph node sampling,
omentectomy, and washings. Findings: Omental cake extending to
the hepatic flexure. Tumor plaque
over the anterior abdominal wall extending down to the bladder
peritoneum. Bilateral enlarged pelvic nodes, which were fixed to
the pelvic side wall and disease involving the ascending,
transverse, and descending colon. Miliary studding along both
gutters and hemidiaphragm. There was resection of as many of
these nodules as possible and aggressive debulking, and Dr.
___ that at the conclusion of surgery residual
disease was approximately 2-3 cm.
___ Chemotherapy delayed due to Acute Kidney Injury, left
hydronephrosis.
___ Dr ___ stent, lesion could not be
bypassed, nephrostomy placed, ureter dilated by balloon by ___,
and since urine flowed freely after that, nephrostomy has been
clamped.
s/p 6 cycles of Carboplatin/Taxol ___ cycle ___, last cycle
___ Nephrostomy tube changed
___: CT Torso:
STUDY DATE: ___ 01:00:29 ___
1. 5 mm noncalcified right lower lobe nodule, small bilateral
effusions, right greater than left.
2. Enlarged aortocaval nodes. Omental/mesenteric stranding,
suspicious for residual disease.
3. Abnormal thickening of the greater curvature of the which
although may be secondary to under distention, gastric
involvement cannot entirely be excluded.
4. Status post hysterectomy and oophorectomy. Presacral soft
tissue stranding likely postoperative. No significantly enlarged
pelvic nodes.
5. Multiple sclerotic metastasis.
___ Left ureteral stent internalized, Dr. ___
-___: left ureteral stent exchange, right ureteral stent
placement
PAST MEDICAL HISTORY:
--Peripheral neuropathy
--Hydronephrosis of left kidney
--Hypercholesterolemia
--HTN
Social History:
___
Family History:
She has a son who died from metastatic colon cancer, otherwise
no GYN malignancies. History of diabetes in siblings (sister and
brother).
Physical Exam:
On day of discharge:
General: A&Ox1, NAD, comfortable
Pertinent Results:
LABORATORY RESULTS:
___ 05:45PM BLOOD WBC-13.4*# RBC-4.09* Hgb-11.7* Hct-37.7
MCV-92 MCH-28.7 MCHC-31.2 RDW-14.6 Plt ___
___ 06:30AM BLOOD WBC-16.2* RBC-3.81* Hgb-11.1* Hct-34.0*
MCV-89 MCH-29.1 MCHC-32.6 RDW-14.9 Plt ___
___ 06:20AM BLOOD WBC-14.3* RBC-3.79* Hgb-10.8* Hct-34.3*
MCV-91 MCH-28.6 MCHC-31.6 RDW-15.7* Plt ___
___ 06:40AM BLOOD WBC-16.9* RBC-3.72* Hgb-10.7* Hct-33.8*
MCV-91 MCH-28.7 MCHC-31.5 RDW-15.6* Plt ___
___ 07:15AM BLOOD WBC-16.0* RBC-3.53* Hgb-10.2* Hct-31.7*
MCV-90 MCH-29.0 MCHC-32.3 RDW-15.7* Plt ___
___ 06:25AM BLOOD WBC-19.9* RBC-3.56* Hgb-10.0* Hct-31.7*
MCV-89 MCH-28.2 MCHC-31.6 RDW-15.8* Plt ___
___ 06:30AM BLOOD WBC-23.0* RBC-3.28* Hgb-9.4* Hct-29.6*
MCV-90 MCH-28.8 MCHC-31.9 RDW-15.6* Plt ___
___ 06:25AM BLOOD WBC-24.6* RBC-3.11* Hgb-8.8* Hct-28.1*
MCV-91 MCH-28.3 MCHC-31.3 RDW-15.8* Plt ___
___ 06:30AM BLOOD WBC-23.9* RBC-2.89* Hgb-8.3* Hct-26.2*
MCV-91 MCH-28.8 MCHC-31.8 RDW-15.1 Plt ___
___ 05:45PM BLOOD Neuts-85* Bands-1 Lymphs-5* Monos-7 Eos-1
Baso-1 ___ Myelos-0
___ 06:30AM BLOOD Neuts-85.8* Lymphs-8.3* Monos-4.9 Eos-0.7
Baso-0.3
___ 06:40AM BLOOD Neuts-82.4* Lymphs-11.7* Monos-4.4
Eos-1.4 Baso-0.1
___ 07:15AM BLOOD Neuts-80.2* Lymphs-13.0* Monos-5.0
Eos-1.5 Baso-0.2
___ 05:45PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Burr-1+
___ 05:45PM BLOOD Glucose-94 UreaN-37* Creat-1.2* Na-139
K-3.5 Cl-102 HCO3-20* AnGap-21*
___ 06:30AM BLOOD Glucose-113* UreaN-31* Creat-1.1 Na-138
K-3.7 Cl-105 HCO3-20* AnGap-17
___ 06:20AM BLOOD Glucose-138* UreaN-23* Creat-1.0 Na-136
K-4.3 Cl-106 HCO3-19* AnGap-15
___ 06:40AM BLOOD Glucose-166* UreaN-19 Creat-1.0 Na-138
K-4.5 Cl-108 HCO3-21* AnGap-14
___ 07:15AM BLOOD Glucose-159* UreaN-16 Creat-1.0 Na-134
K-4.5 Cl-106 HCO3-20* AnGap-13
___ 06:25AM BLOOD Glucose-185* UreaN-13 Creat-0.8 Na-133
K-5.5* Cl-105 HCO3-19* AnGap-15
___ 12:50PM BLOOD Glucose-165* UreaN-12 Creat-0.8 Na-132*
K-5.2* Cl-104 HCO3-20* AnGap-13
___ 06:30AM BLOOD Glucose-158* UreaN-14 Creat-0.8 Na-136
K-4.9 Cl-106 HCO3-19* AnGap-16
___ 06:25AM BLOOD Glucose-145* UreaN-16 Creat-0.8 Na-135
K-4.7 Cl-107 HCO3-20* AnGap-13
___ 06:30AM BLOOD Glucose-139* UreaN-21* Creat-0.8 Na-137
K-4.3 Cl-105 HCO3-19* AnGap-17
___ 05:45PM BLOOD ALT-22 AST-49* AlkPhos-428* TotBili-1.1
___ 05:45PM BLOOD Lipase-18
___ 05:45PM BLOOD Albumin-3.3*
___ 06:30AM BLOOD Calcium-8.4 Phos-2.3*# Mg-1.9
___ 06:20AM BLOOD Calcium-8.0* Phos-1.9* Mg-2.3
___ 06:40AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.0
___ 07:15AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
___ 06:25AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.0
___ 12:50PM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0
___ 06:30AM BLOOD Calcium-8.5 Phos-3.1 Mg-1.9
___ 06:25AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.2
___ 06:30AM BLOOD Calcium-8.7 Phos-2.8 Mg-2.0
___ 05:51PM BLOOD Lactate-2.0
___ 08:15PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-SM Urobiln-2* pH-6.0 Leuks-LG
___ 08:15PM URINE RBC->182* WBC-70* Bacteri-FEW Yeast-NONE
Epi-2 TransE-<1
___ 08:15PM URINE CastHy-15*
___ 08:15PM URINE Mucous-RARE
___ 08:15PM URINE Color-DkAmb Appear-Hazy Sp ___
___ 01:56AM URINE Blood-LG Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 01:56AM URINE RBC->182* WBC->182* Bacteri-MANY
Yeast-NONE Epi-5
___ 01:56AM URINE Color-RED Appear-Cloudy Sp ___
MICROBIOLOGY:
___: URINE CULTURE: MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
___: URINE CULTURE: MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
IMAGING:
CT Ab/Pel w/contrast ___:
IMPRESSION:
1. Tethering of bowel loops centrally, many of which are
dilated with
air-fluid levels concerning for malignant partial small bowel
obstruction.
There is an interval increase in now moderate nonhemorrhagic
abdominal
ascites.
2. Liver metastases throughout all lobes, with new moderate
biliary ductal dilatation and portal venous thrombosis.
3. Hypodensity within the LV apex which is FDG-avid on the
recent PET study is likely secondary to metastasis. Similarly
abnormal appearance of the greater curvature of the stomach is
likely metastatic in nature. Thickening of the left adrenal is
likely metastatic.
4. Unchanged position of bilateral nephroureteral stents,
without
hydronephrosis.
5. Bilateral pleural effusions and adjacent atelectasis.
6. Bony metastases, which are better appreciated on the
comparison PET study.
CXR ___: Interval placement of nasogastric tube with its
tip projecting over the expected location of the stomach. The
proximal portion of bilateral ureteral stents are seen. There
is a small layering right effusion with no focal airspace
consolidation to suggest pneumonia. No pulmonary edema. No
pneumothorax. Stable 2-3 mm calcified nodule in the right upper
lobe likely representing a granuloma. Overall, cardiac and
mediastinal contours are likely stable, given differences in
positioning between studies. Note that the patient's mandible
obscures portion of the apices.
Brief Hospital Course:
Mrs. ___ was admitted to gynecologic oncology service on
___ for further evaluation and management of malignant
partial small bowel obstruction from stage IV endometrial
cancer. Of note she completed 6 cycles of chemotherapy with
inadequate response and had recently been started on Everolimus
prior to admission. A CT of the abdomen and pelvis on ___
revealed tethering of bowel loops centrally, many of which are
dilated with air-fluid levels concerning for malignant partial
small bowel obstruction and interval increase in abdominal
ascites. It also confirmed advanced metastatic disease involving
the left ventricle, liver, biliary ducts, stomach, left adrenal,
with bony metastases.
Her hospital course is summarized below by system:
#Neuro: She reported minimal pain during this admission. Her
pain was managed with PRN IV Tylenol and PR Tylenol. Palliative
care was consulted on ___. Patient had made the decision to
be DNR/DNI on ___ and had expressed interest in home with
Hospice on ___. On ___ she was noted to be less
communicative when discussing her goals of care and would only
respond to questions by yes or no. By ___ she was no longer
oriented to place or time. She also became agitated and had
difficulty following simple commands or going to the bathroom on
her own. Given her altered mental status, decision was made with
health care proxy to pursue inpatient Hospice care. Patient
received Ativan for agitation. Over the next several days,
patient became more clear and adamant in her wish to go home and
was discharged to home with Hospice on ___.
#GI/Nutrition: Given malignant partial SBO and persistent
nausea and vomiting, she was made NPO with ice chips only upon
admission. Maintenance fluids were started. Her nausea was
treated with Compazine, Octreotide, Zofran, and Dexamethasone.
On HD4, ___, patient experienced increased emesis and a
___ tube was placed with improvement in her symptoms.
Interventional Radiology and GI were consulted on ___ and
___ respectively regarding the possibility of placing a
venting G-tube. Both services stated that while technically
possible, they did not recommend placement due to the high risk
of leakage, infection, bleeding, and tumor infiltration. NG tube
was accidently removed by the patient on ___, hospital day
7. Patient experienced some increased nausea and spitting s/p
NGT removal, but tolerated her symptoms with anti-emetics. At
this point in her hospitalization, decision had been made to
move forward with comfort measures only and Hospice care and no
further intervention was undertaken. Patient passed bloody stool
on ___ (HD8), but given CMO and stable VSS, no intervention
was undertaken. Patient was discharged home with Hospice on
zofran, octreotide, compazine, and dexamethasone for nausea.
#GU: Ms. ___ was noted to have hematuria upon admission.
This was thought to be secondary to her bilateral urethral
stents for hydronephrosis. Urine cultures x2 were obtained and
grew mixed flora that was consistent with skin or genital
contamination.
#MSK: Given her extensive hospitalization, physical therapy was
consulted on ___, hospital day 4. She was deemed unsafe for
discharge home and they continued to work with her until she was
admitted to inpatient Hospice.
#End of Life Care: Palliative care was consulted on ___,
hospital day five. Recommendations were appreciated and
instituted. As above, patient was admitted to inpatient Hospice
on ___ and discharged home with Hospice on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. benazepril-hydrochlorothiazide *NF* ___ mg Oral daily
4. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
5. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
6. Docusate Sodium 100 mg PO BID
7. Magnesium Oxide Dose is Unknown PO ONCE Duration: 1 Doses
8. Pyridoxine Dose is Unknown PO DAILY
Discharge Medications:
1. Dexamethasone 4 mg PO Q12H
RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
2. Octreotide Acetate 100 mcg IV Q8H
RX *octreotide acetate 100 mcg/mL (1 mL) inject ___ every
eight (8) hours Disp #*90 Syringe Refills:*2
3. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*2
4. Amlodipine 5 mg PO DAILY
5. Atorvastatin 10 mg PO DAILY
6. benazepril-hydrochlorothiazide *NF* ___ mg Oral daily
7. Docusate Sodium 100 mg PO BID
8. Magnesium Oxide 400 mg PO ONCE Duration: 1 Doses
9. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
10. Pyridoxine 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
metastatic endometrial cancer with malignant small bowel
obsruction
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
You were admitted to the gynecologic oncology service for
management of your malignant small bowel obstruction as a result
of your metastatic endometrial cancer. You were given medication
for your nausea and given intravenous fluids. A nasogastric tube
was placed to relieve your symptoms. This was able to be
discontinued and your symptoms were well-controlled with
medication. Given the severity of your disease, you and your
family decided to proceed with comfort measures only and Hospice
care. Please follow these instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs
* You may eat what you can tolerate
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19742708-DS-14
| 19,742,708 | 28,770,883 |
DS
| 14 |
2193-09-24 00:00:00
|
2193-09-25 16:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline
Analogues / Betadine Viscous Gauze / Morphine Sulfate /
Clindamycin / Scopolamine / Mastisol Stertip / oxycodone /
E-Mycin / Percocet
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
___
1. Revision laminectomy of L5 and S1.
2. Fusion revision L5 to S1 with removal of previous
instrumentation, application of new instrumentation.
3. Autograft.
4. CSF drain.
5. Vertebroplasty of S1.
___ REVISION FUSION LAMINECTOMY LUMBAR L5-S1 ___
___ L5-S1 Posterior Lumbar Decompression ___
___ ANTERIOR FUSION AND DECOMPRESSION L5-S1
History of Present Illness:
___ multiple spinal surgeries, most recently s/p L5-S1
anterior decompression and fusion ___ and posterior
decompression and fusion ___, ___ c/b intraop dural tear
that was repaired. She was doing well in rehab until this
afternoon when she noted significant amounts of clear drainage
from her wound. Denies bowel/bladder incontinence, although she
has a foley in place since the rehab would not allow her to self
straight cath for her known neurogenic bladder. Endorses RLE
paresthesias in the S1 distribution that have not changed since
her surgery. Endorses dizziness with sitting up but denies
headaches.
Past Medical History:
- Spondylolisthesis s/p multiple surgeries
- Hyertension
- Hyperlipidemia
- Vestibular neuropathy c/b ataxia
- Neurogenic bladder
- Depression
- GERD
- Paroxysmal intracranial cluster headache (controlled with
indomethacin)
PSH:
- Total laminectomy L4-L5, fusion L4-L5 (___)
- L shoulder athroscopy with subacromial decompression (___)
- Revision laminectomy L4, laminectomy L3, fusion L3-L5 (___)
- Partial vertebrectomy L3-L4, fusion of L3 to L4, umbilical
hernia repair (___)
- Total laminectomy of L1, L2 and L3, fusion L1-L4 (___)
- T11-L4 fusion, laminotomy T1-T12, vertebroplasties T11-L4
(___)
- Anterior fusion L1-L3, anterior spacers x2 (___)
- Total laminectomy of T10-T11, fusion T11-12, vertebroplasties
x2 (___)
Social History:
___
Family History:
reviewed and non-contributory to admission for spinal fluid
leakage
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Well-appearing female in no acute distress.
Spine exam:
Motor-
Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
-Sensory:
Sensory UE
C5 (Ax) R nl, L nl
C6 (MC) R nl, L nl
C7 (Mid finger) R nl, L nl
C8 (MACN) R nl, L nl
T1 (MBCN) R nl, L nl
T2-L2 Trunk R nl, L nl
Sensory ___
L2 (Groin): R nl, L nl
L3 (Leg) R nl, L nl
L4 (Knee) R nl, L nl
L5 (Grt Toe): R nl, L nl
S1 (Sm toe): R nl, L nl
S2 (Post Thigh): R nl, L nl
DISCHARGE PHYSICAL EXAM:
VITALS: ___ 1132 Temp: 98.2 PO BP: 109/74 R Sitting HR: 113
RR: 18 O2 sat: 92% O2 delivery: Ra
GENERAL: Alert and interactive. Very pleasant in no acute
distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
Systolic
murmur heard best at RUSB.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: Staples in place over lower L-spine with clean, dry
incision without surrounding erythema/induration. No drainage.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No TTP over L thigh where she describes discomfort.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Pertinent Results:
___ 12:00PM BLOOD ___ pO2-26* pCO2-51* pH-7.32*
calTCO2-27 Base XS--1
___ 02:07PM BLOOD ___ pO2-67* pCO2-44 pH-7.41
calTCO2-29 Base XS-2 Comment-GREEN TOP
___ 05:47PM BLOOD CRP-53.1*
___ 05:30PM BLOOD Calcium-8.2* Phos-3.5 Mg-2.3
___ 05:47PM BLOOD Glucose-79 UreaN-11 Creat-1.1 Na-141
K-4.5 Cl-97 HCO3-28 AnGap-16
___ 12:59AM BLOOD Glucose-109* UreaN-18 Creat-0.7 Na-143
K-4.2 Cl-104 HCO3-27 AnGap-12
___ 05:47PM BLOOD ___ PTT-29.0 ___
___ 12:59AM BLOOD ___ PTT-27.6 ___
___ 05:47PM BLOOD Neuts-68.5 Lymphs-17.4* Monos-7.6 Eos-4.9
Baso-0.8 Im ___ AbsNeut-8.07* AbsLymp-2.05 AbsMono-0.90*
AbsEos-0.58* AbsBaso-0.10*
___ 05:47PM BLOOD WBC-11.8* RBC-3.69* Hgb-9.4* Hct-30.9*
MCV-84 MCH-25.5* MCHC-30.4* RDW-19.4* RDWSD-58.2* Plt ___
___ 12:59AM BLOOD WBC-9.8 RBC-2.71* Hgb-7.0* Hct-22.7*
MCV-84 MCH-25.8* MCHC-30.8* RDW-18.6* RDWSD-56.7* Plt ___
RESPIRATORY CULTURE (Final ___:
___. ___ (___) REQUESTS TO WORK UP EVERYTHING ON ___.
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. MODERATE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
KLEBSIELLA OXYTOCA. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| KLEBSIELLA OXYTOCA
| |
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- <=0.25 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S
VANCOMYCIN------------ 1 S
___ 04:08AM BLOOD WBC-8.2 RBC-3.12* Hgb-8.2* Hct-27.2*
MCV-87 MCH-26.3 MCHC-30.1* RDW-20.5* RDWSD-64.9* Plt ___
___ 04:08AM BLOOD Neuts-52.6 ___ Monos-8.2
Eos-16.7* Baso-0.9 Im ___ AbsNeut-4.31 AbsLymp-1.71
AbsMono-0.67 AbsEos-1.37* AbsBaso-0.07
___ 03:22AM BLOOD Neuts-60.8 Lymphs-12.6* Monos-7.8
Eos-16.8* Baso-0.8 Im ___ AbsNeut-7.31* AbsLymp-1.51
AbsMono-0.93* AbsEos-2.01* AbsBaso-0.09*
MR ___ SPINE W/O CONTRAST Study Date of ___ 1:42 ___
1. Extremely limited exam due to motion and lack of intravenous
contrast.
2. Redemonstrated large loculated postoperative fluid collection
in the
subcutaneous tissue and laminectomy bed which may represent a
postoperative
seroma although CSF leak or superinfection cannot be excluded by
this
examination.
3. At least moderate to severe spinal canal narrowing due to
disc extrusion
and postoperative fluid collection at L5-S1.
Brief Hospital Course:
___ with past medical history of HTN, GERD, paroxysmal cluster
headaches (controlled on indomethacin) and multiple spinal
surgeries, most recently s/p L5-S1 anterior decompression and
fusion ___ and posterior decompression and fusion ___,
___ c/b intraop dural tear that was repaired. She was doing
well in rehab until the day of her presentation on ___,
where she noted significant amounts of clear drainage from her
wound. She had no additional changes since the surgery. MRI
showed a persistent fluid collection consistent with a
persistent dural leak. She was admitted to the orthopedics spine
service. Per spine recommendations, an ___ lumbar drain was
attempted but unsuccessful, so she underwent a revision
laminectomy of L5 and S1, fusion revision L5 to S1 with removal
of previous instrumentation, application of new instrumentation,
placement of a CSF drain, and vertebroplasty of S1 on ___.
She was admitted to the TSICU with a plan for 48 hours of
intubation to keep the patient monitored and sedated while lying
flat.
Upon admission to the TSICU, the patient was intubated and
sedated, maintained on low-dose phenylephrine from
intraoperative hypotension. Her lumbar drain was maintained at a
rate of 10cc/hr for the first two days, and she was transitioned
from phenylephrine to norepinephrine on day 2. She was then
extubated successfully on POD 4 (___), initially to ___ and
then weaned to ___. However, she remained confused. A stat head
CT was significant for a possibly new left frontal hypodensity,
concerning for stroke. Neurology was consulted and recommended
MRI and ASA, but these were held as the lumbar drain was not MRI
compatible and ASA was contraindicated while her drain was in
place. Plan per neurology was to obtain MRI once her acute
illness had resolved.
Sputum cultures at that time grew GPCs and GNRs, for which she
was started on vancomycin and cefepime at meningitis dosing
given her altered mental status. CSF was not initially obtained
as, per neurosurgery, accessing her sterile drain circuit would
place the patient at significant risk. Her cultures grew
pan-sensitive klebsiella and MRSA, and on the morning of ___ her
mental status significantly improved. She was AAOx3, and
therefore was de-escalated to vancomycin and ceftriaxone. She
again became altered that afternoon, and a stat head CT showed
no significant change, and likely a chronic infarct. She was
again re-initiated on cefepime and ID was consulted. C-diff was
negative. They recommended continuing these antibiotics and LP
if possible, but this was withheld in favor of empiric treatment
given the extremely high risk that a post-surgical LP would
incur. On ___, her mental status significantly improved,
and she was able to get out of bed to the commode, AAOx3. She
was then transferred to medicine for further treatment.
Following transfer to the floor, she did well overall. Her diet
was advanced by SLP team. Her pain continued to be a problem,
was managed with Tylenol, tramadol, and dilaudid ___ sessions
for a few days. Her dural leak eventually resolved and she was
able to tolerate sitting in a chair and working with ___. She was
treated empirically for culture negative nosocomial meningitis
with spinal hardware with vancomycin and cefepime initially ->
daptomycin/meropenem. Antibiotics were changed due to persistent
eosinophilia which began to downtrend after these changes.
ACUTE/ACTIVE ISSUES:
====================
# Concern for Nosocomial Meningitis
# Possible Pneumonia
# Leukocytosis
Developed worsening leukocytosis and with persistent
encephalopathy and fevers post-op raising concern for infection.
Patient was initially started on Vanc/Cefepime for HAP as had
sputum culture growing Klebsiella and MRSA. ID was consulted and
recommended continuing abx but at meningitic dosing to cover for
possible nosocomial meningitis as well. Cefepime switched to
meropenem ___ given concern for drug-induced eosinophilia;
vanco switched to dapto on ___. Mental status cleared. MRI w
persistent fluid collection, unclear if infected. Will avoid
sampling CSF, yield
from SC pocket likely low. No orthopedic surgeries planned at
this time. IV ___ at meningitic dosing through ___.
# Eosinophilia
Uptrending, now with severe eosinophilia. Given acute rise,
suspect this is medication related with Cefepime initially
thought to be the most likely culprit. No rash on exam and renal
function/LFTs stable making DRESS unlikely. Rising ___ despite
Cefepime being off for a few days, prompting switch from vanco
to dapto on ___. Began to downtrend following d/c vanc.
# S/p Revision fusion laminectomy lumbar L5-S1 with
intraoperative lumbar drain placement
# Serous Drainage from surgical incision
# Concern for persistent Dural Leak
Patient initially presented with symptoms of a dural leak and
had drain placed from ___. After drain removed, initially
without drainage but later started saturating dressings
concerning for recurrence of dural leak. Pt tolerated sitting up
and working with ___ so deferring futher surgical mgmt. for now.
Pain control: standing acetaminophen 1000mg TID, tramadol 50mg
q4h, home pregabalin, indomethacin XR.
# Vertigo
H/o vestibulopathy, but symptoms c/w BPPV
___ benefit from Epley maneuvers w ___ if persistent.
# Dysphagia
Failed S&S bedside post intubation and had ___ in place. S&S
c/s
and advanced diet. Dobhoff removed prior to d/c.
CHRONIC/STABLE ISSUES:
======================
# Chronic CVA seen on MRI brain
Neuro evaluated, felt to be old infarct. ASA 81mg
# Neurogenic bladder
Patient states is a complication of a prior spinal surgery.
Intermittent straight cath at home
# Depression
- Continue home sertraline
- Continue bupropion
# Restless leg syndrome
- Continue home pramipexole
# History of Cluster HA
- indomethacin 75 mg XR bid
# History of Esophagitis
- Continue her home Nexium
# Hypertension
- Continue home amlodipine
- continue losartan at 50mg (half home dose), can increase to
home dose if needed
- continue home metoprolol XL 12.5mg
- Held home Lasix (unclear why on this at home - patient states
for hypertension but no history ___ swelling, HF)
# Hyperlipidemia
- Continue home atorvastatin
TRANSITIONAL ISSUES:
==============
[] Can increase losartan to home dose of 100 mg if tolerated
[] Recommend continued S/S evaluation
[] staples to be removed in orthopedic surgery clinic
[] please repeat cbc w diff in 2 weeks to ensure resolution of
eosinophilia
[] daptomycin and meropenem through ___
# CODE STATUS: full code
# CONTACT/ HCP: ___, Daughter, ___
More than 30 minutes were spent preparing this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. BuPROPion XL (Once Daily) 150 mg PO DAILY
4. Enablex (darifenacin) 15 mg oral QAM
5. Nexium 40 MG Other DAILY
6. Furosemide 20 mg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Pramipexole 0.5 mg PO QHS
10. Sertraline 200 mg PO QHS
11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
12. Pregabalin 100 mg PO TID
13. Indomethacin 75 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Daptomycin 600 mg IV Q24H
3. Meropenem ___ mg IV Q8H
4. Losartan Potassium 50 mg PO DAILY
5. TraMADol 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. amLODIPine 5 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. BuPROPion XL (Once Daily) 150 mg PO DAILY
9. Enablex (darifenacin) 15 mg oral QAM
10. Indomethacin XR 75 mg PO BID
11. Metoprolol Succinate XL 12.5 mg PO DAILY
12. Nexium 40 MG Other DAILY
13. Pramipexole 0.5 mg PO QHS
14. Pregabalin 100 mg PO TID
15. Sertraline 200 mg PO QHS
16. HELD- Furosemide 20 mg PO DAILY This medication was held.
Do not restart Furosemide until told to restart by your PCP
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Dural tear
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your hospital stay.
WHY WAS I HERE?
- You had drainage from your spine incision
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- You had a drain in place to help your spine heal and were
intubated.
- You were given strong antibiotics
WHAT SHOULD I DO WHEN I GO HOME?
- Keep working with ___ to get stronger
Be well!
Your ___ Care Team
Here are the istructions from your orthopedic surgery team:
You have undergone the following operation: Lumbar Decompression
With Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without getting up and
walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet: Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace,this brace is to be worn when you are
walking.You may take it off when sitting in a chair or while
lying in bed.
Wound Care:Remove the dressing in 2 days.If the
incision is draining cover it with a new sterile dressing.If it
is dry then you can leave the incision open to the air.Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery, do not get the incision wet.Cover it with a sterile
dressing.Call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
At the 2-week visit we will check your incision,take baseline
X-rays and answer any questions.We may at that time start
physical therapy
We will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound
Followup Instructions:
___
|
19742708-DS-15
| 19,742,708 | 28,416,946 |
DS
| 15 |
2193-10-24 00:00:00
|
2193-10-24 10:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline
Analogues / Betadine Viscous Gauze / Morphine Sulfate /
Clindamycin / Scopolamine / Mastisol Stertip / oxycodone /
E-Mycin / Percocet
Attending: ___.
Chief Complaint:
Left sided weakness, wound with signs of seroma/fluid
collection.
Major Surgical or Invasive Procedure:
Lumbar Fusion revision ___
Re-admission on ___ for concern of neurologic deficit and
possible wound infection.
History of Present Illness:
___ yo F multiple spinal surgeries, most recently s/p L5-S1
anterior decompression and fusion ___ and posterior
decompression and fusion ___, ___ c/b intraop dural tear
that was repaired but complicated by infection and now s/p
revision on ___.
Patient discharged on ___ and doing well until 1 week
ago-patient complaint pain Left leg hindering her ability to
walk. She reports the pain as an "electrical type shock" which
runs from Left back across buttocks and down the leg. She does
experience some Right leg pain, but this less bothersome vs Left
leg. She also endorses some "soft neuro symptoms" such as
intermittent blurry vision, drooling at times from Right side of
mouth (no facial droop). She endorses full sensation diffusely
bilat upper/lower ext; motor ___ lower ext
w/weakness Left leg secondary to pain; no change in bladder
dysfunction and sensation intact saddle region. Noticeable
erythematous lump L side of thoracic incision. No active
drainage
endorsed.
Past Medical History:
- Spondylolisthesis s/p multiple surgeries
- Hyertension
- Hyperlipidemia
- Vestibular neuropathy c/b ataxia
- Neurogenic bladder
- Depression
- GERD
- Paroxysmal intracranial cluster headache (controlled with
indomethacin)
PSH:
- Total laminectomy L4-L5, fusion L4-L5 (___)
- L shoulder athroscopy with subacromial decompression (___)
- Revision laminectomy L4, laminectomy L3, fusion L3-L5 (___)
- Partial vertebrectomy L3-L4, fusion of L3 to L4, umbilical
hernia repair (___)
- Total laminectomy of L1, L2 and L3, fusion L1-L4 (___)
- T11-L4 fusion, laminotomy T1-T12, vertebroplasties T11-L4
(___)
- Anterior fusion L1-L3, anterior spacers x2 (___)
- Total laminectomy of T10-T11, fusion T11-12, vertebroplasties
x2 (___)
Social History:
___
Family History:
reviewed and non-contributory to admission for spinal fluid
leakage
Physical Exam:
AVSS
Well appearing, NAD, comfortable
BUE: SILT C5-T1 dermatomal distributions
BUE: ___ Del/Tri/Bic/WE/WF/FF/IO
BUE: tone normal, negative ___, 2+ symmetric DTR
bic/bra/tri
All fingers WWP, brisk capillary refill, 2+ distal pulses
BLE: SILT L1-S1 dermatomal distributions
BLE: ___ ___
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
All toes WWP, brisk capillary refill, 2+ distal pulses
Blister in superior pole of incision.
Pertinent Results:
___ 05:23AM BLOOD WBC-12.1* RBC-3.02* Hgb-7.9* Hct-25.4*
MCV-84 MCH-26.2 MCHC-31.1* RDW-17.5* RDWSD-54.5* Plt ___
___ 05:23AM BLOOD Neuts-76.1* Lymphs-10.2* Monos-5.6
Eos-6.8 Baso-0.6 Im ___ AbsNeut-9.22* AbsLymp-1.24
AbsMono-0.68 AbsEos-0.83* AbsBaso-0.07
___ 05:23AM BLOOD Plt ___
___ 05:23AM BLOOD UreaN-16 Creat-0.8
___ 05:23AM BLOOD ALT-7 AST-11 AlkPhos-86 TotBili-0.2
___ 05:23AM BLOOD CRP-173.1*
___ 04:00AM BLOOD WBC-9.2 RBC-2.98* Hgb-7.6* Hct-25.2*
MCV-85 MCH-25.5* MCHC-30.2* RDW-17.3* RDWSD-54.1* Plt ___
___ 04:00AM BLOOD Neuts-64.8 ___ Monos-4.7*
Eos-9.0* Baso-0.8 Im ___ AbsNeut-5.94 AbsLymp-1.83
AbsMono-0.43 AbsEos-0.82* AbsBaso-0.07
___ 04:00AM BLOOD Plt ___
___ 04:00AM BLOOD Glucose-93 UreaN-17 Creat-0.9 Na-142
K-4.1 Cl-108 HCO3-23 AnGap-11
___ 05:23AM BLOOD ALT-7 AST-11 AlkPhos-86 TotBili-0.2
___ 05:23AM BLOOD CRP-173.1*
___ 06:29AM BLOOD Vanco-27.5*
Brief Hospital Course:
___ Neurosurgery Consult Recommendations Opthomology consult
for evaluation of intraocular pressures for
evaluation of venous congestion.
___ Neurology consult Neurology consult for evaluation of
multiple neurological subacute complaints/findings.
#tremor:#cerebellar findings
She likely has an essential tremor given worse with action and
chronicity. It seems to have worsened in the setting of her
acute
medical issues. Additionally, there is a component of cerebellar
tremor, with dysmetria and dysdiadochokinesia on exam. This
could
be indicative of an old cerebellar infarct. Of note, she had an
MRI in ___ (after her symptoms started to worsen) that did not
show sings of cerebellar stroke. She does have multiple previous
lacunar infarcts.
[]Could obtain MRI brain without contrast to evaluate for old
stroke
[]If BP allows, recommend trial of propranolol
#confusion/delirium: consistent episodes of confusion and
hallucinations around periods of sleep. ___ reflect underlying
dementia process worsened by stress of hospitalization,
medications, etc.
[]Recommend outpatient cognitive neurology evaluation for
dementia following discharge
___ Optho consult no signs of dilated tortuous blood
vessels; no signs of conjunctival hyperemia or dilater vessels
and no signs of
pulsations or thrill ___. No ocular manifestations of CCF on
exam.
___ ID reqs Vanco 1GM Q12, and Rifampin 300mg Q12. The
following interactions have been noted with her current home
medications. She was counseled by the pharmacist regarding
these interactions.
Rifampin will interact and decrease serum levels of the above 4
medications mentioned. Proposed management strategies include:
- DARIFENACIN (overactive bladder) - Mrs. ___ is on the
maximum daily dose. Recommend monitoring response on
combination
therapy at current dose. If patient symptomatic/incontinent,
speak with PCP to determine other potential treatment options
and
run a drug interaction check with rifampin. Oxybutinin appears
to have less of an interaction with rifampin and may be an
option.
- NEXIUM (GERD) - Mrs. ___ is on 40mg once daily. As
rifampin can decrease the AUC of PPIs by up to 85%, we can
potentially do BID dosing of esomeprazole, however this may
still
not be enough to control/prevent symptoms of GERD. Adding
famotidine 40 mg BID may help. Famotidine is not metabolized
via
the CYP450 system and is not affected by rifampim.
- ATORVASTATIN (Cholesterol) - Mrs. ___ states that she
was
put on low dose atorvastatin due to borderline high cholesterol
levels. Recommend no empiric action, as the rifampin is
anticipated to only be a few weeks of duration. Potentially
check another lipid panel in 1 month to determine if
atorvastatin
dose increase is required.
- AMLODIPINE - Mrs. ___ mentions that she has labile blood
pressure and can often times become hypotensive but also
hypertensive at times. Recommend no empiric action, as the
rifampin is anticipated to only be a few weeks of duration.
Periodic blood pressure monitoring can be performed and if
consistently elevated, can discuss increase the amlodipine dose.
COUNSELING:
Mrs. ___ was counseled on taking the rifampin twice daily
on
an empty stomach. She was counseled on the potential for liver
injury and therefore we would monitor weekly safety labs. She
was also counseled to be aware that rifampin may discolor urine,
tears, and other bodily fluids to an orange-red color. This is
harmless and expected, and should resolve once the rifampin is
discontinued. Mrs. ___ does not wear contact lenses.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
- Darifenacin 15 mg daily (for overactive bladder)
- Nexium 40 mg daily (for GERD)
- Atorvastatin 10 mg (outpatient - for high cholesterol)
- Amlodipine 5 mg (Outpatient - for labile/high blood pressure)
- Bupropion
- Indomethacin
- Pramipexole
- Pregabalin
- Sertraline
- Vitamin D
- Losartan
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. amLODIPine 5 mg PO DAILY
3. BuPROPion XL (Once Daily) 150 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Losartan Potassium 100 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Pramipexole 0.5 mg PO QHS
10. Pregabalin 100 mg PO TID
11. RifAMPin 300 mg PO Q12H
RX *rifampin 300 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
12. Senna 17.2 mg PO HS
13. Sertraline 200 mg PO QHS
14. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
15. Vancomycin 1500 mg IV Q 24H
RX *vancomycin 1 gram 1500 mg IV once a day Disp #*30 Vial
Refills:*0
RX *vancomycin 1.5 gram 1.5 GM IV once a day Disp #*30 Vial
Refills:*0
16. Vitamin D 800 UNIT PO DAILY
17. darifenacin 15 mg oral DAILY
18. Esomeprazole 40 mg Other DAILY
19. Indomethacin XR 75 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seroma s/p lumbar fusion revision
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You have undergone the following operation: Lumbar Decompression
With Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without getting up and
walking around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet: Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace,this brace is to be worn when you are
walking.You may take it off when sitting in a chair or while
lying in bed.
Wound Care:Remove the dressing in 2 days.If the
incision is draining cover it with a new sterile dressing.If it
is dry then you can leave the incision open to the air.Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower.Do not soak the incision in a
bath or pool.If the incision starts draining at anytime after
surgery, do not get the incision wet.Cover it with a sterile
dressing.Call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___ 2.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision,take baseline X-rays and answer any questions.We may at
that time start physical therapy
___ We will then see you at 6 weeks from the
day of the operation and at that time release you to full
activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound
Followup Instructions:
___
|
19742708-DS-16
| 19,742,708 | 20,827,842 |
DS
| 16 |
2193-11-30 00:00:00
|
2193-11-30 18:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Tetracycline
Analogues / Betadine Viscous Gauze / Morphine Sulfate /
Clindamycin / Scopolamine / Mastisol Stertip / oxycodone /
E-Mycin / Percocet
Attending: ___.
Chief Complaint:
Vertigo
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with h/o HTN, HLD, vestibular neuropathy with
ataxia, neurogenic bladder requiring CIC, spondylolisthesis s/p
multiple spinal surgeries including L5/S1 anterior and posterior
fusion (___) complicated by intra-op dural tear and CSF leak
s/p revision laminectomy (___) and course ___ MRSA surgical
site infection who presents from ___ clinic wound evaluation.
The patient returned home on ___ night this week from rehab
after not being home since her initial hospitalization several
months ago. This morning she reports when she got up she
started
to feel dizzy, nauseous, dyspneic, sweaty and the symptoms
lasted
for hours. She has also had dizziness intermittently over the
last several weeks but this morning it was much greater and the
other symptoms were new. She also reported pain in her back and
upper buttocks shooting pains down the legs. She vomited once
at
home this morning and it was bright orange in color. She also
notes a fluctuant mass at her spinal surgical site that has been
increasing in size and has drained pus and fluids previously.
She says that when she was at her infectious disease appointment
today this area on her back popped and drained a significant
amount of drainage infection. She says that when the ID team
reevaluating the wound later the area was coming up again with
fluid, which is what prompted them to refer her to the emergency
room for further evaluation. She denies any fever, chills, cp,
urinary sx. per patient was clotted today and thus it was pulled
her infectious disease appointment.
The patient has had a complicated course over the last several
months. She initially was hospitalized from ___. She
underwent L5-S1 anterior decompression and fusion ___ and
posterior decompression and fusion ___ with Dr. ___
intra-operative dural tear that was repaired. She was doing well
in rehab until the day of her presentation on ___, where she
noted significant amounts of clear drainage from her wound. Per
spine recommendations, an ___ lumbar drain was attempted but
unsuccessful, so she underwent a revision laminectomy of L5 and
S1, fusion revision L5 to S1 with removal of previous
instrumentation, application of new instrumentation, placement
of
a CSF drain, and vertebroplasty of S1 on ___. Her
hospitalization was complicated by altered mental status for
which an LP was recommended but was unable to be obtained due to
the recent surgery. She was treated for meningitis empirically.
She was also treated for a pneumonia (sputum grew klebsiella and
MRSA).
She was then re-admitted to the spine service from ___
for lower extremity electric pains and swelling/erythema at the
lower margin of the incision which was concerning for infection.
MRI on that admission c/f subcutaneous collection, and L5-S1
soft
tissue abscess. Ultrasound-guided culture of fluid collection
grew MRSA and she was discharged on vancomycin and Rifampin.
In the ED, initial vitals were: 96.9F, HR 96, BP 114/96, RR 19,
98% on RA
Exam was notable for: 1cm fluctuant mass over surgical incision
scar over L4, midline tenderness over L4, otherwise non-focal
neurologic exam.
-
Labs were notable for:
- CBC: normal
- BMP: normal
- Vanc level (random): 34.2 (reportedly drawn shortly after her
AM dose of vancomycin, per patient)
Studies were notable for: MRI L spine with several abnormalities
(see full read below) but no acute findings.
The patient was given: 0.5mg IV dilaudid x2
Orthopedics was consulted who recommended admission to medicine
versus observation for further work-up of patient's current
presentation.
On arrival to the floor, she reports that she feels much better.
She denies any further diaphoresis, nausea, or dizziness. She
denies stool incontinence, weakness or saddle anesthesia.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
- Spondylolisthesis s/p multiple surgeries
- Hyertension
- Hyperlipidemia
- Vestibular neuropathy ___ ataxia
- Neurogenic bladder
- Depression
- GERD
- Paroxysmal intracranial cluster headache (controlled with
indomethacin)
PSH:
- Total laminectomy L4-L5, fusion L4-L5 (___)
- L shoulder athroscopy with subacromial decompression (___)
- Revision laminectomy L4, laminectomy L3, fusion L3-L5 (___)
- Partial vertebrectomy L3-L4, fusion of L3 to L4, umbilical
hernia repair (___)
- Total laminectomy of L1, L2 and L3, fusion L1-L4 (___)
- T11-L4 fusion, laminotomy T1-T12, vertebroplasties T11-L4
(___)
- Anterior fusion L1-L3, anterior spacers x2 (___)
- Total laminectomy of T10-T11, fusion T11-12, vertebroplasties
x2 (___)
Social History:
___
Family History:
Reviewed and non-contributory to admission.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.9, BP 119 / 80, HR 97, RR, 18, 96% Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: Well-healed incision, small amount of granulation tissue
projecting out from the superior part of the incision, no
drainage noted
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM:
========================
VITALS:
___ Temp: 98.5 PO BP: 163/79 HR: 68 RR: 20 O2 sat: 95%
O2 delivery: RA
GENERAL: Alert and interactive. NAD
HEENT: NC/AT, EOMI. Sclera anicteric and without injection. MMM.
No nystagmus.
CARDIAC: RRR, no M/R/G.
LUNGS: CTAB. No wheezes, rhonchi or rales. No increased work of
breathing.
BACK: Well-healed incision, small amount of granulation tissue
projecting out from the superior part of the incision, no
drainage noted, 1-2cm area of fluctuation tender to palpation.
ABDOMEN: Soft, NTND. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Reduced sensation over
right ___ tibia compared to left.
Pertinent Results:
___ 07:45AM BLOOD Glucose-107* UreaN-22* Creat-1.4* Na-147
K-4.8 Cl-112* HCO3-22 AnGap-13
___ 10:37AM BLOOD CRP-13.8*
MR ___ & W/O CONTRAST (___):
1. Study is severely limited by motion and spinal hardware
artifact.
2. Compared to ___ prior exam, grossly stable large
loculated fluid collections in the subcutaneous tissue overlying
the lumbar spine and within the lumbar spine laminectomy bed,
decreased in size from prior study, compatible with resolving
postoperative seroma. However, CSF leak or uperinfection cannot
be excluded.
3. Grossly stable appearance of the L5-S1 intervertebral disc
space
peripherally enhancing soft tissue density abutting the ventral
thecal sac, which may represent a disc extrusion with adjacent
granulation tissue. However, abscess cannot be definitively
excluded.
4. Peripherally enhancing collection at the L5-S1 intervertebral
disc space with prevertebral extension is again seen and
unchanged from prior study. Findings again may represent
abscess or postoperative change.
5. No new focal fluid collections identified.
6. Stable L1 compression deformity.
7. T2 hyperintense cystic lesions in the kidneys, incompletely
characterized.
8. On limited imaging the pelvis, question 2.4 cm right adnexal
cystic
structure versus artifact. If clinically indicated, consider
dedicated pelvis MRI or ultrasound for further evaluation.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
=================================
___ year old female with h/o vestibular neuropathy, neurogenic
bladder, spondylolisthesis s/p multiple spinal surgeries
including L5/S1 anterior and posterior fusion complicated by
intra-op dural tear s/p revision laminectomy and course ___ MRSA
surgical site infection who presented w back pain, dyspnea,
dizziness and recent change in antibiotics from IV vancomycin/PO
rifampin to PO tedizolid. Her vertigo improved during her
hospital stay and was felt possibly secondary to vancomycin. She
underwent MRI lumbar spine which revealed stable fluid
collections. Given lack of fever or leukocytosis, less likely
abscess. ID consulted and agreed with this assessment. A
pressure dressing was placed due to concern for ongoing CSF leak
as a cause for persistent fluid collections. Patient with
notable ___ and treated with IVF with resolution.
ACUTE/ACTIVE ISSUES:
====================
#Chronic Vestibulopathy
#Dizziness
Likely represents worsening of known vestibulopathy in the
setting of vancomycin use vs. vanc toxicity. Other
considerations include posterior circulation TIA, BPPV given
position symptoms, or vestibular neuritis. Symptoms have
improved but were still ongoing at time of discharge. Patient
was able to walk around and expressed understanding to rest for
a few seconds between lying down and siting as well as sitting
to standing. Vanc was d/c'ed on ___ under the conclusion that
it may be causing vestibular neuritis and she was started on
tinezolid.
#Spondylolisthesis s/p multiple spinal surgeries
#CSF leak s/p revision laminectomy (___)
#Recent MRSA surgical site infection.
#Serous Drainage from surgical incision
Concern for persistent drainage from surgical wound site with
possible prolapse of deeper tissue structures vs sinus tract
formation with ?ongoing CSF leak vs abscess vs seroma. MRI L
spine did not show any acute findings, but not definitive for
the classification of fluid collections. Neurologic exam is
intact and patient remains afebrile without a leukocytosis. -
Ortho spine managing wound site care, no acute intervention at
this time given MRI findings but did recommend pressure dressing
to assist with possible ongoing CSF leak as a cause for the
persistent fluid collections. Pt was continued on tinezolid
___ QD.
___
Cr 1.5 up from baseline around 1. I/s/o recent nausea/vomiting
and vancomycin use. s/p 2L IVF ___ and 1L on ___. Cr 1.4 on
day of discharge. She was given repeat IVF bolus prior to
discharge and encourage to have good PO intake once home.
CHRONIC/STABLE ISSUES:
======================
# Neurogenic bladder: Patient states is a complication of a
prior spinal surgery. Continued intermittent straight cath q8hrs
and PRN per patient
request. Held darifenacin (NF)
# Depression: Continued home sertraline and bupropion
# Restless leg syndrome: continued home pramipexole
# History of Cluster HA: continued indomethacin 75 XR bid for
prophylaxis
# History of Esophagitis
# GERD:
Trialed on reglan and omeprazole while I/P which seemed to have
some improvement in symptoms.
# Hypertension: continued home amlodipine, losartan, metoprolol
# Hyperlipidemia: continued home statin
# Chronic pain: Pregabalin 100 mg PO TID and TraMADol 50 mg PO
Q6H:PRN Pain - Moderate; standing tylenol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. darifenacin 15 mg oral DAILY
2. Esomeprazole 40 mg Other BID
3. Acetaminophen 650 mg PO TID
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Pramipexole 0.5 mg PO QHS
8. Pregabalin 100 mg PO TID
9. Sertraline 200 mg PO QHS
10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
11. Vitamin D 800 UNIT PO DAILY
12. RifAMPin 300 mg PO Q12H
13. Indomethacin XR 75 mg PO BID
14. amLODIPine 5 mg PO DAILY
15. Losartan Potassium 100 mg PO DAILY
16. Vancomycin 1500 mg IV Q 24H
17. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Medications:
1. tedizolid ___ mg oral DAILY
RX *tedizolid [Sivextro] 200 mg 1 tablet(s) by mouth once a day
Disp #*7 Tablet Refills:*0
2. Acetaminophen 650 mg PO TID
3. amLODIPine 5 mg PO DAILY
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
5. darifenacin 15 mg oral DAILY
6. Esomeprazole 40 mg Other BID
7. Indomethacin XR 75 mg PO BID
8. Losartan Potassium 100 mg PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Pramipexole 0.5 mg PO QHS
13. Pregabalin 100 mg PO TID
14. Sertraline 200 mg PO QHS
15. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
16. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Vertigo
SECONDARY DIAGNOSES
===================
Spondylolisthesis s/p multiple surgeries
Hypertension
Hyperlipidemia
Vestibular neuropathy ___ ataxia
Neurogenic bladder
Depression
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for worsening vertigo, nausea, and back
pain.
What was done for me while I was in the hospital?
- Your vertigo improved after discontinuation of vancomycin.
- You underwent imaging that showed no new abscess in your back.
- You were given medications for your pain.
- You were given fluids to help your kidneys.
What should I do when I leave the hospital?
- Please continue to take your medications as prescribed.
- Please follow up with your doctor's appointments as listed in
your discharge paperwork.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19742932-DS-20
| 19,742,932 | 20,427,181 |
DS
| 20 |
2172-01-22 00:00:00
|
2172-01-22 14:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
___
Coronary artery disease x 2 Left internal mammory artery -> Left
anterior descending, Reverse saphenous vein graft-> Obtuse
marginal
History of Present Illness:
___ yo male with PMH of DMII, HLD, HTN, who presents from OSH
with chest pain. The patient reports that he began to experience
jaw/neck pain last night while
backing up his car, which radiated down to his chest. He had
never experienced this pain before, which he describes as "heavy
pain." He did describe SOB with climbing stairs. Denied SOB,
nausea, vomiting with the neck/chest pain. Pain
resolved spontaneously after ~ 20 minutes. He took a shower and
then pain returned. Patient then presented to OSH ED where he
was given ASA and started on a heparin drip. Pain again resolved
spontaneously. He was found to have a troponin of 0.02 which
elevated to 0.59 and he was transferred to ___ for further
evaluation. He is currently asymptomatic. Cath today revealed
multivessel disease. ___ consulted for CABG eval.
Cardiac Catheterization: Date: ___ Place: ___: The LMCA was short with mild distal tapering.
LAD: The LAD had a minimal ostial plaque. There was a 40%
stenosis after an early bifurcating D1 with mild post-stenotic
dilatation/ectasia. The proximal-mid LAD after a high D2 was
diffusely diseased to 75% over ~30 mm (by QCA). D2 had
mild-moderate mid vessel disease. The small D3 had a moderate
origin stenosis. The mid-distal LAD had a 70% stenosis just
after a small D4. The distal LAD had mild plaquing and wrapped
around the apex. Flow in the LAD was delayed and pulsatile,
consistent with microvascular dysfunction.
LCX: The CX had a mild ostial plaque and supplied a large atrial
branch, a tiny OM1, a small OM2, and a modest caliber OM3.
OM4/LPL1 was a bifurcating vessel with a proximal 70% stenosis
and middistal angulated disease to 50% in the upper pole. LPL2
had mild proximal plaquing and a terminal bifurcation. LPL3 and
the codominant LPL4 were smaller vessels. Flow in the CX was
delayed, consistent with microvascular dysfunction. RCA: The RCA
had mild plaquing throughout to 30% with delayed pulsatile flow
consistent with microvascular dysfunction. The AM/RV branches
were tortuous. The RPDA was long vessel with multiple laterally
oriented sidebranches. The distal AV groove RCA
supplied several short RPLs and the AV nodal branch. There was a
suggestion of distal RPDA collaterals to a small distal OM.
Impressions:
1. Two vessel coronary artery disease including diffuse
proximal-mid LAD in a diabetic
2. Diffuse slow flow consistent with microvascular dysfunction.
3. Normal left ventricular diastolic pressures.
Past Medical History:
Diabetes - on oral agents
hypertension
hyperlipidemia
esophageal stricture
Sciatica
GERD
Back injury at work - ? progressing spinal stenosis
Past Surgical History:
Right knee meniscus repair surgery
Right should rotator cuff surgery
Umbilical hernia repair
Tonsillectomy
Social History:
___
Family History:
Uncle with CHF
Type III diabetes on mother's side
Physical ___:
Pulse:64 Resp:18 O2 sat:100% RA
B/P Right: 124/73 Left:
Height: 6' Weight: 213#
General: Awake, alert in NAD, pleasant
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI []
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
___ Right: 2+ Left: 2+
Radial Right: TR band Left:2+
Carotid Bruit Right:none Left:none
Discharge PE:
Pulse:79, SR rare PVC Resp:18 O2 sat:92% RA
B/P : 113/65
Height: 6' Weight: 93.7kg (preop 96.62kg)
General: Awake, alert in NAD, pleasant
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Sternum: incision stable, healing well, no drainage or erythema
[x]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel
sounds+ [x]
Extremities: Warm [x], well-perfused [x]
Right Leg: incision stable, healing well, no drainage or
erythema [x]
Edema: none [x]
Neuro: Grossly intact [x]
Pulses:
DP Right: 2+ Left: 2+
___ Right: 2+ Left: 2+
Radial Right: 2+ Left:2+
Pertinent Results:
Cardiac catheterization ___
1. Two vessel coronary artery disease including diffuse
proximal-mid LAD in a diabetic.
2. Diffuse slow flow consistent with microvascular dysfunction.
3. Normal left ventricular diastolic pressures.
Chest Pa+ Lat ___
No previous images. There is hyperexpansion of the lungs with
flattening hemidiaphragms consistent with chronic pulmonary
disease. Some coarseness of interstitial markings is consistent
with this diagnosis. Cardiac silhouette is within upper limits
of normal and there may be mild elevation of pulmonary venous
pressure. Atelectatic changes are seen at the bases, but no
evidence of acute focal pneumonia.
TTE ___
The left atrial volume index is normal. Normal left ventricular
wall thickness, cavity size, and global systolic function (3D
LVEF = 56 %). Doppler parameters are most consistent with normal
for age left ventricular diastolic function. Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. IMPRESSION: Normal
biventricular regional/global systolic function.
Labs:
Discharge:
___ 05:44AM BLOOD WBC-11.2* RBC-3.29* Hgb-10.3* Hct-31.3*
MCV-95 MCH-31.3 MCHC-32.9 RDW-12.9 RDWSD-44.5 Plt ___
___ 05:44AM BLOOD Glucose-102* UreaN-22* Creat-1.1 Na-137
K-5.0 Cl-102 HCO3-25 AnGap-15
___ 05:44AM BLOOD ALT-75* AST-48* LD(LDH)-248 AlkPhos-66
Amylase-44 TotBili-0.6
___ 05:44AM BLOOD Lipase-23
___ 05:44AM BLOOD Albumin-3.3* Mg-2.3
___ 06:15AM BLOOD WBC-9.4 RBC-3.17* Hgb-10.0* Hct-30.0*
MCV-95 MCH-31.5 MCHC-33.3 RDW-12.8 RDWSD-44.4 Plt ___
___ 01:15AM BLOOD WBC-10.5* RBC-3.10* Hgb-10.0* Hct-28.6*
MCV-92 MCH-32.3* MCHC-35.0 RDW-12.9 RDWSD-43.3 Plt ___
___ 03:53PM BLOOD WBC-10.3* RBC-3.35* Hgb-10.6* Hct-31.0*
MCV-93 MCH-31.6 MCHC-34.2 RDW-13.0 RDWSD-43.7 Plt ___
___ 01:39AM BLOOD WBC-9.7 RBC-3.24* Hgb-10.2* Hct-30.6*
MCV-94 MCH-31.5 MCHC-33.3 RDW-12.6 RDWSD-43.9 Plt ___
___ 05:35PM BLOOD WBC-9.7 RBC-3.31* Hgb-10.4* Hct-31.6*
MCV-96 MCH-31.4 MCHC-32.9 RDW-12.7 RDWSD-44.3 Plt ___
___ 01:15AM BLOOD ___ PTT-26.4 ___
___ 01:39AM BLOOD ___ PTT-27.6 ___
___ 05:35PM BLOOD ___ PTT-25.0 ___
___ 06:15AM BLOOD Glucose-130* UreaN-18 Creat-1.0 Na-136
K-3.9 Cl-101 HCO3-26 AnGap-13
___ 01:15AM BLOOD Glucose-215* UreaN-16 Creat-1.1 Na-132*
K-3.7 Cl-98 HCO3-24 AnGap-14
___ 03:53PM BLOOD Glucose-196* UreaN-17 Creat-0.9 Na-134
K-4.0 Cl-102 HCO3-23 AnGap-13
___ 05:35PM BLOOD UreaN-18 Creat-0.9 Cl-109* HCO3-23
AnGap-10
___ 07:25AM BLOOD Glucose-220* UreaN-21* Creat-1.1 Na-140
K-4.2 Cl-105 HCO3-22 AnGap-17
Brief Hospital Course:
The patient was brought to the Operating Room on ___ where the
patient underwent coronary artery disease x 2 Left internal
mammory artery -> Left anterior descending, Reverse saphenous
vein graft-> Obtuse marginal. Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring. POD 1
found the patient extubated, alert and oriented and breathing
comfortably. The patient was neurologically intact and
hemodynamically stable. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued without
complication. Oral diabetic medications were increased due to
hyperglycemia and Lantus was started for better blood sugar
control. Once his home Januvia and glimepiride were available,
he was able to wean from Lantus insulin support. Amiodarone was
started for burst atrial fibrillation, but he converted to sinus
and did not require anticoagulation. The patient was evaluated
by the physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 7 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to home with
___ services in good condition with appropriate follow up
instructions.
Medications on Admission:
1. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
2. glimepiride 4 mg oral DAILY
3. SITagliptin 25 mg oral DAILY
4. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
max 4000mg/day please
2. Amiodarone 400 mg PO BID afib
400mg BID x 1 wk, then 200mg BID x 1 wk, then 200mg daily
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*1
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
5. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Metoprolol Tartrate 75 mg PO Q8H
RX *metoprolol tartrate 75 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
8. Losartan Potassium 25 mg PO DAILY
RX *losartan 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
9. MetFORMIN XR (Glucophage XR) 500 mg PO BID
RX *metformin [Glucophage XR] 500 mg 1 tablet(s) by mouth twice
a day Disp #*60 Tablet Refills:*0
10. glimepiride 4 mg ORAL DAILY
11. SITagliptin 12.5 mg oral DAILY
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Coronary artery disease s/p revascularization
Diabetes - on oral agents
hypertension
hyperlipidemia
esophageal stricture
Sciatica
GERD
Back injury at work - ? progressing spinal stenosis
Right knee meniscus repair surgery
Right should rotator cuff surgery
Umbilical hernia repair
Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Right leg Incision - healing well, no erythema or drainage
Edema - none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19743084-DS-8
| 19,743,084 | 22,732,827 |
DS
| 8 |
2170-08-29 00:00:00
|
2170-09-04 14:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ YOM with uncertain history of GERD/dyspepsia presents with
gradual onset epigastric pain. Patient was in bar after eating
___ ___, plate of fries, 4 whiskey & waters. Over an hour he
experienced a gradual onset of dull to sharp epigastric and
right upper quadrant pain. He left the bar one hour after the
onset of pain. Mr. ___ took 3 Advil for relief. Over the next
hour the pain progressively became "unbearable." The pain
worsened with inspiration and he felt it "shoot" to his back.
There was also some associated pain spreading to lower right
chest. There has been nausea but no vomiting. Last bowel
movement was the day prior to admission, without hematochezia.
Even with history of GERD/dyspepsia, patient reports that
nothing has felt similar to this presentation. Patient does not
currently have established care with PCP. Denies regular NSAID
usage.
Of note, patient is visiting from ___. He drove
from ___ to visit his new nephew in ___. He then stopped in
___ to meet up with some friends and watch ___ play
___ at ___.
In the ED, initial VS were Temp: 97.2 HR: 60 BP: 143/87 Resp: 20
O(2)Sat: 100, Pain ___.
-On exam he was noted to be mildly intoxicated. Abdomen tender
to palpation in epigastric region. Nondistended, nonrigid, but
rebound in the right upper quadrant.
-Labs showed WBC 10.2, Hgb 12.8, Cr 1.3 and mildly elevated
liver enzymes ALT 32, AST 49, Tbili 0.6, normal lipase of 50.
0.03% BAC.
-UA showed 4 RBC's, 0 WBC's, 4 casts.
-Imaging: RUQ US showing cholelithiasis without evidence of
acute cholecystitis. CXR showed no acute cardiopulmonary
process, no free air under the diaphragm.
-Received morphine, ondansetron, pantoprazole, donnatal, viscous
lidocaine, Aluminum Hydroxide/Magnesium Hydroxide/Simethicone,
3L NS.
-Transfer VS were T 98.1, HR 82, BP 113/65, RR 20, O2 92% RA,
Pain ___.
Surgery was consulted for consulted about further imaging vs
early RUQ process. Decision was made to admit to medicine for
further management.
On arrival to the floor, patient reports feeling significant
improvement over the previous 1.5 hours. He reports still
feeling pressure but denies persistance of prior frank abdominal
pain.
REVIEW OF SYSTEMS:
(+): As per HPI
(-): Denies shortness of breath, chest pain, vomiting, BRBPR,
hematochezia, dysuria.
All other 10-system review negative in detail.
Past Medical History:
Unclear history of GERD/dyspepsia diagnosed ___ years ago.
Social History:
___
Family History:
Patient says there is a FH of peptic ulcer disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS - 97.9, 135/83, 74, 18, 93%RA
GENERAL: NAD, comfortable reclining in bed
HEENT: anicteric sclera, pink conjunctiva, MMM, good dentition
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: slightly distended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Negative ___ sign.
No palpable masses.
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: No focal deficits
DISCHARGE PHYSICAL EXAM
=======================
VS - Tc 97.7, HR 50, BP 106/63, RR 18, 02 sat 96% on RA
GENERAL: NAD, comfortable reclining in bed
HEENT: anicteric sclera, pink conjunctiva, MMM, good dentition
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: slightly distended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Negative ___ sign.
No palpable masses.
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: No focal deficits
Pertinent Results:
ADMISSION LABS
==============
Blood
-----
___ 01:14AM BLOOD WBC-10.2* RBC-4.10* Hgb-12.8* Hct-38.0*
MCV-93 MCH-31.2 MCHC-33.7 RDW-12.9 RDWSD-43.0 Plt ___
___ 01:14AM BLOOD Neuts-79* Bands-0 Lymphs-17* Monos-4*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-8.06* AbsLymp-1.73
AbsMono-0.41 AbsEos-0.00* AbsBaso-0.00*
___ 01:14AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 01:14AM BLOOD Plt Smr-NORMAL Plt ___
___ 01:14AM BLOOD Glucose-103* UreaN-18 Creat-1.4* Na-142
K-3.6 Cl-99 HCO3-27 AnGap-20
___ 01:14AM BLOOD ALT-32 AST-49* AlkPhos-42 TotBili-0.6
___ 01:14AM BLOOD Albumin-5.3* Calcium-9.9 Phos-3.9 Mg-2.0
___ 01:14AM BLOOD ASA-NEG Ethanol-34* Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 01:23AM BLOOD Lactate-1.4
Urine
-----
___ 05:00AM URINE Color-Yellow Appear-Clear Sp ___
___ 05:00AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:00AM URINE RBC-4* WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
___ 05:00AM URINE CastHy-4*
___ 05:00AM URINE Mucous-FEW
DISCHARGE LABS
==============
Blood
-----
___ 06:11AM BLOOD Glucose-99 UreaN-16 Creat-1.3* Na-141
K-4.4 Cl-100 HCO3-28 AnGap-17
___ 06:11AM BLOOD ALT-29 AST-48* AlkPhos-40 TotBili-0.5
___ 06:11AM BLOOD Albumin-4.9 Calcium-9.2 Phos-3.8 Mg-1.8
___ 06:07AM BLOOD WBC-8.3 RBC-3.93* Hgb-12.2* Hct-37.5*
MCV-95 MCH-31.0 MCHC-32.5 RDW-13.1 RDWSD-45.5 Plt ___
___ 06:07AM BLOOD Glucose-72 UreaN-13 Creat-1.4* Na-140
K-4.3 Cl-102 HCO3-27 AnGap-15
Urine
-----
___ 08:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:15PM URINE Color-Straw Appear-Clear Sp ___
IMAGING STUDIES
===============
LIVER OR GALLBLADDER US (SINGLE ORGAN)
TECHNIQUE: Grey scale and color Doppler ultrasound images of
the abdomen were obtained.
COMPARISON: None.
FINDINGS:
-LIVER: The hepatic parenchyma appears within normal limits. The
contour of the liver is smooth. There is no focal liver mass.
The main portal vein is patent with hepatopetal flow. There is
no ascites.
-BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 2 mm.
-GALLBLADDER: There are two mobile stones within a minimally
distended
gallbladder. The larger of which measures 9 mm. There is no
pericholecystic fluid or gallbladder wall thickening to suggest
acute inflammation.
-PANCREAS: Imaged portion of the pancreas appears within normal
limits, without masses or pancreatic ductal dilation, with
portions of the pancreatic tail obscured by overlying bowel gas.
-KIDNEYS: Survey views of the right kidney do not demonstrate
any masses, hydronephrosis, or stones.
-RETROPERITONEUM: Visualized portions of aorta and IVC are
within normal
limits.
IMPRESSION:
Cholelithiasis without evidence of acute cholecystitis.
CHEST X-RAY PA AND LAT
TECHNIQUE: Chest PA and lateral
COMPARISON: None available.
FINDINGS:
The lungs are well inflated and clear. The cardiomediastinal
silhouette, hilar contours, and pleural surfaces are normal.
There is no pleural effusion or pneumothorax. There is no free
air under the diaphragm.
IMPRESSION:
No acute cardiopulmonary process. No free air under the
diaphragm.
Brief Hospital Course:
___ year old male with history of GERD/dyspepsia who presented
with gradual onset epigastric pain, likely gastritis. Hospital
course was complicated by transient acute urinary retention
which spontaneously resolved, most likely an adverse effect of
medication he was given in the emergency department.
HOSPITAL COURSE/ACUTE ISSUES:
=============================
# Epigastric pain
# Cholelithiasis
Reported history of GERD/dyspepsia. Gradual onset epigastric
pain likely gastritis. Daily alcohol consumption and NSAID use
the day of presentation. Normal lipase. ALT and Alk Phos normal,
AST only slightly elevated. Liver enzymes were trended and they
showed no change over several hours. Despite original suspicion
for biliary etiology and an ultrasound showing gallstones, there
was no evidence of acute cholecystitis. No recent hematochezia,
diarrhea, vomiting. Patient showed significant clinical
improvement over several hours. This was felt to be most likely
consistant with gastritis (from puptic ulcer disease vs GERD vs
alcohol/NSAIDs). By noon the day of admission the patient was
___ on the pain scale. Diet was advanced as tolerated and
patient was comfortable eating. He was discharged on a PPI.
Biliary colic is also a possibility, and patient should consider
having non-emergent laprascopic cholecystectomy.
# Urinary retention: Patient reported difficulty urinating in
ED. Cr 1.5, RBC's seen on UA. Prior to discharge patient
reported he had still not urinated in 12 hours. Straight cath
and 1.5L of urine drained. Most likely was from anti-cholinergic
drug cocktail and opioids for GI/pain relief. Patient urinated
spontaneously in the evening ___ and in the AM ___. Patient
denied dysuria, urinary urgency. Evening UA ___ unremarkable
with no RBCs. Creatinine remained stable.
# Elevated Creatinine, likely chronic
Creatinine on presentation was 1.4. Cr during hospitalization
fluctuated from 1.3 - 1.4. Good UOP. UA initially with mild
hematuria, but repeat UA unremarkable. Unknown baseline Cr.
Will need close ___ and referral to Renal.
# Anemia, likely chronic
Mild, normocytic anemia noted on routine labs, with HCT ranging
from 36 - 38. Stable throughout hospitalization without any
active blood loss noted. No melena or hematochezia to suggest
GI bleeding. Will need ___ CBC and further work-up at PCP
___.
TRANSITIONAL ISSUES
===================
- Patient will need to establish care with PCP for further
workup of gastritis, anemia and elevated Cr
- Patient started on PPI for suspected gastritis in context of
unclear Hx of GERD
- consider referral to Surgery for laprascopic cholecystectomy
for cholelithiasis
- Creatinine 1.4 at admission and stable at discharge with
unclear etiology for elevation; may consider further workup
- Normocytic anemia of unknown etiology. Hgb stayed stable at
~12 throughout admission. Peripheral blood smear normal.
Consider further workup.
- patient was provided the contact information for hospitalist
attending, so that he or his PCP can call with questions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Gastritis
Secondary:
Acute urinary retention
Elevated creatinine
Normocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___
for epigastric pain, likely gastritis. You were seen in the ED
and given medications for pain and to calm down your stomach.
There are many reasons a person can develop gastritis, including
peptic ulcer disease and alcohol use. Please take Prilosec 30
min prior to breakfast to prevent these symptoms. When you get
back home you will need to establish care with a primary care
physician (PCP) to find out exactly what caused your gastritis.
If you do not ___ with a doctor, you might experience a
similar episode in the future. There is also a risk of bleeding
into the stomach or intestines. Please call ___ or go to an ED
immediately if you feel lightheaded, weak and/or notice dark,
tarry stool since this might be a sign of internal bleeding. You
should see your PCP within the next two weeks. In the meantime
you should not consume any alcohol, and you should try to limit
your intake of fatty and greasy foods.
When you were in the hospital we noticed you had a high
creatinine (meaning poor kidney function) and we could not
determine the cause. You also had a low red blood cell count
which was not explained despite multiple lab tests. It is very
important that when you return home you establish care with a
PCP so he or she can pursue further workup.
Finally, we kept you overnight because of urinary retention. The
night after admission you were urinating without pain, and we
felt that the symptoms were just a temporary side-effect of
medications used for pain management.
It was a pleasure caring for you. We're sorry you missed the Sox
game too. Again, we cannot encourage you strongly enough to seek
out a PCP when you return home to avoid going through this again
in the future.
All the best,
Your Care Team at ___
Followup Instructions:
___
|
19743151-DS-11
| 19,743,151 | 23,790,584 |
DS
| 11 |
2111-02-12 00:00:00
|
2111-02-12 13:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
loss of leg strength and sensation
incontinence
loss of sensation in saddle region
Cauda Equina Syndrome with back pain x 5 days
Major Surgical or Invasive Procedure:
lumbar decompression, L2-4 laminectomy, L34 discectomy
History of Present Illness:
___ presents with 10 days of worsening back pain with acute
worsening and bilateral lower extremity weakness over the past 3
days. He was able to walk with pain on ___, requiring
crutches on ___ and essentially unable to walk today. He
also reports difficulty with urination (difficult to start a
stream and loss of control of urine) and that he has not had a
bowel movement in 3 days. He states his whole butt feels numb
and he has numbness that goes down both his legs. His leg pain
is equal bilaterally, but he is weaker with his right foot and
toes vs. left. He did try "cupping" yesterday which brought no
meaningful relief of his pain.
Past Medical History:
HTN
Gout
Back pain
Hx Lumbar Compression Fx, unknown origin
Social History:
works in ___
No tobacco, occasional EtOH no other drug use
Physical Exam:
Able to flex at hip with some difficulty bilaterally. Knee
extension and flexion intact, but limited by pain. ___ ankle
dorsiflexion, plantarflexion and ___ on right. ___ ankle
dorsiflexion, plantarflexion and ___ on left. diminished
perianal
sensation. Rectal tone intact, but unable to voluntary contract
sphincter.
Sensation intact to light touch, but subjectively diminished
below L2.
Post op
minimal to no motion at ankles and feet bilaterally
good strength with hip and knee motion
improved sensation at saddle region and both legs
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery
was without complication and the patient was transferred to the
PACU in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Initial postop pain was
controlled with a PCA. Diet was advanced as tolerated. The
patient was transitioned to oral pain medication when tolerating
PO diet. Physical therapy was consulted for transfers to
chairs. PRAFO boots placed to prevent equinus contracture.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H
2. Bisacodyl 10 mg PO/PR DAILY
3. Diazepam ___ mg PO Q8H:PRN spasm
RX *diazepam 2 mg 1 to 2 tablets by mouth every eight (8) hours
Disp #*60 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 to 2 tablet(s) by mouth every four (4)
hours Disp #*80 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
lumbar stenosis with disc herniation causing cauda equina
syndrome
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 have undergone the following operation: Lumbar Decompression
Without Fusion for Cauda Equina Syndrome
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without moving around.
-Rehabilitation/ Physical Therapy:
oTherapy will work on leg strength and return to walking
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry
then you can leave the incision open to the air. Once the
incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing and call the office.
-You should resume taking your normal home medications.
-You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
-Follow up:
oPlease Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
oAt the 2-week visit we will check your incision, take baseline
X-rays and answer any questions. We may at that time start
physical therapy.
oWe will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
wheelchair transfers
leg strengthening for eventual ambulation if tolerated or
possible
Treatment Frequency:
dressing change daily
keep steristrips on; if they fall off in shower, that is fine
keep incision clean dry and intact, monitor for drainage,
redness
may shower, NO BATHS
Followup Instructions:
___
|
19743417-DS-9
| 19,743,417 | 20,793,630 |
DS
| 9 |
2172-06-14 00:00:00
|
2172-06-15 08:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male with history of CAD with prior
NSTEMI, HFrEF (LVEF ___, atrial flutter, DVT, CKD stage 4,
and history of heart block with recent PPM on ___ who presents
as a transfer from ___ with chief complaint of dyspnea on
exertion and found to be in heart failure with worsening ___ and
hyperkalemia.
Patient had a PPM placed a ___ on ___ at ___ for complete
heart block. Since this admission, patient has had increasing
weight, lower extremity edema, and shortness of breath with
exertion. he was discharged on Lasix 40mg daily. He had
increased
his dose to 40mg BID due to increasing weight and shortness of
breath. Despite the increase, continue to have increasing
weight.
Called into his cardiology office where his dose was increased
to
Lasix 60mg BID. Despite the increase, he continue to have
shortness of breath resulting in presentation to BI-M.
At BI-M, he was found to be volume overloaded. He had taken 60mg
Lasix po prior to arrival and was given no additional Lasix. His
labs are noted below but were notable for elevated BNP, Cr, K,
and LFTs. He was given calcium gluconate, insulin/dextrose, and
albuterol for hyperkalemia. Given his recent PPM at ___, he
was
transferred to ___ for evaluation by cardiology and renal.
- In the ED, initial vitals were: T 97.7, HR 60, BP 113/67, RR
16, SpO2 97% RA
- Exam was notable for 3+ pitting edema bilateral extremities
and
crackles bilateral bases.
- Labs were notable for BUN 121, Cr 3.9, K 5.9, HCO3 15 at
___.
At BI-M, K 6.4, INR 3.1, BNP 21947, TropT 0.112, MB 5.6, ALT
117,
AST 65, AL 185
On arrival to the floor, patient endorses the story outlined
above. Notes a few pound weigh gain. Has had worsening fatigue
and loss of appetite over the past several days. Worsening DOE
and lower extremity edema. No urinating as much to Lasix.
Past Medical History:
Complete heart block in past while on BB s/p PPM in ___
Atrial flutter and question of Afib per family
Systolic congestive heart failure with an ejection fraction of
30%-35%.
CAD s/p NSTEMI (unclear whether type 1 or type 2).
Chronic kidney disease, stage 4.
DVT
Iliac artery aneurysm
Social History:
___
Family History:
No known history of heart disease, early MI, sudden cardiac
death.
Physical Exam:
ADMISSION EXAM:
===================
VITALS: ___ 0534 Temp: 97.4 PO BP: 120/84 R Lying HR: 61
RR:
18 O2 sat: 99% O2 delivery: RA
GENERAL: Alert and interactive. In no acute distress. Oriented
x3.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: Difficult to assess JVD due to size of EJ which is very
distended.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Mildly labored respirations. Bilateral crackles half way
up back.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: 3+ pitting edema in bilateral lower extremities.
SKIN: Warm. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE EXAM:
==================
VITALS: 97.4 93/62 73 20 96 Ra
WEIGHT: 179 lbs
GENERAL: Alert and interactive. In no acute distress.
HEENT: Sclera anicteric and without injection. MMM.
NECK: JVP ~11cm.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Mildly labored respirations. Bilateral crackles to mid
lungs.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: 1+ pitting edema to mid shins.
SKIN: Warm. No rashes.
Pertinent Results:
ADMISSION LABS:
===================
___ 08:57AM WBC-12.2* RBC-3.23* HGB-10.7* HCT-32.6*
MCV-101* MCH-33.1* MCHC-32.8 RDW-15.7* RDWSD-57.3*
___ 08:57AM PLT COUNT-172
___ 08:57AM ___ PTT-32.5 ___
___ 08:57AM ___ 03:30AM GLUCOSE-80 UREA N-121* CREAT-3.9*# SODIUM-136
POTASSIUM-5.9* CHLORIDE-102 TOTAL CO2-15* ANION GAP-19*
___ 08:57AM CALCIUM-10.1 PHOSPHATE-6.1* MAGNESIUM-2.9*
IRON-33*
___ 09:28AM LACTATE-2.0
___ 03:25PM CK-MB-13* cTropnT-0.28*
DISCHARGE LABS:
===================
___ 08:00AM BLOOD WBC-6.8 RBC-3.22* Hgb-10.6* Hct-33.7*
MCV-105* MCH-32.9* MCHC-31.5* RDW-16.5* RDWSD-60.0* Plt ___
___ 08:00AM BLOOD ___
___ 08:00AM BLOOD Glucose-100 UreaN-118* Creat-3.1* Na-141
K-4.2 Cl-99 HCO3-26 AnGap-16
___ 12:13PM BLOOD ALT-40 AST-31 AlkPhos-116 TotBili-0.5
___ 08:00AM BLOOD Calcium-9.3 Phos-5.1* Mg-2.6
IMAGING/STUDIES:
===================
CXR ___ IMPRESSION:
Stable mild cardiomegaly. Mild interstitial pulmonary edema.
RENAL ULTRASOUND ___ IMPRESSION:
1. Severely atrophic right kidney. normal size left kidney with
cortical atrophy, no hydronephrosis
2. Bilateral simple renal cysts
TTE ___ CONCLUSION:
The left atrial volume index is SEVERELY increased. The right
atrium is moderately enlarged. There is no evidence for an
atrial septal defect by 2D/color Doppler. The inferior vena cava
is dilated (>2.5 cm). There is
mild symmetric left ventricular hypertrophy with a normal cavity
size. There is moderate regional left ventricular systolic
dysfunction with akinesis/dyssynchrony of the mid to distal
anteroseptal segments (see
schematic) and mild global hypokinesis of the remaining
segments. No thrombus or mass is seen in the left ventricle (the
lack of lumason contrast reduces sensitivity for clot). There is
visual left ventricular
dyssnchrony. The visually estimated left ventricular ejection
fraction is ___ with severe apical dysfunction. Left
ventricular cardiac index is depressed (less than 2.0 L/min/m2).
There is no resting left ventricular outflow tract gradient.
Mildly dilated right ventricular cavity with moderate global
free wall hypokinesis. There is abnormal septal motion c/w
conduction abnormality/paced rhythm. The aortic sinus is mildly
dilated with mildly dilated ascending aorta. The aortic arch is
mildly dilated with a mildly dilated descending aorta. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is mild [1+] aortic regurgitation.
The mitral valve leaflets appear structurally normal with no
mitral valve prolapse. There is an eccentric jet of moderate to
severe [3+] mitral regurgitation. Due to the Coanda effect, the
severity of mitral regurgitation could be UNDERestimated. The
pulmonic valve leaflets are normal. The tricuspid valve leaflets
appear structurally normal. There is an eccentric jet of
moderate [2+] tricuspid regurgitation. Due to acoustic
shadowing, the severity of tricuspid regurgitation may be
UNDERestimated. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Severe global left ventricular systolic dysfunction
with regional variation as above. The apical segments are not
thinned so some of the regional dysfunction could be due to
dyssynchrony from pacing with an underlying cardiomyopathy
versus CAD. This would be better assessed with a nuclear
perfusion study. Moderate to severe mitral regurgitation
accoutning for shadowing. At least moderate tricuspid
regurgitation. Mild pulmonary hypertension. Dilated thoracic
aorta.
TEE ___ CONCLUSION:
There is no spontaneous echo contrast or thrombus in the body of
the left atrium/left atrial appendage. The left atrial appendage
ejection velocity is normal. No spontaneous echo contrast or
thrombus is seen in the body of the right atrium/right atrial
appendage. There is no evidence for an atrial septal defect by
2D/color Doppler. There is moderate regional left ventricular
systolic dysfunction with inferolateral hypokinesis. There are
diffuse simle atheroma in the aortic arch with diffuse simple
atheroma in the descending aorta to from the incisors. The
aortic valve leaflets (3) appear structurally normal. No masses
or vegetations are seen on the aortic valve. No abscess is seen.
There is mild [1+] aortic regurgitation.
The mitral valve leaflets are mildly thickened with mild
systolic prolapse. No masses or vegetations are seen on the
mitral valve. No abscess is seen. There is a central jet of
moderate to severe [3+] 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 [1+] tricuspid regurgitation.
IMPRESSION: No thrombus in the left atrium/left atrial
appendage/right atrium/right atrial appendage. Moderate-severe
(3+) mitral regurgitation. Diffuse simple atheroma in the aortic
arch and descending aorta.
CXR ___ IMPRESSION:
Dual lead left-sided pacemaker is intact. Heart size is
enlarged but stable. There are low lung volumes with patchy
opacities at the lung bases. There is mild pulmonary edema.
There are no pneumothoraces.
Brief Hospital Course:
TRANSITIONAL ISSUES:
-Discharge weight 179 lbs
-Discharge Cr 3.1
-Discharge INR 2.4
[ ] Should have INR, Chem 10 drawn on ___
[ ] Discharged on Torsemide 60mg BID
[ ] The patient was transitioned from home warfarin to apixaban
2.5mg BID on ___. However, given elevated Cr, apixaban was
discontinued on day of discharge, ___. Patient told to take
warfarin 2.5mg on ___. He will get INR drawn on ___. Warfarin
dosing will then be adjusted. Can consider transition to
apixaban 2.5mg BID if renal function improves.
[ ] Will take amio 400mg daily until ___. Starting ___, he will
take amio 200mg daily.
[ ] Patient should have repeat TTE in 1 month.
Mr. ___ is a ___ year old male with history of CAD with prior
NSTEMI, HFrEF (LVEF ___, atrial
fibrillation/atrial flutter, DVT, CKD stage 4, and history of
heart block with recent PPM on ___ who presents as a transfer
from BI-M with chief complaint of dyspnea on exertion and found
to be in heart failure with worsening ___ and hyperkalemia. Now
off lasix gtt and transitioned to PO diuretic.
ACUTE/ACTIVE ISSUES:
====================
# Acute on chronic heart failure with reduced EF (___)
Patient presented with increased weight (on admission: 187 lbs),
worsening lower extremity edema, and DOE despite escalating
doses of Lasix. Most recently was taking Lasix 60mg BID with
minimal UOP. Onset of symptoms have worsened since PPM. Most
likely etiology of his heart failure is persistent
tachyarrhythmia. The patient has been having atrial tachycardia
and has been V-paced. Also concerned for possibility of
pacing-induced LV systolic dysfunction or valve disruption
related to pacing wire. Low suspicion for ischemic event. For
the patient's tachyarrythmia, the patient underwent TEE showing
no thrombus. He was shocked with 300J with return to sinus
rhythm by EP. Pre-DCCV ECG: Atrial fibrillation, 90 bpm;
Post-DCCV ECG: AS/AP, VP rhythm with frequent ventricular ectopy
in ___s. Per EP recs, he was started on 2 week course of 400mg
amio (___), followed by 200mg amio daily ___).
TTE ___ with LVEF ___, mod-severe MR, moderate TR. Diuresed
with IV lasix boluses and lasix gtt up to 30mg/hr. Discharged on
Torsemide 60mg BID. For afterload reduction, patient is
discharged on hydralazine 20mg Q8H, isosorbide mononitrate ER
60mg daily. Weight on discharge 179 lbs, Cr 3.1. Patient should
have repeat TTE in 1 month.
# ___ on CKD
Cr up to 3.9 from 2.4 two weeks prior to admission. Worsening
urine output despite increasing dosages of Lasix. Volume
overloaded on exam. Given presentation, concerned for
cardiorenal syndrome. Renal ultrasound showed severely atrophic
right kidney but no hydronephrosis. Cr improved to 2.6 on ___.
On day of discharge (___), however, Cr elevated to 3.1.
However, given ___, and patient and family's strong
preference to be at home for the holiday, indicated that it was
ok for patient to be discharged home, as he has been on oral
diuretic. Plan for repeat Chem 10 to be drawn on ___.
# Type II NSTEMI
# CAD
Presented with trop of 0.11 in setting of HF exacerbation. No
chest pain. EKG with evidence of V-paced. Somewhat difficult to
interpret in setting ___ on CKD. Suspect type II NSTEMI. Trop
0.11 (OSH) -> 0.28 -> 0.28. Atorvastatin initially held in the
setting of transaminitis, but restarted when LFTs returned to
normal levels.
# History of CHB s/p PPM
Recent PPM at end of ___ for CHB ___ Azure Xt ___ ___
___ W1DR01). Recent PPM check demonstrated that pacer is
functioning well with acceptable lead measurements and battery
status. EP made the following programming changes: Atrial
sensing threshold decreased to 0.15mV to prevent inappropriate
pacing from undersensing when patient is in AF. Upper
tracking/sensing rate limit decreased from 130bpm to 110bpm.
# Atrial flutter / Atrial fibrillation
# Supratherapeutic INR
History of AF. EKG V-paced. On warfarin at home. INR
supratherapeutic to 3.1 at OSH in setting of liver dysfunction.
Transitioned patient to apixaban 2.5mg BID on ___ as renal
function improved, but given Cr elevated to 3.1 on day of
discharge, discontinued apixaban. Patient's last dose of
apixaban was at 8am on ___. No warfarin given on ___. Plan
upon discharge was for patient to take warfarin 2.5mg on ___
and recheck INR on ___.
# Hyperkalemia, resolved
K up to 6.4 at OSH, down to 5.9 after receiving insulin/dextrose
and albuterol. No evidence of T wave peaking on EKG. Etiology
likely related to ___ on CKD. K 5.2 on discharge.
# Elevated transaminases, resolved
ALT 110, AST 67, Alk Phos 182 on admission. Given presentation,
concerns for congestive hepatopathy in setting of HF
exacerbation. Improved to normal on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Co Q-10 (coenzyme Q10) 100 mg oral TID
4. Furosemide 60 mg PO BID
5. HydrALAZINE 10 mg PO TID
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Naproxen 220 mg PO DAILY
9. Vitamin D 5000 UNIT PO DAILY
10. Warfarin 5 mg PO 3X/WEEK (___)
11. Warfarin 2.5 mg PO 4X/WEEK (___)
Discharge Medications:
1. Amiodarone 400 mg PO DAILY
RX *amiodarone 200 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*1
2. Torsemide 60 mg PO BID
RX *torsemide [Demadex] 20 mg 3 tablet(s) by mouth twice a day
Disp #*180 Tablet Refills:*0
3. HydrALAZINE 20 mg PO Q8H
RX *hydralazine 10 mg 2 tablet(s) by mouth three times a day
Disp #*180 Tablet Refills:*0
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
RX *isosorbide mononitrate 60 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*1
5. Allopurinol ___ mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Co Q-10 (coenzyme Q10) 100 mg oral TID
8. Multivitamins 1 TAB PO DAILY
9. Vitamin D 5000 UNIT PO DAILY
10. Warfarin 2.5 mg PO 4X/WEEK (___)
11. Warfarin 5 mg PO 3X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
ACUTE ON CHRONIC HEART FAILURE WITH REDUCED EJECTION FRACTION
SECONDARY DIAGNOSES:
___ ON CKD
ATRIAL FLUTTER / ATRIAL FIBRILLATION
TYPE II NSTEMI
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 privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital after having increased work of
breathing.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have extra volume as a result of your heart
not pumping well.
- You were giving a medication through the IV (lasix) to help
remove the volume.
- You were found to be in a fast rhythm. The EP cardiologists
gave you a shock to return you to a normal rhythm. They also
made some adjustments to your pacemaker.
- You were started on amiodarone 400mg daily.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Take warfarin 2.5mg on ___.
- Get your INR and electrolyte levels checked on ___. Your
warfarin dose may then be adjusted depending on your INR level.
- Take your amiodarone 400mg daily until ___. Starting ___, take
200mg daily.
- Please attend your follow-up appointments as scheduled.
- Please return if you feel any chest pain or if you feel you
are short of breath.
- Your weight at discharge is 179 lbs.
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19743492-DS-13
| 19,743,492 | 28,330,176 |
DS
| 13 |
2128-11-07 00:00:00
|
2128-11-13 09:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tramadol / Keflex / Augmentin / Sulfa (Sulfonamide Antibiotics)
/ Flagyl / Morphine / Ketorolac / Zithromax Z-Pak
Attending: ___.
Chief Complaint:
Lower extremity pain
Major Surgical or Invasive Procedure:
Lidocaine infusion ___
Intralesional injections (under general anesthesia) ___
History of Present Illness:
___ with PmHx of Hypothyroidism, Thyroid acropathy, Petibial
Myxedema, Severe Keloids, and Chronic ___ pain presenting with
b/l ___ pain and swelling s/p plane flight this week.
Pt was recently at ___ for work up of her complicated
medical conditions. She went there for a ___ opinion and to
"close the book" on those issues as she initially had been
diagnosed there with Thyroid Acropathy. She was told by them
that this is one of the worst cases they have seen and that
there isn't much that can be done for her. She says she wasn't
surprised to hear this.
Now presenting to ___ ER ___ uncontroleld pain in her B/L ___
after going to ___ for the same issue. She flew back
this week from ___ and reports new b/l ___ swelling and
worsening pain. At ___ she had ___ U/S which was negative for
DVT. She says they were going to admit her for pain control but
since all her care has been here, they transfered her to the
___ ER. To the ER staff here she reportd she has been
incerasing percocets at home but feels unsafe doing much more so
came in - does not endorse this to overnight physician. She
reports the pain is similar to flares she's had in the past, her
last was a few years ago. Previously she sayd her flares were
controlled with IV morphine drips until she became allergic to
it and now it requires IV dilaudid. She says the pain is so bad
now that it is difficult for her to walk. She also endorses that
after getting back from her plane flight her feet were red and
swollen - she shows me pictures of how her feet looked just ___
days ago and they look quite different than currently.
In the ED, initial VS were: 97.8 77 122/68 16 99% ra. B/L ___ U/S
negative for DVTs. Given ondansetron x 1 and two doses of 1mg IV
dilaudid. Admitted to medicine for pain control. VS on transfer
were pain ___ 68 107/69 16 100%.
On arrival to the floor, patient lying in bed quietly. Reports
the IV dilaudid she was given in the ER has worn off and the
pain is coming back. Also feels a bit nauseated although she
says she thinks this is from the pain meds.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
1) ___'s dz dxed ___ tx with radioactive iodine ablation and
subsequently placed on thyroid replacement
2) Thyroid acropathy dxed ___ at ___ after full consultations
with rheum, endocrine, and neurology
3) Left hip pain
4) hx of C.diff
5) severe keloids
6) pretibial myxedema
7) kidney stones
8) ureteral reflux
9) s/p appendectomy
10) s/p L salpingo-oophrectomy
11) s/p resection left fourth and fifth toes
12) s/p debulking keloid left foot
13) s/p status post massive debulking exophytic macerating
keloid right leg
14) s/p resection of the right and left fourth metatarsal head
15) s/p excision of keloid right buttock and advancement flap
Social History:
___
Family History:
No fam hx of autoimmune diseases, thyroid disease. Family hx of
aneurysm (grandmother)
Physical Exam:
Admission:
VS - Temp 97.9F, BP 111/63, HR 87, R 16, O2-sat 99% RA, 102lbs
GENERAL - thin female lying quietly in bed in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK - supple
LUNGS - CTA bilat, good air movement
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, above her
ankle on her RLE there is a 5in x 2in patch of irregular reddish
skin with keloid formation, no skin breaks, ___ toes of LLE
are missing with small keloids where they used to be, neither
lower ext is particularly swollen, red, or warm
NEURO - awake, A&Ox3, strength grossly intact and equal
Discharge:
Generally unchanged. After intralesional injections, there was
regression of the keloided areas (appeared less puffy, less
erythematous) in both the right
lower leg and the left foot. Swelling in the ___ digit of the
left foot was also improved.
Pertinent Results:
Labs on admission:
___ 12:15AM PLT COUNT-221
___ 12:15AM NEUTS-58.4 ___ MONOS-6.6 EOS-1.2
BASOS-0.8
___ 12:15AM WBC-5.0 RBC-3.83* HGB-12.5 HCT-35.0* MCV-91
MCH-32.5* MCHC-35.6* RDW-12.0
___ 12:15AM GLUCOSE-88 UREA N-11 CREAT-0.6 SODIUM-139
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-26 ANION GAP-11
Labs on discharge (most recent):
___ 08:00AM BLOOD WBC-4.3 RBC-3.97* Hgb-12.7 Hct-37.2
MCV-94 MCH-32.0 MCHC-34.2 RDW-12.4 Plt ___
___ 08:00AM BLOOD Glucose-84 UreaN-10 Creat-0.5 Na-138
K-4.3 Cl-103 HCO3-26 AnGap-13
___ 08:00AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.8
Micro:
- Stool culture ___: Negative for pathogens
- C. difficile PCR ___: Negative
___ CHEST (PA & LAT):
IMPRESSION: No acute intrathoracic process.
___ BILAT LOWER EXT VEINS:
IMPRESSION: No lower extremity DVT.
___ HIP UNILAT MIN 2 VIEWS:
FINDINGS: There are no signs for acute fractures or
dislocations. Bilateral hip joint spaces are relatively
preserved. There is some spurring at the pubic symphysis.
There is a metallic spring-like density projecting over the
right hip, likely external to the patient. There are also
degenerative changes of the sacroiliac joints, left side worse
than right. There is a prominent L5 transverse process on the
left.
___ TIB/FIB (AP & LAT) SOFT:
IMPRESSION: There has been no change in the extent of mild
smooth periosteal thickening on the lateral aspect of the shaft
of the tibia and posterior to the upper fibula. Marked soft
tissue irregularity in the lower portion of the lower extremity
laterally shows severe maceration of the flesh.
___ FOOT AP,LAT & OBL LEFT:
FINDINGS: There are postsurgical changes from prior ___ and ___
toe amputations. There is soft tissue swelling involving the
___ phalanx, without fracture or dislocation seen. Irregularity
involving the distal tuft of the ___ toe is again noted
(unchanged in comparison to prior exam). No new areas of bony
erosions. No radiopaque foreign bodies seen. IMPRESSION:
Minimal soft tissue swelling involving the ___ phalanx without
fracture or evidence of osteomyelitis.
Brief Hospital Course:
HOSPITAL SUMMARY: ___ with past medical history of Grave's
Disease status post radiofrequency ablation in ___ complicated
by thyroid acropathy, pretibial myxedema, severe keloids, and
chronic ___ pain who presented with worsening of bilateral lower
extremity pain and was admitted for pain control. She initially
required much higher doses of narcotic pain medication than she
takes at baseline, and still did not find sufficient relief;
ultimately her symptoms improved after intralesional injections
by Dr. ___ on ___. She was discharged home the following
day.
ACTIVE ISSUE:
# PAIN CONTROL: The patient complained of ___ severe pain to
the point that she was unable to ambulate. Patient was started
on oxycodone 10 mg Q4 hours and dilaudid 0.5 mg IV Q3 hours in
addition to standing tylenol and initiation of low-dose
gabapentin (100 mg PO TID) early in this admission, as her
primary issue was pain control. She initially experienced some
improvement in pain, however then she began experiencing
worsening pain and neuropathic symptoms in her right leg and
foot. Narcotic pain medications were uptitrated to oxycodone 15
mg Q3H with dilaudid 0.5-1 mg Q3H PRN, and gabapentin increased
up to 600 TID. The pain service was consulted given her severe
pain and arranged for lidocaine infusion in the pain clinic on
___ she was transported to this appointment by
ambulance while remaining inpatient. The lidocaine infusion
provided temporary benefit, but within hours the patient
reported that her pain was virtually unchanged from prior,
though she had numbness in her hands and face. She was also
evaluated by the plastic surgery consult service on behalf of
Dr. ___, and on ___ she was taken to the OR for
intralesional injections done under general anesthesia; a total
of 5 cc of Kenalog 10 solution was diluted with 5 cc of 0.25%
bupivacaine plus epinephrine; 4 cc was injected on the left side
and 6 cc was injected into the dense portion of the scars on the
anterior aspect of the right leg. Following this treatment, the
lesions on the right leg and left foot were observed to visibly
regress, and her pain was improved to the point that she was
able to walk safely with use of a walker.
At discharge, she was transitioned back to her home dose of
___ mg Percocet QID, with additional oxycodone 5 mg PRN
breakthrough (#60). She was also discharged on gabapentin 600
mg Q8H, ibuprofen 600 mg Q6H, and nortriptyline 25 mg QHS per
recommendations of the pain service. She will require follow up
with her PCP and the pain clinic to discuss ongoing pain
management as well as follow up with her plastic surgeon (Dr.
___ to discuss resumption of regular injections, as this
approach seems to be effective.
# TOE SWELLING: On hospital day #5, the patient began noting
swelling and blue discoloration of ___ toe on left foot. Plain
films were obtained as above but did not show bony involvement.
The podiatry service was consulted, but given findings on plain
films felt there was no role for podiatric involvement at this
time. The swelling subsided on its own, moreso after the
intralesional injections to her left foot as above.
# PRETIBIAL MYXEDEMA, THYROID ACROPATHY: The patient underwent
additional work up and evaluation in ___ at the ___
with Dr. ___, who is a specialist in this field. Notes
from those visits are included in the patient's chart from this
admission. She underwent PET scans that did not show active bony
involvement. It was also Dr. ___ that she
should discontinue intralesional injections as above, though per
the patient this is the only thing that provides much relief.
INACTIVE ISSUES:
# HYPOTHYROIDISM: Thyroid studies from ___ were
reasonably good on her current dose of levothyroxine. She was
continued on levothyroxine 125mcg daily.
# INSOMNIA: Occasionally she takes PRN ativan for sleep. She was
continued on lorazepam for sleep while in house.
TRANSITION OF CARE:
- Follow up with PCP to discuss ongoing pain management and
coordination of care
- Follow up with pain management to discuss changes to
medications started during this admission, and for consideration
of repeat lidocaine infusion
- Follow up with endocrinology for her thyroid disease
- Follow up with plastic surgery for additional intralesional
injections as needed
- Defer rheumatology follow up for now
- Defer dermatology follow up for now
- Patient will have home ___
- Patient will use Lovenox for DVT prophylaxis until ambulating
for 5 minutes every 3 hours while awake (boyfriend will
administer)
- Code status during this admission was full
- Contact during this admission was ___ (aunt
___, Cell: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 125 mcg PO DAILY
2. Ondansetron 4 mg PO Q6H:PRN nauseda
3. solifenacin *NF* 5 mg Oral daily
4. oxyCODONE-acetaminophen *NF* ___ mg Oral QID
5. Lorazepam 0.5 mg PO HS:PRN insomnia
6. Ascorbic Acid ___ mg PO DAILY
7. Probiotic Complex *NF* (lactobacillus combo no.6) unknown
Oral unknown
Unsure which probiotic
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Lorazepam 0.5 mg PO HS:PRN insomnia
4. Ondansetron 4 mg PO Q6H:PRN nauseda
5. Probiotic Complex *NF* (lactobacillus combo no.6) 0 units
ORAL Frequency is Unknown
Unsure which probiotic
6. solifenacin *NF* 5 mg Oral daily
7. Gabapentin 600 mg PO Q8H
RX *gabapentin 300 mg 2 capsule(s) by mouth every eight (8)
hours Disp #*180 Capsule Refills:*0
8. Ibuprofen 600 mg PO Q6H
9. Nortriptyline 25 mg PO HS
RX *nortriptyline 25 mg 1 tab by mouth at bedtime Disp #*30
Capsule Refills:*0
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every
six (6) hours Disp #*30 Tablet Refills:*0
11. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 1 injection subcutaneously daily
Disp #*10 Syringe Refills:*0
12. Acetaminophen 325-650 mg PO Q6H pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
13. oxyCODONE-acetaminophen *NF* ___ mg ORAL QID
RX *oxycodone-acetaminophen [Endocet] 10 mg-325 mg 1 tablet(s)
by mouth four times a day Disp #*120 Tablet Refills:*0
14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN breakthrough
pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every four (4)
hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- Thyroid acropathy
- Pretibial myxedema
SECONDARY:
- hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you during this hospital stay. You
were admitted to ___ with a flare of pain in your legs. The
pain was severe, so you were evaluated by the rheumatology,
endocrinology and pain management services. You received
multiple different types of pain medications in an effort to
find the most effective regimen for you. You were transported
for a lidocaine infusion on ___ and underwent intradermal
injections on ___ with limited improvement.
We suggest that you continue to follow up with your
endocrinologist, rheumatologist, plastic surgeon and the pain
management team.
With increases in your narcotic pain regimen, you may experience
constipation. If this is the case, we recommend that you take
docusate sodium (Colace), which is a stool softener, 100 mg
twice per day and Miralax, which is a laxative, one packet
before bed. These medications are available over the counter at
your local pharmacy.
You may continue to take Lovenox subcutaneous injections once
daily to prevent blood clots. Once you are up and moving about
every few hours during the day, you no longer need this
medication.
Finally, our physical therapy team recommended that you continue
to work with a home therapist. We are arranging for a physical
therapist to work with you at home.
Please take your medications as prescribed.
Followup Instructions:
___
|
19743788-DS-12
| 19,743,788 | 24,044,536 |
DS
| 12 |
2158-05-12 00:00:00
|
2158-05-12 11:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
ibuprofen
Attending: ___.
Chief Complaint:
left pneumothorax
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old male who is transferred from OSH
for concern of a pneumothorax. While playing softball, he ran to
catch a fly ball and went over a wall, forcing his left into
went into his left chest. He immediately felt dyspneic and had
chest pain. At the outside hospital, a chest x-ray was
performed and was concerning for 10% pneumothorax. He was placed
on a nonrebreather and transferred for further management. On
arrival, he was feeling well and not complaining of dyspnea
Past Medical History:
history of glomerulonephritis
CKD
h/o bilateral knee arthroscopy
Social History:
___
Family History:
Non-contributory
Physical Exam:
On arrival:
Temp: 98.1 HR: 60 BP: 91/60 Resp: 20 O(2)Sat: 97 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation, no chest wall tenderness, no
crepitus
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
On discharge:
Vitals:98.3 60 100/50 16 100%RA
HEENT: Normocephalic, atraumatic
Chest: Clear to auscultation, mild left chest wall tenderness,
no crepitus
Cardiovascular: Regular Rate and Rhythm
Abdominal: Nontender, Nondistended, +BS
Extr/Back: No cyanosis, clubbing or edema. Abrasion to posterior
lower left arm with some ecchymosis
Pertinent Results:
___ CXR:
COMPARISON: Comparison is made to radiograph of the chest
obtained three
hours prior at ___, ___.
FINDINGS: PA and lateral views of the chest demonstrate a
persistent small apical pneumothorax on the left, not
significantly changed since the prior study. No pneumothorax is
identified on the right. There is mild left basilar
atelectasis. The cardiomediastinal silhouette is unremarkable,
and there is no evidence of tension. No displaced rib fractures
are identified. There is no pleural effusion or focal airspace
opacity.
IMPRESSION: Small left apical pneumothorax.
___ am CXR:
IMPRESSION:
Persistent small left apical pneumothorax, overall unchanged
compared to the prior exam.
___ ___ CXR:
INDINGS: In comparison with study of earlier in this date, the
left pneumothorax is essentially unchanged. Continued basilar
opacification consistent with pleural fluid and atelectatic
changes. Right lung is essentially clear.
___ AM CXR:
IMPRESSION:
1. Small left hydro pneumothorax is stable.
2. Small bilateral pleural effusions and bibasilar atelectasis
unchanged.
Brief Hospital Course:
Mr. ___ was transferred to ___ and admitted to the Acute
Care Surgery service on ___ after sustaining a left sided
pneumothorax. The patient was initially on a non-rebreather mask
and was then placed on nasal canula to improve absorption of the
pneumothorax. The patient had no issues with oxygen saturation
and was able to ambulate without supplemental oxygen without
issue. Serial CXRs were performed which demonstrated a stable
pneumothorax. The patient remained on a regular diet while in
the hospital and was voiding without difficulty. On ___ the
patient was discharged home in stable condition with instruction
regarding his pneumothorax and clear return precautions as well
as instruction to follow up with his PCP ___ 1 week.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q4-6H:PRN pain
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
left pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ after sustaining an injury that
resulted in a left sided pneumothorax.
What is a collapsed lung?
A collapsed lung, also called a pneumothorax, happens when air
enters the space between your rib cage and one of your lungs.
The air causes all or part of the lung to collapse. It is then
hard to breathe normally and your body gets less oxygen. A
collapsed lung can be life-threatening. In some cases, the air
collecting around the lung can completely collapse the lung and
put pressure on the heart. Then the heart cannot pump normally.
A collapsed lung may be caused by an injury to the chest, such
as a car accident, stab or bullet wound, or broken ribs. It may
also be caused by lung damage from chronic lung diseases,
electric shock, or near drowning. Sometimes there is no known
cause for the lung to collapse. This is called a spontaneous
pneumothorax.
How can I take care of myself when I go home?
How long it takes to get better depends on the cause of your
collapsed lung, your treatment, how well you recover, your
overall health, and any complications you may have.
Management
Your provider ___ give you a list of your medicines when you
leave the hospital.
-Take your medicines exactly as your provider tells you to.
Diet, Exercise, and Other Lifestyle Changes
Follow the treatment plan your healthcare provider ___.
Get plenty of rest while youre recovering. Try to get at least
7 to 9 hours of sleep each night.
Eat a healthy diet.
you may exercise.
Don't smoke. Smoking can increase your risk for a collapsed
lung.
Follow activity restrictions, such as not driving or operating
machinery, as recommended by your healthcare provider or
pharmacist, especially if you are taking pain medicines.
Do not fly in an airplane for at least 3 months as the
difference in pressure can cause your pneumothorax to expand.
Call emergency medical services or 911 if you have new or
worsening:
Chest pain that does not get better with medicine
Coughing up blood
Trouble breathing
Bluish or gray color of your lips or fingernails
Feeling like you are going to die
Do not drive yourself if you have any of these symptoms.
Call your healthcare provider if you have new or worsening:
Anxiety
Chest pain when you take a breath
Chills or sweats
Confusion
Coughing up mucus that is thick or blood-stained
- You have a fever higher than 101.5° F (38.6° C).
- You have chills or muscle aches.
Trouble breathing that wakes you at night or having shortness
of breath when lying flat in bed
Wheezing
Followup Instructions:
___
|
19744071-DS-15
| 19,744,071 | 23,941,193 |
DS
| 15 |
2123-11-18 00:00:00
|
2123-11-18 11:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
inability to ambulate
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with hx of EtOH abuse, depression presenting with inability
to ambulate in the setting of intoxication. History is obtained
from patient and ED notes, which differ substantially from each
other. Per ED ___, pt was found on the steps of a building,
unable to ambulate. FSBG 138, arousable to verbal stimuli. She
was apparently requesting detox, denied drug use other than
EtOH, and denied SI/HI. RN in ED noted deep cough, with SaO2
___. In the ED, pt apparently denied sputum production fevers,
although noted to be intoxicated so ability to relate history
limited in ED.
In the ___ ED:
98.0, 98, 129/67, 16. 93%->86% RA->96% 3L
Labs notable for:
VBG 7.33/56
BUN/Cr ___
ALT/AST 61/102, alk phos 77, Tbili 0.1, lipase 45
WBC 7.4, WBC 13.4, plt 272
Lactate 5.31->2.5
UTox positive for benzos
Serum EtOH 458
CXR: ?Bibasilar infiltrates, ?aspiration
Received thiamine, folate, MVI, 3L NS, Vanc/zosyn
On arrival to the floor, pt is unable to provide entirely
coherent history. She states that she was brought to the ___
ED because of difficulty breathing and coughing, and that she
was brought to ___ directly from ___ ED, where she says she
had been for 2 days receiving treatment for a possible
pneumonia. She endorses 1 month history of cough productive of
nonbloody, yellow sputum, with associated difficulty breathing
at night, subjective fevers/chills, drenching night sweats,
without associated chest pain, ___ edema. She notes that she has
been staying at a homeless ___, ___, and that due
to her difficulty sleeping at night, she has had excessive
daytime sleepiness; in this setting, her coat and IDs have been
stolen.
With respect to her alcohol use, she reports that, in the 1990s,
she was a heavy drinker, and at that time had frequent seizures
and DTs related to EtOH. Since then, she reports that she has
not had seizures, although subsequently says that she sometimes
drinks a beer in the morning to prevent seizure. She states that
she drinks 2 beers per day when she has the money, and that "if
someone gives me a drink, I'll drink it." She reports that her
last drink was on ___ in the am. She denies tobacco,
marijuana, cocaine, IV drugs. When asked about her alcohol
level, which seems out of proportion to her report of 2 beers
per day, she states that she "may have been given" additional
EtOH by someone.
I spoke to ___, MD, at ___, who provided care for this
patient on ___ in the ED. Pt was admitted with slurred
speech, unsteady gait. She had a cough, but SaO2 fine, so did
not receive CXR or treatment for pneumonia. She was not
admitted. No labs except FSBG. She told the ED that she had rxs
at the pharmacy, and asked for new rxs for gabapentin, which
were declined on the basis that the pharmacy already had rxs on
file for her. According to their EMR, pt has been prescribed
quetiapine of unknown dose, gabapentin 300 mg TID and trazodone
100 mg qHS. The plan had been for her to come back on ___
for alcohol detox planning. She presented on ___ at 7:50 pm,
and was discharged at 5 am on ___.
ROS: All else negative
Past Medical History:
EtOH abuse
Depression
Social History:
___
Family History:
Noncontributory to current presentation
Physical Exam:
ADMISSION EXAM
VS: 97.3, 115/90, 85, 20, 93% 3.5L
Gen: Pleasant, somewhat disheveled, interactive, tangential, NAD
HEENT: PERRL, EOMI, clear oropharynx, anicteric sclera
Neck: supple, no cervical or supraclavicular adenopathy
CV: RRR, no m/r/g
Lungs: Bibasilar rhonchi, bibasilar inspiratory wheeze
Abd: soft, nontender, nondistended, no rebound or guarding, +BS,
no hepatomegaly
GU: Foley in place
Ext: WWP, no c/c/e, scabs over R knee
Neuro: tangential, CN II-XII intact, strength ___ in UE and ___
bilaterally. Intact heel-to-shin, very mild dysmetria by
finger-to-nose, no asterixis. Gait exam deferred.
DISCHARGE EXAM
VS: 98.3- ___ on 3L-->96 on 1L--> 96% on RA.
Gen: Pleasant, somewhat disheveled, interactive, somewhat
tangential, NAD, speaks in full sentences
HEENT: PERRL, EOMI, clear oropharynx, anicteric sclera
Neck: supple, no cervical or supraclavicular adenopathy
CV: RRR, no m/r/g
Lungs: decreased breath sounds at the bases
Abd: soft, nontender, nondistended, no rebound or guarding, +BS,
no hepatomegaly
GU: no foley
Ext: WWP, no c/c/e, scabs over R knee
Neuro: tangential, face symmetric, strength ___ in UE and ___
bilaterally. Intact heel-to-shin, very mild dysmetria by
finger-to-nose, no asterixis. Gait exam deferred, but pt reports
she walked well to bathroom w/o issues.
Pertinent Results:
___ 03:48PM ___ TEMP-36.7 RATES-/24 O2 FLOW-3
PO2-34* PCO2-56* PH-7.33* TOTAL CO2-31* BASE XS-1 INTUBATED-NOT
INTUBA VENT-SPONTANEOU COMMENTS-NASAL ___
___ 03:48PM LACTATE-2.5*
___ 03:48PM O2 SAT-51
___ 02:30PM URINE HOURS-RANDOM
___ 02:30PM URINE HOURS-RANDOM
___ 02:30PM URINE GR HOLD-HOLD
___ 02:30PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 02:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:30PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 01:40PM LACTATE-5.31*
___ 01:30PM GLUCOSE-92 UREA N-4* CREAT-0.5 SODIUM-142
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-19* ANION GAP-24*
___ 01:30PM estGFR-Using this
___ 01:30PM ALT(SGPT)-61* AST(SGOT)-102* CK(CPK)-81 ALK
PHOS-77 TOT BILI-0.1
___ 01:30PM LIPASE-45
___ 01:30PM CK-MB-2
___ 01:30PM ALBUMIN-4.1 CALCIUM-8.7 PHOSPHATE-3.2
MAGNESIUM-1.4*
___ 01:30PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
___ 01:30PM WBC-7.4 RBC-3.75* HGB-13.4 HCT-40.6 MCV-108*
MCH-35.7* MCHC-33.0 RDW-12.5 RDWSD-49.6*
___ 01:30PM NEUTS-43.6 ___ MONOS-13.5* EOS-3.9
BASOS-1.2* IM ___ AbsNeut-3.24 AbsLymp-2.77 AbsMono-1.00*
AbsEos-0.29 AbsBaso-0.09*
___ 01:30PM ___ PTT-31.3 ___
___ 01:30PM PLT COUNT-272
___ ___ ___ ___ ___
Department of
Radiology
___ ___ ___
(___) ___
___ ___ EU
___ 2:25 ___
CHEST (PORTABLE AP)
Clip # ___
Reason: acute process
History: ___ with cough,hypoxia
acute process
No contraindications for IV contrast
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
FINAL REPORT
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with cough, hypoxia
TECHNIQUE: Upright AP view of the chest
COMPARISON: Chest radiograph ___
FINDINGS:
Assessment is slightly limited by patient rotation.
Cardiac silhouette size
is normal. Mediastinal and hilar contours are grossly
unremarkable. Lung
volumes are low with crowding of bronchovascular
structures. There is
probable mild pulmonary vascular congestion. Patchy
bibasilar airspace
opacities are noted, with possible trace bilateral
pleural effusions. No
pneumothorax is detected. No acute osseous abnormality
is present. Remote
fracture of multiple left sided ribs and the left mid
clavicle are re-
demonstrated.
IMPRESSION:
Probable mild pulmonary vascular congestion and possible
small bilateral
pleural effusions. Patchy bibasilar airspace opacities,
nonspecific, and may
reflect atelectasis though infection or aspiration cannot
be excluded.
Brief Hospital Course:
___ with history of EtOH abuse, depression presenting with
inability to ambulate in the setting of intoxication, found to
be hypoxic with productive cough, likely had aspiration
pneumonitis, as well as community acquired pneumonia. Hypoxia
improved quickly. She was discharged to a dual diagnosis
facility.
# Community acquired pneumonia: CXR showed aspiration vs
pneumonia, in the setting of productive cough and shortness of
breath she likely has community-acquired pneumonia. Her initial
hypoxia was more likely related to aspiration pneumonitis as
opposed to aspiration pneumonia, since she improved so quickly
and was able to be weaned to room air. As such, she was treated
for community=acquired pneumonia as opposed to aspiration
pneumomia (anaerobic coverage less important in this setting).
She is at high risk for aspiration given her EtOH use. This is
consistent with ___ ED reports - report of cough is consistent
with reported symptoms at ___, although she was apparently
not hypoxic during her ED visit at ___ ___, the difference
was intoxication. No ___ edema or known risk factors for PE.
Ambulatory O2 sat 94-96% on room air. She completed a 5 day
course of levofloxacin while in the hospital.
# Inability to ambulate: Acutely intoxicated, per RN report from
ED pt was found laying outside, lethargic but easily a rousable.
Serum EtOH elevated. UTox positive for benzos, although pt
denies. No focal deficits on exam. Suspect her imbalance related
to her intoxication, with perhaps underlying cerebellar
dysfunction related to chronic EtOH use. Ambulated well with
nursing.
# Alcohol abuse: Stating a desire to go to detox in ED, although
on arrival to floor she denies significant alcohol abuse. She is
on the CIWA protocol here. Will continue MVI/thiamine/folate and
work with social work for detox placement, preferable dual
diagnosis. Her goal is to detox and move to ___ to be with
her daughter ___ who has multiple medical issues (spinal musc
atrophy). Despite multiple calls and several days of trial with
___ - there was no bed available - and the decision was
to discharge Ms. ___ to post-detox unit to forestall any
Etoh use and transition her ultimately to a dual diagnosis
facility.
# Depression. She is trazodone, also on gabapentin (300mg,
unknown frequency), as well as Seroquel (unknown dose). Will
restart gabapentin only for now.
# Emergency contact: Daughter, ___ ___ (pt
states ___ is her HCP but does not have paperwork).
# Dispo: Discharge to ___ facility if able.
Attempted to contact her mental health provider, ___
___ at ___ to confirm med list, but unable. Attempted to
search for patient's primary care provider (a PA named
___ at ___ but none in current directory).
She is medically clear for discharge to a psychiatric, dual
diagnosis, or ___ facility.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. TraZODone 100 mg PO QHS:PRN insomnia
2. QUEtiapine Fumarate Dose is Unknown PO BID
3. Gabapentin 300 mg PO TID
Reportedly prescribed but not yet filled - based on discussion
with pt and ED provider at ___
___ Medications:
1. Gabapentin 300 mg PO TID
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Aspiration pneumonitis
Acute respiratory failure
Hypoxia
Community acquired pneumonia
Alcohol dependence and intoxication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care at ___. You were
admitted for difficulty walking in the setting of intoxication,
low oxygen levels, and cough. You were found to be intoxicated
with alcohol, and probably aspirated during that time. Your low
oxygen levels improved. You also were found to have pneumonia,
which we will treat with an antibiotic.
Followup Instructions:
___
|
19744146-DS-6
| 19,744,146 | 29,881,534 |
DS
| 6 |
2200-01-06 00:00:00
|
2200-01-09 11:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Augmentin
Attending: ___.
Chief Complaint:
painful R shin lesion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year female with a past medical history significant
for htn, hl here with a right painful erythematous shin skin
rash for the past 7 days. She was initially treated with 4 days
of bactrim without improvement, followed by 3 days of
clindamycin (2 IV doses, then PO since) with only minimal
improvement. She had a recent strep throat infection 3 weeks ago
and was treated with keflex for a ___nding
approximately 1.5-2 weeks ago. She has multiple small
erythematous, non-painful papular lesions that have now
resolved. The strep throat symptoms were sore throat, fevers to
101's, chills, and odynophagia that improved with a single dose
of IV steriods, IV fluids, and kefelx. She denies any fever,
chills, sore throat, dysuria, diarrhea, constipation, joint
pain, and other skins lesion(other than those describe above).
She is planning to flight out on ___ to see family and was
hoping to have a more definitive answer regardin this skin
lesion. She had a plan x-ray of the R shin at ___
that per patient was read as soft tissue swelling without
evidence of osteomyolitis.
In the ED, initial vs were unremarkable (afebrile). Labs were
unremarkable, except for a slightly elevated platelet count to
462 and ESR to 56. Blood cutures from ___ are no growth to
date. Normal UA. Patient was given a single dose of vancomycin.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
HTN
HL
recent strep throat infection
Social History:
___
Family History:
negative for significnant inflammatory or autoimmune diseases
Physical Exam:
Admission Exam:
Vitals: T: 98.4 BP:118/78 P:74 R:16 O2:97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: painful, blanching erythematous macule on the anterior
skin that had migrated towards the distal foot from the prior
outline.
Neuro: non-focal
Discharge Exam:
Vitals: T: 98.2 BP:108/72 P:76 R:18 O2:97% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: painful(less so), blanching erythematous macule on the
anterior skin that had migrated towards the distal foot from the
prior outline.
Neuro: non-focal
Pertinent Results:
Admission Labs:
___ 12:20PM BLOOD WBC-8.4 RBC-3.96* Hgb-12.6 Hct-37.6
MCV-95 MCH-31.8 MCHC-33.6 RDW-12.4 Plt ___
___ 12:20PM BLOOD Neuts-64.8 ___ Monos-3.8 Eos-1.1
Baso-0.9
___ 12:20PM BLOOD Glucose-98 UreaN-8 Creat-0.6 Na-138 K-4.3
Cl-101 HCO3-23 AnGap-18
___ 12:31PM BLOOD Lactate-1.0
Discharge Labs:
___ 07:30AM BLOOD WBC-5.7 RBC-3.97* Hgb-12.7 Hct-37.1
MCV-94 MCH-32.0 MCHC-34.2 RDW-12.1 Plt ___
___ 07:30AM BLOOD Glucose-94 UreaN-12 Creat-0.6 Na-137
K-4.2 Cl-100 HCO3-28 AnGap-13
Imaging:
TARGETED RIGHT SHIN ULTRASOUND: Targeted ultrasound was
performed at the site of erythema at the level of the right
ankle anteriorly. No drainable fluid collection is identified.
Superficial vasculature within this region is patent.
IMPRESSION: No drainable fluid collection at site of cellulitis
along the right anterior shin at the level of the ankle.
Brief Hospital Course:
___ yo female with R Shin Lesion of Erythema Nodosum.
#. Erythema Nodosum- The patient has had a painful single
erythematous lesion over right shin, starting 2 weeks after a
strep throat infection. The patient has taken keflex, bactrim,
and clindamycin without improvement to the lesion. Given recent
strep throat, derm was consulted to evaluated for erythema
nodosum vs. cellulits. Derm agrees that R shin lesion is likely
Erythema Nodosum. Lesion improved with naproxen overnight.
Patient encourage to continue naproxen 500 q8. She was given
return precautions.
# HL- continue crestor
# HTN- continue atenolol
Medications on Admission:
1. Atenolol 12.5 mg PO DAILY
2. Rosuvastatin Calcium 5 mg PO DAILY
Discharge Medications:
1. Atenolol 12.5 mg PO DAILY
2. Naproxen 500 mg PO Q8H
3. Rosuvastatin Calcium 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
erythema nodosum
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___. We believe you
have a condition called erythema nodosum, which sometimes occurs
after a strep throat infection. It might take a few weeks for
the pain and inflammation to get better. Please continue to
take naproxen 500mg every 8 to 12 hours until the inflammation
resolves. If the pain or swelling gets worse, or if you develop
a fever, please contact your primary care provider.
Followup Instructions:
___
|
19744393-DS-2
| 19,744,393 | 29,234,265 |
DS
| 2 |
2174-02-12 00:00:00
|
2174-02-17 20:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
acute kidney injury
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ a history of asthma, osteogenesis ___, diabetes,
referred from ___ after his PCP discovered acute
kidney injury. He started feeling unwell approximately 5 days
ago, felt nauseous, and had ___ episodes of clear emesis. He was
able to tolerate some fluids but not able to take most of his
medications. He saw his PCP the following day, who drew labs and
noted acute kidney failure, thus requesting that he present to
the emergency department. PCP also prescribed carafate, and
nausea improved, and he was able to restart his medications.
Denies chest pain, shortness of breath, abdominal or flank pain,
fevers, chills, rash, diarrhea, lower extremity swelling. He has
not taken any new medications. He last took ibuprofen ___ weeks
ago.
In the ED intial vitals were: 98.2 81 ___ 92% 0
Labs notable for BUN 79, Creat 5.9, HCO3 19, WBC 13.7 with 8.2%
eosinophils. Developed shortness of breath and hypoxemia to 87%.
Patient was given: 3L IVF for hypotension
Vitals on transfer: 98.2 82 93/53 100% 3L NC
On the floor, patient has no complaints.
Past Medical History:
Osteogenesis ___
Diabetes mellitus, type II
Asthma/COPD
Hyperlipidemia
Hypertension
Anxiety
Social History:
___
Family History:
- No history of renal disease
- Father - died of pancreatic cancer
- Mother - healthy
- Brother - pre diabetic
- Sister - ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.6 BP 109/61 P 80 R 14 Sat 100% 3L
Weight 83 kg
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Mild wheezing, faint bibasilar cracles ___ lung bases
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley, no CVAT
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Left shin with well-healed skin graft from remote tib/fib
fracture
Neuro- CNs2-12 intact, motor function grossly normal, mild
resting tremor of the left arm
DISCHARGE PHYSICAL EXAM:
- Vitals: Tcurrent/Tmax 97.8/98.5, 134/103 (116-138/75-95), 93
(81-93), 18 (___), 95% (93-95%) on RA
- 24-hr fluid balance: +300 mL
- BG: 8 AM (89/0H), 12 ___ (158/1H), 4 ___ (296/3H), 10 ___
(193/35L), 7 AM (158)
- General: alert; laying quietly in bed; no acute distress
- HEENT: PERRL; MMM; oropharynx clear; blue sclera
- Lungs: occasional wheeze b/l; no crackles or rhonchi
- Back: no CVA tenderness; mild TTP of T11 spinous process
- CV: RRR, normal S1 + S2, no murmurs, rubs, or gallops
- Abdomen: +BS, soft, non-tender, non-distended, no organomegaly
- Ext: WWP; 2+ radial, ___, and DP pulses b/l; no clubbing,
cyanosis or edema
Pertinent Results:
==================
ADMISSION LABS:
==================
___ 08:20PM BLOOD WBC-13.7* RBC-4.49* Hgb-14.1 Hct-40.8
MCV-91 MCH-31.4 MCHC-34.7 RDW-14.9 Plt ___
___ 08:20PM BLOOD Neuts-64.9 ___ Monos-6.9 Eos-8.2*
Baso-0.9
___ 08:20PM BLOOD Glucose-68* UreaN-79* Creat-5.4* Na-135
K-3.7 Cl-98 HCO3-19* AnGap-22*
___ 08:20PM BLOOD Calcium-8.7 Phos-5.1* Mg-1.8
___ 09:05PM URINE Color-Straw Appear-Clear Sp ___
___ 09:05PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 09:05PM URINE RBC-0 WBC-6* Bacteri-FEW Yeast-NONE Epi-0
___ 09:05PM URINE CastHy-3*
___ 09:05PM URINE Mucous-RARE
___ 09:05PM URINE Hours-RANDOM UreaN-388 Creat-76 Na-85
K-12 Cl-65 TotProt-17 Phos-21.4 HCO3-LESS THAN Prot/Cr-0.2
___ 09:05PM URINE Osmolal-356
==============
IMAGING:
==============
RENAL U.S. ___ 9:10 ___
1. No hydronephrosis.
2. Right renal cyst.
3. Echogenic focus in the interpolar region of the left kidney,
likely represent column of Bertin. Correlation with prior exams
and attention on followup is recommended.
CHEST (PA & LAT) ___ 11:01 ___
IMPRESSION: No acute cardiopulmonary process. Compression
deformities at the thoracolumbar junction of indeterminate age.
Correlate for site of point tenderness. There may also be mild
compression deformities along the mid-to-lower thoracic spine,
again not well assessed.
==================
DISCHARGE LABS:
==================
___ 08:10AM BLOOD WBC-6.3 RBC-3.87* Hgb-12.6* Hct-35.0*
MCV-90 MCH-32.4* MCHC-35.9* RDW-14.6 Plt ___
___ 08:10AM BLOOD Plt ___
___ 08:10AM BLOOD Glucose-121* UreaN-40* Creat-2.3* Na-136
K-3.8 Cl-102 HCO3-21* AnGap-17
___ 08:10AM BLOOD Calcium-9.8 Phos-4.0 Mg-1.7
Brief Hospital Course:
Mr. ___ is a ___ male with a history of asthma,
osteogenesis ___, and T2DM who presents with acute kidney
injury in the setting of 4 days of nausea/vomiting and decreased
oral intake.
ACUTE DIAGNOSES:
# ___:
Given the patient's history of decreased PO, nausea/vomiting,
and SBPs to ___ in the ED in the setting of lisinopril use,
renal ischemia was thought to result in ATN. The patient
underwent renal ultrasound, which did not show any evidence of
hydronephrosis to suggest a post-renal etiology. The patient did
not have signs of uremia, acidemia, hyperkalemia, or severe
fluid overload to necessitate hemodialysis. He was treated with
intravenous fluids and encouraged to resume oral intake,
resulting in improvement of creatinine from 6.2 on hospital day
2 to 2.2 on discharge. The patient was asked to match his urine
output with oral intake at home. He was sent home with home ___
to monitor electrolytes. The patient's home lisinopril,
ibuprofen, metformin, and glyburide were held during the
hospital course. Metformin should be resumed on discharge.
Consider restarting lisinopril and replacing glyburide with
glipizide, which is hepatically rather than renally cleared.
# Hypotension:
SBPs was ___ in the ED. Most likely cause is hypovolemia
secondary to nausea, vomiting, and poor oral intake. BP was
responsive to IV fluids. The patient's home metoprolol and
lisinopril were held given his low BPs and ___. Metoprolol
should be resumed on discharge. Consider restarting lisinopril
as outpatient.
CHRONIC DIAGNOSES:
# Osteogenesis ___:
The patient has a history of 93 fractures. His most recent
fracture of his ribs was several months ago, and his last major
fracture was a T11 compression fracture ___ yrs ago. The
patient's home oxycodone was renally dosed and gradually
increased back to his home dose by the time of discharge.
# COPD/asthma:
The patient had normal O2 sats on room air and mild wheezing on
exam. He was continued on his home albuterol, tiotropium,
fluticasone, and montelukast.
# T2DM:
The patient was continued on his home Lantus 35U qHS and sliding
scale Humalog. His home metformin and glyburide were held during
the hospitalization. Metformin should be resumed on discharge.
Consider replacing glyburide with glipizide, which is
hepatically rather than renally cleared.
# HLD:
The patient was continued on his home simvastatin.
# Anxiety:
The patient was continued on his home clonazepam.
TRANSITIONAL ISSUES:
- Check BUN & creatinine.
- Consider restarting lisinopril and replacing glyburide with
glipizide, which is hepatically rather than renally cleared
- Echogenic focus in the interpolar region of the left kidney,
likely represent column of Bertin. Correlation with prior exams
and attention on followup is recommended.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. GlyBURIDE 10 mg PO BID
3. Simvastatin 20 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Levemir 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q6h:prn wheezing
9. ClonazePAM 0.5 mg PO TID:PRN anxiety
10. Lorazepam 0.5 mg PO HS:PRN insomnia
11. OxyCODONE SR (OxyconTIN) 50 mg PO Q8H
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheeze
13. Montelukast Sodium 10 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH HS
15. Advil ___ (ibuprofen-diphenhydramine) 200-38 mg oral HS:prn
insomnia, pain
16. Sucralfate 1 gm PO QID:PRN nausea
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheeze
2. ClonazePAM 0.5 mg PO TID:PRN anxiety
3. Lorazepam 0.5 mg PO HS:PRN insomnia
4. Montelukast Sodium 10 mg PO DAILY
5. OxyCODONE SR (OxyconTIN) 50 mg PO Q8H
6. Simvastatin 20 mg PO DAILY
7. Tiotropium Bromide 1 CAP IH HS
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q6h:prn wheezing
9. Metoprolol Tartrate 25 mg PO BID
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
11. Outpatient Lab Work
ICD-9: Acute kidney failure 584.9
Please check chem10 twice weekly (sodium, potassium, chloride,
bicarb, creatinine, BUN, calcium, magnesium, phosphage)
Contact:
Name: ___
Location: ___
Address: ___
Phone: ___
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Levemir 35 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute kidney injury
Secondary diagnoses:
Osteogenesis ___
Type 2 diabetes
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for acute kidney injury. You
were treated with intravenous fluids, and your kidney function
markers (BUN, creatinine) were monitored. These markers
improved, and it was thought that your kidney injury was due to
decreased oral intake and dehydration. We recommend close
follow-up with your primary care physician. We recommend not
resuming some of your previous medications (lisinopril,
ibuprofen) until your kidney function has been confirmed as
stable by your primary care physician. Given your recent kidney
injury, your glyburide may be substituted with glipizide; please
discuss this medication change with your primary care physician.
Please use a urinal to measure the amount of urine you make and
make sure to drink the same amount of fluid to replace it.
Followup Instructions:
___
|
19744665-DS-21
| 19,744,665 | 28,193,518 |
DS
| 21 |
2179-09-29 00:00:00
|
2179-10-01 15:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
heart palpitations, syncope with resultant MVC
Major Surgical or Invasive Procedure:
Endocardial Ablation of AVNRT ___
History of Present Illness:
Mr. ___ is a ___ year old man with a history of SVT and HTN
who was transfered to ___ from ___ due for
management of SVT and syncope.
Patient reports that he has had palpitations for approxaimtely ___
years which he manages with carotid sinus massage. At the time
of initial presentation, he remembers being very worked up about
a work issue, and feeling his heart racing. He was diaphoretic,
and subsequently went to an emergency department, where they
gave him medication IV, and taught him carotid msasage. He has
been managing the palpitations on his own with CSP since that
time. He reports that in the past 6 weeks, the palpitaions have
become more frequent and have lasted longer during each episode.
He reports that on the day of admission, he was driving in the
car when he felt the palpitations start. He tried CSP with
little effect. He then began seeing spots in front of his eyes.
He next recalls waking up with his car in a tree. He was
transferred to ___. He recieved adenosine 6mg,
12mg, 12mg, dilt 10mg, and amiodarone 150mg. He converted to
sinus rhythm before he arrived at ___. Work-up included CT
head, c-spine which were negative. He was transfered to ___
for further eval and treatment.
In the ED, initial vitals were 98.4 90 153/103 16 100% 2L Nasal
Cannula. Labs and imaging significant for a CXR that showed no
acute process, but a nodule projecting over left lung apex for
which nonurgent repeat with PA and apical lordotic suggested.
This morning, patient reports that he is feeling well. No
further episodes of palpitations, dizziness, syncope. No chest
pain, SOB.
Past Medical History:
- PSVT -> diagnosed ___ yrs ago
- HTN -> for ___ years
- Prior motorcycle accident with fractured RLE and aortic injury
requiring surgical repair ___ years ago
Social History:
___
Family History:
Negative for premature CAD or sudden cardiac death. Father died
of lung cancer at age ___. Mother died of breast cancer when he
was ___ years old.
Physical Exam:
Admission Exam:
VS: Tm 98.5 Tc 98.5 BP 120/74 HR 81 RR 18 98 RA
GENERAL: NAD, AAOx3
HEENT: EOMI, conjunctiva clear, oropharynx clear, no LAD
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No ___ edema.
SKIN: No stasis dermatitis, ulcers. Large scar on the right shin
from prior motorcycle accident.
PULSES: 2+ DPs in the bilateral feet
Discharge Exam:
VS: T98.1, BP 123/73, HR 78, RR 18, 98%RA
GENERAL: NAD, AAOx3
HEENT: EOMI, conjunctiva clear, oropharynx clear, no LAD
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No ___ edema.
SKIN: No stasis dermatitis, ulcers. Large scar on the right shin
from prior motorcycle accident. c/d/i dressings over groin
bilaterally
PULSES: 2+ DPs in the bilateral feet
Pertinent Results:
Admission Labs:
___ 07:40AM BLOOD WBC-4.4 RBC-4.15* Hgb-13.1* Hct-40.4
MCV-97 MCH-31.6 MCHC-32.5 RDW-12.2 Plt ___
___ 07:40AM BLOOD ___ PTT-25.2 ___
___ 07:40AM BLOOD Glucose-115* UreaN-18 Creat-0.9 Na-139
K-4.0 Cl-105 HCO3-26 AnGap-12
___ 07:40AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.0
No other labs drawn.
Imaging:
___ ECG: Sinus rhythm and occasional atrial ectopy. No
previous tracing available for
comparison.
TRACING #1
Read ___
___
___
___ CXR: Single portable view of the chest. No prior. The
lungs are clear
of focal consolidation. Linear opacity at left lung base
suggestive of
atelectasis. Nodular opacity projects over the anterior left
first rib,
potentially within it or in the left lung apex. Lungs are
otherwise clear.
The cardiomediastinal silhouette is within normal limits.
Osseous and soft
tissue structures are grossly unremarkable.
IMPRESSION: No acute cardiopulmonary process or cardiomegaly.
Nodular
opacity projecting over the left lung apex, potentially within
the rib or
lung. Dedicated two-view chest with apical lordotic view
suggested when
patient is amenable for further characterization.
___ ECG: Sinus rhythm. Left atrial abnormality. Compared to
the previous tracing
of ___ no diagnostic interim change.
TRACING #2
Read ___
___
___
___ CXR: The reported abnormality on the prior study appears
quite dense,
measuring about 8 mm in diameter and continuing to overlie the
left anterior
first rib. This may reflect a small bone island and less likely
an apical
lung nodule. There has been apparent previous surgery in the
left hemithorax
with changes suggestive of left thoracotomy, accompanied by mild
volume loss
and areas of parenchymal and pleural scarring. Heart size is
normal. Aorta
is mildly tortuous. Right lung and pleural surfaces are clear.
IMPRESSION: Dense left apical nodular opacity is not fully
localized or
characterized on this study but probably reflects a small bone
island or
calcified right apical granuloma. As the patient has apparently
had prior
surgery, there are likely prior outside radiographs that could
be procured for
comparison. This may be helpful to document retrospective
stability and to
avoid the need for further imaging such as a CT scan.
OSH EKG: SVT at 200 bpm. pseudo r' in V1. Most likely avnrt.
.
OSH CT Head: No evidence of acute intracranial pathology. Mucous
retention cysts in both maxillary sinuses. Small linear
radiopaque foreign body in the right frontal region.
.
OSH C-Spine: No appearnt Fx or subluxation. Mark DJD C3 through
T1 with disk osteophite complexes.
Brief Hospital Course:
___ yoM with h/o SVT and HTN who was transferred for an
endocardial ablation for suspected AVNRT that has been
intermittent but increasingly frequent and resistant to
noninvasive interventions. Last episode of SVT lead to syncope
while driving and resultant motor vehicle collision without
injury.
.
# SVT: EKG at OSH was most suggestive of AVNRT. Given the
severity of presentation (syncope) and the fact that his
episodes were occurring more frequently and have been less
responsive to carotid massage, the patient underwent successful
endocardial ablation, which confirmed AVNRT. He was observed for
the day and discharged on aspirin 325mg for one month with EP
follow up.
# Syncope/Motor Vehicle Collision: Work up and OSH ruled out
trauma/injury. Patient was without pain or other complaints.
Accident was ___ syncope as a result of his AVNRT, which was
treated this admission with endocardial ablation.
# HTN: Well controlled on home regimen
(HCTZ/Lisinopril/Triamterene) which was continued in house.
.
# Pulmonary Nodule: CXR this admission shows a dense left apical
nodular opacity which probably reflects a small bone island or
calcified right apical granuloma. Radiology suggests comparison
with prior studies, which has been deferred to outpatient
management given his short stay in the hospital.
Transitional Issues:
- The patient was instructed to make a follow up appointment
with Dr. ___ 2 months.
- He was also instructed to make a follow up appointment with
his PCP ___ the next 2 weeks.
- A pulmonary nodule was noted on CXR repeatedly this admission.
Patient likely has prior chest imaging previously given prior
surgery, which should be used to compare the nodule over time to
determine stability. If no prior imaging can be obtained by the
PCP, patient should have reimaging in 6months time.
Medications on Admission:
Lisinopril 10 mg Daily
HCTZ/Triamterene 37.5-25 mg Daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: AVNRT
Secondary Diagnosis: Syncope, Motor Vehicle Collision, HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for an arrhythmia of your heart that caused
you to lose consciousness and have a car accident. Luckily you
were not injured and your heart converted out of the arrhythmia
prior to your arrival at ___.
Because this arrhythmia is occurring for you more frequently, it
was decided that you should have an endocardial ablation which
was successfully performed today.
No changes were made to your home medications.
For the next month, you should take Aspirin 325mg by mouth
daily. Please purchase this over the counter at your local
pharmacy.
Please also make sure to follow up with Dr. ___ in 2 months.
Followup Instructions:
___
|
19744711-DS-8
| 19,744,711 | 29,072,032 |
DS
| 8 |
2136-01-12 00:00:00
|
2136-01-14 16:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Shortness of breath/hypoxia.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o ___ M with PMH including HTN, CAD s/p CABG
(___), COPD, CVA, sarcoidosis and gout who p/w one week of
subjective fevers, night sweats and SOB.
.
.
On ___ morning ___ woke up feeling severely weak and
fatigued. He has since had daily subjective fevers and chills,
drenching night sweats, SOB at rest, intermitent ___ headaches
and mild photophobia which improve with tylanol, mild dry cough.
His weakness, fatigue and SOB have been worsening progressivley
since. He went to see his PCP today who ___ him to the ED.
He denies any other accompanying symptoms including nasal
congestion, ST, sinus pain, dysphagia, temporal pain or
mandibular claudication, N, V, D, constipation, dysuria, rash,
joint pain, myalgias. Has not gained or lost weight recently.
Has not noted edema or lymphadenpathy. No PND/orthopnea/leg
swelling. No recent travel/immobilization, no h/o DVT/PE.
.
Patient was in his USOH until ___ AM. At baseline he is fully
ADL independent, lives at home and takes care of his elderly
father, does shopping and house chores, ambulates independently
with cane, climbs up and down 10 stairs several times daily with
no limitations and no DOE or CP with activities. He has history
of smoking and COPD per PFT's but denies chronic cough or h/o of
exacerbations, never used inhalers. He says he has been treated
with oral iron for anemia for the past year, he has h/o severe
GI bleed but denies any recent black or bloody stools. No sexual
exposures for the past ___ years, says he had neg HIV test one
year ago. He has history of sarcoidosis which presented ___ years
ago with visual changes which resolved with prednisone, he has
had no recent visual complaints. He has known mediastinal
lymphadenopathy but does not have h/o symptomatic pulmonary
involvment with sarcoidosis. No recent dental or other invasive
procedures. No recent medication changes. No sick contacts. No
travels in the past year. No outdoor activities. No animal
contacts. No dietary changes or suspicious meals. Got flu shot
this ___. Denies any history of TB or TB contacts but does
have history of positive PPD per Atrius records.
.
ED Course:
- Initial Vitals: 97.6, 83, 143/88, 22, 100% on 2L
- sats off O2 -> dropped to 80%, then improved to 100% on 2L
- labs notable for Hct 30.8 at baseline, Cr:BUN = 1.5:19 (cr
baseline 1.4 ___ 1.1) , also BNP = 483, trop neg X1,
lactate normal.
- EKG: (my read) SR at 80, p wave changes in II and V1
suggestive of left atrial abnormality, marginally abnormal left
axis (~ -___, NI, SRWP across precordial leads, no ischemic
changes.
- CXR: (my read) mildly enlarged hard shadow, fluid in left
fissure, some haziness minimally obscuring left heart border on
anterior view, otherwise no pulm edema or effusions.
CTA: no PE to the segmental levels - distally limited by
breathing/contrast phase, no dissection, intramural hematoma;
lymphadentopathy c/w sarcoidosis, pulmonary hypertension;
nonspecific ground glass in posterior segment of right upper
lobe- infection vs inflammation.
[X] ED interventions:
15:07 Aspirin 325mg Tablet 1
16:41 Albuterol 0.083% Neb Soln
16:42 Ipratropium Bromide Neb 2.5mL Vial 1
18:34 Gabapentin 300mg Capsule 2
___ MethylPREDNISolone Sodium Succ 40mg Vial 2
- Lines & Drains: #18 l fa
- Fluids: none
- Most Recent Vitals:82, RR: 16, BP: 140/65, O2Flow: 2l, Pain:
___.
Past Medical History:
- HTN
- HLD
- CAD: ___:
CARDIAC CATH ___: native three vessel disease, wide
patent LIMA-LAD, SVG-PDA, SVG-OM1, SVG-D2 with 99% proximal
stenosis. Succesful PCI of SVG-D2 with three overlapping BMS.
- s/p Patent Foramen Ovale Closure
- MOD MITRAL VALVE INSUFFICIENCY
- DM II- last HbA1C ___ 7.2 , c/b Diabetic neuropathy
- COPD (based on PFTs, patient denies symptoms)
- h/o lower GIB (gastritis, diverticulosis) ___
- L pontine stroke ___: "blurred vision," slurred speech and
"trouble with balance"
- OA
- sarcoidosis: ___ years ago, spontanous blind on both eyes for 2
hours, steroid-therapy ___ year at ___, no symptoms hence.
- gout
- depression
- BPH (benign prostatic hypertrophy)
- Mitral Valve Disorder
- TOTAL HIP REPLACEMENT and right revision ___
- POSITIVE PPD
- Erectile dysfunction
Social History:
___
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father, ___ y/o, HTN, DMII and dementia. Mother
died age ___ from stroke, HTN, DMII. Two sisters and two
brothers, in good health per patient. One sister with h/o
sarcoid.
.
Physical Exam:
Physical exam upon discharge:
Vital signs
Weight 86kg, 69 inches, T ___, BP 166-150/80, RR 20 96% ra
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, mildly distended but soft/NT, hypertympanic, no
flank dulness, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions, no EN lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ right side, ___ left. Decreased sensation to light touch on
left side. cerebellar exam intact.
Pertinent Results:
CT Chest:
CT ANGIOGRAM CHEST: ___
HISTORY: ___ man with acute shortness of breath,
positive D-dimer. History of sarcoidosis per medical record.
TECHNIQUE: Contiguous axial images were obtained through the
chest, both
before and after the administration of intravenous contrast.
Coronal and
sagittal reformats were reviewed.
COMPARISON: Comparison is made to previous exam from ___.
FINDINGS: There is no filling defect within the main, left,
right lobar or
proximal segmental pulmonary arteries to suggest pulmonary
embolus.
Evaluation of more distal vessels is limited secondary to phase
contrast and
respiratory motion, particularly at the lung bases.
There is no intramural hematoma or evidence of dissection in the
aorta.
Again seen is extensive bilateral hilar and mediastinal
lymphadenopathy,
similar to prior and compatible with patient's history of
sarcoidosis. These
are not significantly changed since previous exam. There is,
however, some
narrowing of the basilar segmental bronchi bilaterally secondary
to the
adjacent nodes. More central airways are patent.
Linear bibasilar opacities are most suggestive of atelectasis.
Linear opacity
in the anterior segment of the right upper lobe (series 4, image
68) may be
due to atelectasis or scarring as well. Nonspecific ground-glass
opacity in
the posterior segment of the right upper lobe. There is no
pleural effusion.
Note is made of partial anomalous pulmonary venous return with
the left upper
lobe pulmonary vein draining into the left brachiocephalic vein.
There is
enlargement of the main pulmonary artery which measures up to
3.9 cm in
diameter at the level of the ascending aorta suggesting
pulmonary
hypertension. Postoperative changes of CABG are noted with
atherosclerotic
calcifications also seen within the aorta and native coronary
arteries.
Degenerative change is seen in the spine and at the
costovertebral junction
and lower spine on the left. No suspicious osseous lesions
identified.
IMPRESSION:
1. No evidence of central pulmonary embolism to the segmental
level. No
aortic dissection or intramural hematoma to explain patient's
symptoms.
2. Bilateral hilar or mediastinal adenopathy, similar to prior
exam,
compatible with patient's history of sarcoidosis.
3. Pulmonary artery enlargement suggesting pulmonary
hypertension.
4. Nonspecific ground-glass opacity in the posterior segment of
the right
upper lobe, potentially due to inflammation or infection.
--------
COMPARISON: Chest CT on ___.
TECHNIQUE: PA and lateral chest radiograph.
FINDINGS: The lungs are well expanded. The right lung is clear.
Linear
opacity across the left lower lung field likely represents
scarring vs
atelectasis. There is moderate cardiomegaly and equivocal bulky
hila, but the
cardiomediastinal and hilar contours are unchanged from prior.
There is no
pleural effusion or pneumothorax. Sternotomy wires are noted in
the midline
and there are no other fractures.
IMPRESSION: No evidence of acute cardiopulmonary process.
------------
___ 07:55AM BLOOD WBC-13.5*# RBC-3.67* Hgb-10.0* Hct-33.0*
MCV-90 MCH-27.1 MCHC-30.1* RDW-14.5 Plt ___
___ 07:50AM BLOOD WBC-6.4 RBC-3.61* Hgb-9.9* Hct-31.2*
MCV-86 MCH-27.5 MCHC-31.8 RDW-14.3 Plt ___
___ 02:50PM BLOOD WBC-7.6 RBC-3.55* Hgb-9.9* Hct-30.8*
MCV-87 MCH-27.9 MCHC-32.2 RDW-14.3 Plt ___
___ 07:50AM BLOOD ___ PTT-36.1 ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD ESR-56*
___ 07:55AM BLOOD Glucose-160* UreaN-22* Creat-1.4* Na-138
K-4.4 Cl-102 HCO3-25 AnGap-15
___ 07:50AM BLOOD Glucose-354* UreaN-20 Creat-1.5* Na-135
K-5.1 Cl-101 HCO3-23 AnGap-16
___ 02:50PM BLOOD Glucose-121* UreaN-19 Creat-1.5* Na-141
K-4.6 Cl-105 HCO3-27 AnGap-14
___ 02:50PM BLOOD ALT-15 AST-21 LD(LDH)-165 AlkPhos-109
TotBili-0.3
___ 02:50PM BLOOD Lipase-41
___ 02:50PM BLOOD cTropnT-<0.01
___ 02:50PM BLOOD proBNP-463*
___ 07:55AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.4
___ 04:41PM BLOOD D-Dimer-741*
___ 02:50PM BLOOD TSH-0.47
___ 02:50PM BLOOD CRP-24.8*
Brief Hospital Course:
___ y/o ___ M with PMH including HTN, CAD s/p CABG
(___), COPD, CVA, sarcoidosis and gout who p/w one week of
subjective fevers, night sweats and SOB.
Shortness of breath: The patient presented to the ED after a
week of worsening shortness of breath. The patient stated that
at baseline he is able to ambulate a few city blocks without
becoming short of breath and his ADL's are not limited by his
shortness of breath. Prior to coming to the ED, his shortness of
breath was so limiting that he could not walk 5 feet without
becoming short of breath. In the ED, he required 6L via NC to
maintain oxygen saturation. He was given nebs, IV solumedrol
125mg, and antibiotics for presumed treatment of a COPD flare.
His chest CT showed hilar adenopathy, pulmonary hypertension,
and a ground glass opacity consistent with the patients previous
history sarcoidosis. Upon arrival to the floor the patient was
afebrile, on 2L nc with a sa02 of 98%, and in no signs of
respiratory distress. Given his normal white count, lack of
cough, and rapid response to the steroids plus his chest CT was
consistent with pulmonary sarcoid, antibiotics were held. The
patient was given standing nebulizers and placed on prednisone
40mg for treatment of possible sarcoid/COPD flare. On HD1, the
patient was saturating 95% on room air. He became mildly
dyspneic while ambulating so he was kept for an additional day.
HD2 patient could ambulate off supplemental oxygen and maintain
sats above 95%. He was discharged with close follow with his PCP
on ___ 4 day course of prednisone 40mg and advair inhaler.
-5 day course of PO prednisone at 40mg QD.
-Advair inhaler for symptomatic relief if COPD exacerbation.
-Please consider workup for pulmonary sarcoid.*
==================
Chronic issues:
# CRF: This is secondary to hypertension and DM2. His serum
stayed at baseline. His medications were renally dosed.
.
# CAD:
- continue Plavix, aspirin, BB, statin
.
# HTN:
- continue losartan, metoprolol, tamsulosin
.
# diabetic neuropathy:
- continue gabapentin: reduce home dose to 300 mg Q12h per GFR.
.
# DM:
- hold metformin for now and cover with ISS
.
# GERD and h/o GI bleed:
- continue Famotidine 20mg QDAY
.
# BPH:
- continue tamsulosin 0.4mg QHS
Medications on Admission:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO Q TUE/SAT ().
7. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
10. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
6. furosemide 20 mg Tablet Sig: One (1) Tablet PO Q TUE/SAT ().
7. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
9. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
10. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
13. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
Disp:*1 unit* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
COPD/sarcoidosis flare
Secondary diagnoses:
CAD s/p CABG
HTN
DMII
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for shortness of breath, fevers,
chills and night sweats. You responded very well to a steroid
medication called prednisone and this helped you breath much
better. Your chest CT showed images consistent with pulmonary
sarcoidosis. While sarcoid might not be the cause of your
breathing problems, you should certainly discuss with your
primary care physician about being evaluated and potentially
treated for sarcoid. Your shortness of breath may also be due to
a COPD exacerbation. Either way both of these conditions are
treated with steroids and inhalers. You should discuss this with
your primary care doctor and consider arranging an appointment
with a doctor who specializes in lung diseases. When you return
home we would like you to resume your normal home medications.
1. Please start Prednisone 40mg per day for the next 4 days.
2. Please start taking Advair inhaler, 1 puff twice a day.
If you experience any of the danger signs as listed below please
come back to the emergency department or call your primary care
doctor.
Followup Instructions:
___
|
19744789-DS-19
| 19,744,789 | 27,118,921 |
DS
| 19 |
2143-10-06 00:00:00
|
2143-10-06 08:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
Codeine / Flu / adhesive tape / Iodized Lime / Aloe
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year female s/p breast reconstruction with bilateral
latissimus flap on ___ by Dr. ___. Today presents to ED
with 48 hours of fevers, chills, and night sweats. Reported home
temp of 101.3 last night. Patient was seen in clinic yesterday
and started on Augmentin. Currently denies SOB, CP, abd pain,
urinary symptoms. Does report an episode of nausea and vomiting
that occurred yesterday afternoon. JP drains in place with
serous output, left darker than right.
Past Medical History:
-right knee meniscus injury-->surgery in ___,
-hysterectomy in ___
-two prior lumpectomies in ___ and ___
-oophorectomy
-Bladder polyp was removed in ___
-C-sections x 4
-broken right wrist, a ligament injury
-injury of the left ankle after falling on ice
-bronchitis
-bilateral lung nodules
-Pulmonary embolism: Work-up for Pulmonary embolism which was
inconclusive with 2 negative CTAs, low prob V/Q scan in ___
which was 4 months post-op from mastectomy. Patient presented
with shortness of breath and chest pain but there was no
evidence of PE. Patient was treated empirically with Lovenox.
-left arm DVT: Left arm superficial thrombophlebitis
(non-occlusive clot in cephalic vein) in ___ arm with
peripheral IV.
-___ VATS RLL x 3 (Path negative for malignancy)
-Obesity
-Peripheral neuropathy of hands and feet (uses walker)
Social History:
___
Family History:
Her mother was diagnosed with breast cancer at age ___ and is now
in her ___.
Physical Exam:
On admission:
VS - T 100.0 HR 88 BP 132/88 RR 18 Sats 99% 2L NC
Gen - A&O female sitting up on hospital stretcher in NAD
CV - pulses regular
Pulm - breathing unlabored
Chest - bilateral breast incisions c/d/i sutures in place with
out erythema, induration, or drainage. JPs in place bilaterally
holding suction with ~15 cc of serous fluid in each. Posterior
wounds c/d/i with out erythema, induration, or drainage.
Inferior aspect of right posterior wound warm to touch with some
fullness and TTP but no induration.
Discharge PE unchanged.
Pertinent Results:
___ 12:45PM URINE HOURS-RANDOM
___ 12:45PM URINE GR HOLD-HOLD
___ 12:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 11:09AM TYPE-ART COMMENTS-GREEN TOP
___ 11:09AM LACTATE-1.9
___ 11:00AM GLUCOSE-199* UREA N-13 CREAT-0.9 SODIUM-135
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
___ 11:00AM estGFR-Using this
___ 11:00AM CALCIUM-8.6 PHOSPHATE-2.2*# MAGNESIUM-1.8
___ 11:00AM WBC-16.9*# RBC-4.07* HGB-11.4* HCT-34.5*
MCV-85 MCH-27.9 MCHC-32.9 RDW-13.9
___ 11:00AM NEUTS-92.8* LYMPHS-3.9* MONOS-2.5 EOS-0.7
BASOS-0.1
___ 11:00AM PLT COUNT-475*#
___ 11:00AM ___ PTT-27.1 ___
Brief Hospital Course:
The patient was admitted to the plastic surgery service on ___
for fevers after her recent surgery. Her initial CT in the ER
on admission showed no PE, but showed fluid collection on the
chest wall. The JP drains were still in place and draining, and
it was not purulent. The pt was started on vancomycin and
defervesed by ___. In brief, she continued to normalize and
feel well, tolerating PO and having bowel movement and urinating
without difficulty. The hospital stay was only complicated by
the fact that her right JP drain fell out. We decided not to
seek percutaneous placement of another drain due to her
continued improvement. After a period of observation, the
patient felt well enough to go home, and seeing no indicaiton
for further admission, she was discharged with cipro and
duricef.
Neuro: Pain and fever were well controlled here. Always
maintained normal mentation.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: Pt was tolerating PO on admission with BM and urination.
She maintained the same while here.
ID: She was started on vancomycin while here for presumed gram
positive coverage. She was discharged with Cipro and duricef.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating,
voiding without assistance, and pain was well controlled.
Medications on Admission:
Albuterol
Furosemide 20mg: 2 tabs in AM, 1 tab at ___ (total of 60mgs/day)
Omeprazole 40mg po QD
Tamoxifen 20mg po QD
Aspirin 325mg po QD
Calcium w/vitamin D3 QD
Ferrous Sulfate QD
Discharge Medications:
Albuterol
Furosemide 20mg: 2 tabs in AM, 1 tab at ___ (total of 60mgs/day)
Omeprazole 40mg po QD
Tamoxifen 20mg po QD
Aspirin 325mg po QD
Calcium w/vitamin D3 QD
Ferrous Sulfate QD
1. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
2. cefadroxil 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 10 days: Take until the bottle is empty.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Post operative fevers, chest wall seromas.
Discharge Condition:
Mental status: normal mentation.
Ambulatory: at baseline, which is without assistance.
Discharge Instructions:
You were admitted to the hospital because of your fevers after
your operation. After a CT we determined that you have you a
collection of fluid in your chest wall. The treatment for this
is time, and your body will slowly absorb it all. We started
you an antibiotics, because your fever may have been from a
bacterial infection. Eventually while here you started to feel
better and your fever broke. After discussion with you and Dr.
___ agreed that it's safe for you to go home.
Personal Care:
1. You may keep your breast dressings in place until
your follow up appointment with Dr. ___. If dressings become
wet underneath, then you may remove them and leave your
incisions open to air or covered with a clean, sterile gauze.
2. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s) ___
times per day.
4. A written record of the daily output from each drain should
be brought to every follow-up appointment. your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. DO NOT wear a bra for 3 weeks. You may wear a camisole for
comfort as desired. You may also wear a front zip up or front
closing sports bra that is not too tight. No underwires.
6. You may shower daily with assistance as needed. Be sure to
secure your drains to a laniard that hangs down from your neck
so they don't hang down and pull out.
7. The Dermabond skin glue will begin to flake off in about ___
days.
8. No pressure on your chest or abdomen
9. Okay to shower, but no baths until after directed by Dr.
___.
.
Activity:
1. You may resume your regular diet.
2. Keep hips flexed at all times, and then gradually stand
upright as tolerated.
3. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity for 6 weeks following surgery.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered .
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength
Tylenol for mild pain as directed on the packaging. Please note
that Percocet and Vicodin have Tylenol as an active ingredient
so do not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softerner if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
Followup Instructions:
___
|
19744950-DS-19
| 19,744,950 | 25,468,001 |
DS
| 19 |
2176-10-06 00:00:00
|
2176-10-07 09:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
umbilical hernia repair
History of Present Illness:
___ yo M w/ umbilical hernia for the past year who developed ___
pain on ___ night that lasted for a few hours then improved,
and has had 8 episodes of nausea and vomiting since yesterday
afternoon, last episode a few hours ago, nonbloody, possibly
slightly bilious. He continues to pass flatus and bowel
movements without any difficulty. No weight loss or fevers, but
endorses some sweats and possibly chills within the last day. He
feels better now and is actually hungry, denies nausea. He also
says that he has been able to keep down liquids between the
episodes of emesis. No sick contacts or diarrhea or trauma to
the abdominal wall, and he has never had an abdominal surgery
before. He was referred to one of the general surgeons here to
get this fixed but had not had the chance to follow up yet. He
cannot recall who he was scheduled to see. Work-up revealed
umbilical hernia and he was admitted to the ___ service for
repair.
Past Medical History:
GERD
depression
anxiety
OCD
chronic venous stasis
Social History:
___
Family History:
+ for malignancy.
Physical Exam:
Admission:
VS: 97.9 76 110/67 18 98%RA
geN: NAD, lying in bed
CV: RRR, no m/r/g
P: CTAB
ABd: soft, nondistended, minimally tender over umbilical hernia
with 2 cm defect, reducible hernia with no appreciable bowel
contents. He does have some minimal overlying skin changes with
darkening of the skin, but no erythema or warmth. He is
minimally
tender periumbilically to palpation but I cannot appreciate any
masses. There is no guarding or rigidity.
Ext: WWP, hyperpigmentation of both feet in sock like
distribution
Discharge:
Gen - a&o x3, NAD
CV - RRR, no murmur
Resp - cta bilat
Abd - surgical dressing in place, c/d/i; soft, NT, ND, +bs
Extr - warm, 2+ pulses
Pertinent Results:
___ 04:55AM BLOOD WBC-5.5 RBC-4.26* Hgb-12.5* Hct-39.5*
MCV-93 MCH-29.3 MCHC-31.6* RDW-14.1 RDWSD-47.8* Plt ___
___ 04:55AM BLOOD Glucose-97 UreaN-21* Creat-1.0 Na-141
K-4.1 Cl-106 HCO3-27 AnGap-12
CT a/p -
1. Umbilical hernia containing small bowel mesentery with
associated
inflammatory changes, findings consistent with a recently
reduced obstructive
hernia.
2. Dilated hyperemic small bowel without clear transition; it is
highly likely
that the obstruction was due to bowel incarceration within the
recently-reduced umbilical hernia.
3. Trace intra-abdominal ascites.
4. Moderate hiatal hernia.
Brief Hospital Course:
Mr. ___ was admitted to the ACS service from the Emergency
Department for repair of his reduced umbilical hernia. He had
eaten a sandwich while in the ED, so his surgery was planned for
the morning of HD 2. He had no further nausea or abdominal pain
overnight. He was brought to the operating room and underwent an
uncomplicated ___ repair of his umbilical hernia, details of
which are in the dictated operative report. Post-operatively his
pain was well-controlled with oral medications. He tolerated a
regular diet and was able to ambulate independently. All of his
questions were answered to his satisfaction.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
Do not take more than 4000mg of acetaminophen daily.
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Do not drive while taking this medication. Please take a stool
softener to prevent constipation.
3. Omeprazole 20 mg PO DAILY
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
umbilical hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 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.
o You may start some light exercise when you feel comfortable.
o 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:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o 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:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. 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).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o 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.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. 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.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o 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.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o 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.
Followup Instructions:
___
|
19745415-DS-20
| 19,745,415 | 22,238,682 |
DS
| 20 |
2132-12-02 00:00:00
|
2132-12-02 18:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Hypertensive emergency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F transferred for concerns of hypertensive emergency after
findings of b/l retinal hemorrhages and BP 210/110. Pt reports
vision changes x2 weeks. She states it is like she has to "wipe"
her left eye off, as though there is a shadow. This relieves
with putting her glasses on. CT head from ___ showed:
1) Mild prominence of lateral ventricles, patchy hypodensity
w/in periventricular white matter, more prominent than would be
expected in a patient of this age. Findings may be related to
mild hydrocephalus and chronic intracranial HTN.
2) CSF prominence within sella turcica with effacement of
pituitary gland suggesting empty sella syndrome, which may also
be associated with intracranial HTN
3) 9 mm focus of increased subependymal increased attenuation
adjacent to posterior horn of R lateral ventrical, most
suggestive of small acute probably hemorrhage.
She received 130 mg total labetalol at ___. Came in on gtt
100 mg/hr.
In the ED, initial vitals:
97.8 71 130/81 18 95% RA. Chem-7, CBC, and coags were WNL. PE in
the ED was notable for finger-to-nose ataxia b/l. R pupil >L,
but reactive; notably had eyes dilated at 1230AM for fundus
exam.
On transfer, SBP 120-130s, on labetalol gtt.
On arrival to the MICU, patient corroborates HPI from ED. 2
weeks ago, patient started experiencing worsening blurry vision
of L eye. She made an appointment to be seen by her
ophthalmologist. Before she saw her ophthalmologist however, she
presented to the ED on ___ prior to presenting to her
ophthalmologist on ___. She had gone to ED because one of the
children she works with had thrown a toy at her causing a
forehead lac. SBPs were noted to be in 210s. She was given a
prescription for labetalol at that time; however, her local
pharmacy did not have the correct dose, so she was unable to
take her medication. Given bilateral retinal hemorrhages with
uncontrolled hypertension, she was sent to ___ for further
evaluation and treatment.
Endorses nausea but no HA; nausea passed by end of initial
assessment. No CP/SOB. No vision changes. No urinary symptoms.
No feelings of confusion. No weakness.
Review of systems:
As per HPI, otherwise negative
Past Medical History:
Preeclampsia
C-section x2
ALL, diagnosed age ___, treated with chemotherapy and whole head
radiation
Fertility treatments, intra-uterine and ___ ___
1 miscarriage at 8 weeks
Social History:
___
Family History:
- no history of pre-eclampsia
- Mother - HTN, developed later in life, controlled with meds
- Father - glioblastoma ___
Physical Exam:
ADMISSION EXAM:
Vitals: T:97.5 BP:125/70 P:76 R: 18 O2: 96%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear; central forehead
with small cm lac, with c/d/I steristrips; EOMI
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: intact, no rashes
NEURO: AOx3, CN II-XII intact; bilateral LEs and UEs with ___
strength; sensation intact; R > L pupil, reactive to light
DISCHARGE EXAM:
Vitals: 97.3 130/92 (120-150)/(50-90) 78 18 98%RA
General: Sleeping comfortably in bed, NAD
HEENT: NC/AT, EOMI, PERRL
Lymph: No LAD
CV: RR, +S1/S2, no m/r/g
Lungs: CTAB, no r/r/w
Abdomen: Soft, ND, NTTP, +BS throughout
GU: No foley
Ext: Warm, dry and well perfused. No edema.
Neuro: CN II-XII intact. ___ strength. Sensation grossly intact.
No ataxia.
Skin: No rashes or lesions
Pertinent Results:
ADMISSION LABS:
___ 10:45PM BLOOD WBC-8.4 RBC-4.40 Hgb-12.1 Hct-37.1 MCV-84
MCH-27.5 MCHC-32.6 RDW-14.0 RDWSD-43.0 Plt ___
___ 10:45PM BLOOD Neuts-66.8 ___ Monos-6.4 Eos-2.4
Baso-0.4 Im ___ AbsNeut-5.61 AbsLymp-2.01 AbsMono-0.54
AbsEos-0.20 AbsBaso-0.03
___ 10:45PM BLOOD ___ PTT-28.2 ___
___ 10:45PM BLOOD Glucose-143* UreaN-9 Creat-0.5 Na-139
K-3.6 Cl-104 HCO3-24 AnGap-15
___ 06:14AM URINE Color-Yellow Appear-Clear Sp ___
___ 06:14AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 06:14AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-1
___ 06:14AM URINE UCG-NEGATIVE
PERTINENT LABS:
Metanephrines, Fract., Free
Normetanephrine, Free 0.64 nmol/L <
0.90
Metanephrine, Free <0.20 nmol/L <
0.50
Renin: Pending
Aldosterone: Pending
DISCHARGE LABS:
___ 07:25AM BLOOD WBC-5.5 RBC-4.71 Hgb-13.0 Hct-40.5 MCV-86
MCH-27.6 MCHC-32.1 RDW-14.4 RDWSD-45.0 Plt ___
___ 07:25AM BLOOD Glucose-96 UreaN-7 Creat-0.6 Na-139 K-4.1
Cl-103 HCO3-28 AnGap-12
___ 07:25AM BLOOD Calcium-9.4 Phos-3.5 Mg-2.4
___ 06:10AM BLOOD TSH-1.5
IMAGING:
=========
___ MRI
Impression:
1. Late subacute/chronic hemorrhage in the right parietal
periventricular
white matter with numerous other punctate foci of chronic
microhemorrhages in the right frontal, parietal, occipital
lobes, right basal ganglia, right midbrain, and bilateral
cerebellar hemispheres, likely hypertensive in etiology or due
to cavernous malformations.
2. Extensive, nonspecific white matter lesions, most likely
representing the sequela of chronic small vessel ischemic
changes given the patient's provided history of preeclampsia and
hypertension. No signs of reversible
encephalopathy syndrome
3. Normal MRA of the head and neck.
4. Empty sella intra which slightly tortuous optic nerves are
nonspecific
finding which could be seen in patients with pseudotumor
cerebri.
___ Doppler US Kidney
FINDINGS:
The right kidney measures 10.8 cm. The left kidney measures 11.4
cm. There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical
echogenicity and corticomedullary differentiation are seen
bilaterally.
Renal Doppler: Intrarenal arteries show normal waveforms with
sharp systolic peaks and continuous antegrade diastolic flow.
The resistive indices of the right intra renal arteries range
from 0.53-0.63. The resistive indices on the left range from
0.56-0.57. Bilaterally, the main renal arteries are patent with
normal waveforms. The peak systolic velocity on the right is
84.0 centimeters/second. The peak systolic velocity on the left
is 101 centimeters/second. Main renal veins are patent
bilaterally with normal waveforms.
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
Normal renal ultrasound. No evidence of renal artery stenosis.
___ CT head from ___ showed:
1) Mild prominence of lateral ventricles, patchy hypodensity
w/in periventricular white matter, more prominent than would be
expected in a patient of this age. Findings may be related to
mild hydrocephalus and chronic intracranial HTN.
2) CSF prominence within sella turcica with effacement of
pituitary gland suggesting empty sella syndrome, which may also
be associated with intracranial HTN
3) 9 mm focus of increased subependymal increased attenuation
adjacent to posterior horn of R lateral ventrical, most
suggestive of small acute probably hemorrhage.
Brief Hospital Course:
___ w/ h/o preeclampsia, childhood ALL s/p whole brain
radiation, transferred here from ___ for concern of
hypertensive emergency given bilateral retinal hemorrhages and
ICH noted on CT head in setting of systolic BPs in the 220s.
#Hypertensive emergency: Patient presentd to ___ with SBP
in the 220's, she received 130 mg total labetalol at ___
and presented to ___ on labetalol gtt 100 mg/hr. Bilateral
retinal hemorrhages were identified on exam and CT at ___
with question of ICH on CT exam. No evidence of other end organ
damage and no focal deficits noted on neuro exam upon admission
to the ICU at ___. Upon arrival to the ICU, SBPs were in the
120-130's and labetalol drip was decreased and then stopped.
Patient was started on 200 mg of labetalol BID with target BP
range of 140-160 with holding parameter of SBP <120. Work up for
secondary causes of hypertension was initiated: HCG is negative
and plasma metanephrins normal. US of kidney shows no evidence
of renal artery stenosis. UA showed trace level of protein.
Serum renin and aldosterone PND on discharge. CK-MB/Tropnin
2/<0.01. Labetalol increased to 400 mg BID; given persistent
requirement of PRN meds (PO 10 hydral), she was subsequently
increased to 400 TID. Patient was discharged on HCTZ 25mg and
Amlodipine 7.5mg daily with BPs in 130/90s.
#ICH: Patient s/p whole brain radiation making vessels more
friable and long term hypertension may also be contributing.
Neurology was consulted and recommends BP control with goal of
systolic < 160 and permanent avoidance of aspirin and NSAIDS.
Neurologically at baseline at discharge. Plan to follow-up with
Neurology as an out-patient.
#Retinal Hemorrhages: Occurred in the setting of severely
elevated SBPs (220). Seen by out-patient ophthalmologist who
recommended hospitalization for BP control. Per patient report,
instructed that vision would likely improve with better BP
control. Scheduled to see retina specialist on ___. Continue
BP as above.
TRANSITIONAL ISSUES:
=====================
- Testing pending at discharge: serum renin, aldosterone, and
urine metanephrine
- MRI showed empty sella, this may not be an issue. Should
follow up with neurologist.
- Started on blood pressure control with amlodipine 7.5mg and
HCTZ 25mg. Should have repeat lytes within one week. Should have
blood pressure closely monitored given brain and retinal
microhemmorages.
- Should have A1c and lipids checked as outpatient.
- Avoid NSAIDs and ASA given risk of bleed; Patient should
discuss with her PCP and neurologist before
initiating OCP or any fertility treatments in the future given
potential of worsening HTN.
- Please encourage a low salt diet
- CODE: Full
- PCP: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
**1. losartan-hydrochlorothiazide unknown oral DAILY (**NEVER
FILLED**)
2. Prenatal Vitamins 1 TAB PO DAILY
Discharge Medications:
1. Prenatal Vitamins 1 TAB PO DAILY
2. Amlodipine 7.5 mg PO DAILY
RX *amlodipine 5 mg 1.5 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hypertensive emergency
Retinal hemorrhage
Cerebral hemorrhage
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 recent
hospitalization at ___. You were transferred here after you
presented to ___ and were found to have elevated
blood pressure, bleeding behind your eyes ("retinal
hemorrhages") and a small area of possible bleeding on a CT scan
of your head.
Your blood pressure was controlled with IV medicines which was
then transitioned to two new medicines called
hydrochlorothiazide and amlodipine. You are being discharged on
these medicines. The reason for your elevated blood pressure is
still unclear.
While you were here, you were seen by Neurologists. An MRI
showed a small amount of bleeding, most likely due to your high
blood pressure. It also showed an "empty sella" which is an area
of the brain that should have tissue, but does not. This can
often be asymptomatic, but sometimes a sign of increased
pressure in the brain or a result of radiation to the brain,
which you have had. If you continue to have headaches, speak to
your neurologist.
Please avoid NSAIDs (which are medicines like ibuprofen,
excedrine, naproxen) and aspirin as an outpatient given bleeding
Please avoid birth control pills as these can cause high blood
pressure. Please discuss with your primary doctor initiating any
in the future and maintain a low salt diet.
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
19745487-DS-2
| 19,745,487 | 27,146,041 |
DS
| 2 |
2115-08-02 00:00:00
|
2115-08-03 11:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest mass
Major Surgical or Invasive Procedure:
1. Right sternoclavicular joint debridement with partial
clavicle resection.
2. Debridement, right sternoclavicular bone. Sharp excision of
skin and subcutaneous tissue and bone, 6 x 3 cm. Pectoralis
major muscle advancement flap and closure.
History of Present Illness:
___ h/o hepatitis C cirrhosis, IDDM, obesity, who is transferred
from ___ for MRI showing large septic effusion,
sternal infection.
The patient notes a mass progressively growing in size on his
chest for the past 3 weeks. He presented to ___
where he had a CT scan and an xray that were reportedly
unremarkable. He then went to see a "bone doctor" and was
prescribed medication for gout which did not relieve his pain or
reduce the size of his mass. The mass continued to grow causing
discomfort. He was told he needed an MRI but would have to wait
3 weeks. Due to continued pain, he had an MRI more urgently
done, showing soft tissue edema and a large joitnt effusion
involving the clavicle and manubrium that culd represent
inflammatory arthropathy, inflammation or rheumatoid/crystalline
arthropathy/pseudogout.
At ___, he received Ceftriaxone and vancomycin and
transferred to ___.
Vitals in the ED: 99.1 100 136/78 20 100% RA
Labs notable for wbc 3.5, H/H 12.1/33.8, Plt 98, normal chem 7,
lactate 1.7, ALT 20, AST 139, AP 68, Tbili 1.1, Tn <.01, INR
1.3.
Thoracic consultation was obtained, and they felt the mass was
hard to palpation, without fluid collection, and did not feel
there was a role for thoracic surgery at this time; recommending
repeat MRI with contrast
Patient given: morphine, zofran, and dilaudid and admitted to
the floor.
On the floor, the patient c/o significant pain near his chest
mass. He endorses decreased appetite, fatigue, and difficulty
sleeping. No history of GI bleed. No recent confusion or
encephalopathy
Past Medical History:
- Obesity BMI 43
- Type 2 diabetes, complicated with neuropathy
- Chronic hepatitis C,
-history of right lower extremity cellulitis in ___
- Chronic headaches.
Social History:
___
Family History:
no hx liver disese
Physical Exam:
ADMISSION PE:
Vitals - T: 98.6 BP: 130/79 HR: 103 RR: 20 02 sat: 92% RA
GENERAL: in some distress secondary to pain, elevated BMI
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM,
good dentition
NECK: tender neck secondary to mass, unable to assess for LAD
CARDIAC: distant heart sounds, RRR, S1/S2, no murmurs, gallops,
or rubs. Hard neck mass, 3x5 cm, TTP, no fluctuance, skin is
unopened, no pus or blood
LUNG: CTAB anteriorly, no accessory muscle use no wheezes
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, (+) edema, moving all 4
extremities with purpose. difficulty raising RUE secondary to
pain
NEURO: alert, oriented
SKIN: warm and well perfused, hyperpigmentation of b/l lower
extremities c/w venous stasis
DISCHARGE PE:
Vitals - T: 98.9 BP: 127/75 HR: 98 RR: 18 02 sat: 94% RA
GENERAL: AAAOx3, NAD
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM,
good dentition
NECK: Surgical wound at R SC joint dressed, w/ JP tubes in place
draining serosanguinous fluid
CARDIAC: distant heart sounds, RRR, S1/S2, no murmurs, gallops,
or rubs.
LUNG: CTAB anteriorly, no accessory muscle use no wheezes
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. marked ascites.
EXTREMITIES: no cyanosis, clubbing, (+) edema, moving all 4
extremities with purpose.
SKIN: warm and well perfused, hyperpigmentation of b/l lower
extremities c/w venous stasis
Pertinent Results:
LABS
====
___ 09:45PM BLOOD WBC-3.5* RBC-3.78* Hgb-12.1* Hct-33.8*
MCV-89 MCH-31.9 MCHC-35.8* RDW-16.7* Plt Ct-98*
___ 09:45PM BLOOD Neuts-66.4 ___ Monos-10.9 Eos-2.2
Baso-0.1
___ 09:45PM BLOOD Plt Ct-98*
___ 09:45PM BLOOD Glucose-263* UreaN-9 Creat-0.5 Na-125*
K-7.3* Cl-95* HCO3-25 AnGap-12
___ 09:45PM BLOOD ALT-20 AST-139* AlkPhos-68 TotBili-1.1
___ 06:47AM BLOOD Calcium-7.3* Phos-2.7 Mg-1.8
___ 11:25PM BLOOD CRP-155.5*
___ 09:51PM BLOOD Lactate-1.7
MICRO:
======
___ Joint Fluid Cx: Strept. Viridans
STUDIES/IMAGING:
================
- US-GUIDED R SC JOINT ASPIRATION (___):
1. Procedure- Technically successful ultrasound-guided right
sternoclavicular joint aspiration yielding 1 cc of
serosanguineous fluid. Samples were sent to the laboratory for
Gram stain/culture, crystal analysis, and cytology.
2. Findings- prominent soft tissue thickening and
hypervascularity overlying the right sternoclavicular joint,
correlating to the abnormal soft tissue seen on the outside
hospital MRI from ___.
- CXR (___): There is prominent soft tissue opacity
projecting in the right paratracheal region which corresponds to
the area of soft tissue abnormality seen on the MR and
ultrasound there is a small amount of fluid within the major
fissure on the right. There is a small left effusion. The heart
is upper limits normal in size. The aorta is slightly tortuous.
There is no focal infiltrate.
- TRANSTHORACIC CARDIAC ECHO (___): 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 may be
dilated and borderline hypokinetic. No significant valvular
abnormality. Unable to assess pulmonary artery systolic
pressure. Cannot exclude endocarditis due to poor image quality.
- TISSUE PATHOLOGY FROM JOINT DEBRIDEMENT (___):
1. Sternoclavicular joint, right, debridement (1A-1C):
a. Skeletal muscle and fibrous tissue with acute and chronic
inflammation, necrosis and granulation tissue.
b. Bone with acute and subacute osteomyelitis.
2. Clavicular head, right resection (2A-2B): Acute and subacute
osteomyelitis.
3. Mediastinal soft tissue (3A): Granulation tissue with acute
and chronic inflammation; bone fragments.
4. Manubrium (4A): Acute and subacute osteomyelitis.
Brief Hospital Course:
Mr. ___ presented to ___ holding at ___ on ___ and
for right sternoclavicular joint debridement with partial
clavicle resection and on ___ for debridement, right
sternoclavicular bone, sharp excision of skin and subcutaneous
tissue and bone, 6 x 3 cm, and pectoralis major muscle
advancement flap and closure. He tolerated the procedures well
without complications (Please see operative note for further
details). After a brief and uneventful stay in the PACU, the
patient was transferred to the floor for further post-operative
management.
Neuro: The patient was followed by the Acute Pain Service. When
tolerating oral intake, the patient was transitioned to oral
pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI: Post-operatively, the patient was made NPO with IV fluids.
Diet was advanced when appropriate, which was well tolerated.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary. Acetaminophen was limited
given pt's hx of chronic HCV and evident ascites.
GU: The patient voided without difficulty.
ID: Septic Sternoclavicular joint - Fluid grew GPCs which
speciated to Strep viridans. Patient was started on IV
ceftriaxone and underwent joint washout with bone bx and
clavicular head resection on ___. Infectious disease team
was consulted and patient underwent TTE which showed no
significant valvular abnormality, although study was of poor
quality due to body habitus (TEE contraindicated due to grade IV
esophageal varices). PICC line was placed in LUE on ___ for
continuation of IV antibiotic regimen on discharge. Per ID pt
should undergo 6 week course of treatment, ending ___. Will
be administered by coordinated care by home infusion company and
home ___ services. Pain controlled with PO oxycodone, IV
morphine, tylenol and Naproxen this admission. Hep C - continued
home Ledipasvir/Sofosbuvir and home lasix.
Hematology: The patient's complete blood count was examined
routinely.
Endocrine: DM was monitored by ___: continued insulin and SSI
this admission, titrated as needed. pt still having blood sugars
in the 200s, and should follow-up re: improved diabetes
management with his PCP.
Skin: The incision was well approximated and intact. JP drain
with hemostat placed during flap procedure by plastics, which
will stay in place after discharge. Pt should record daily
outputs and call Plastics when it is under 30cc/day, as then the
JP can come out. Pt also should f/u in clinic with Dr. ___ in
1 week, number added to discharge instructions.
Prophylaxis: The patient received subcutaneous heparin. Patient
wore venodyne boots and was encouraged to get up and ambulate as
early as possible following surgery.
On HD10, the patient was discharged to home with home ___ and
home infusion company services. At discharge, he was tolerating
a regular diet, passing flatus, stooling, voiding, and
ambulating independently. He will follow-up in clinic in ___
weeks with both Plastics and Thoracic Surgery. This information
was communicated to the patient directly prior to discharge with
verbalized understanding and agreement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. Ledipasvir/Sofosbuvir 1 TAB PO DAILY
3. Amaryl (glimepiride) 4 mg oral DAILY
4. Humalog 50-50 30 Units Breakfast
Humalog 50-50 30 Units Bedtime
5. Oxycodone-Acetaminophen (5mg-325mg) Dose is Unknown PO
Frequency is Unknown back pain
Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. Ledipasvir/Sofosbuvir 1 TAB PO DAILY
3. Amaryl (glimepiride) 4 mg oral DAILY
4. Humalog 50-50 30 Units Breakfast
Humalog 50-50 30 Units Bedtime
5. Docusate Sodium 100 mg PO BID
Do not take if having diarrhea or loose stools.
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
Do not drive or drink alcohol while taking this medication.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp
#*100 Tablet Refills:*0
7. CeftriaXONE 2 gm IV Q24H
Continue for 6 weeks (started ___, last day ___
RX *ceftriaxone 2 gram 2 g IV daily Disp #*38 Vial Refills:*0
8. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
9. Milk of Magnesia 30 mL PO QHS:PRN constipation
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 mL by
mouth every night Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Septic Arthritis of Right sternoclavicular joint
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your hospitalization.
You were admitted for a swelling mass on your chest. We feel
this is due to an infection of your joint. You were given IV
antibiotics and had the joine washed out with the surgical
service.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You 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 is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
General Discharge Instructions:
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, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please record the daily output of your JP drain from your
surgical incision site. Once the output is under 30mL per day,
please call Plastic Surgery at the office of Dr. ___ ___ and let them know that it is time for the drain to come
out.
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19745809-DS-2
| 19,745,809 | 26,437,517 |
DS
| 2 |
2148-12-31 00:00:00
|
2148-12-31 16:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Falls
Major Surgical or Invasive Procedure:
Paracentesis (3L removed) ___
Paracentesis (2L removed) ___
EGD
History of Present Illness:
Patient is a ___ with history of
atrial fibrillation on warfarin, aortic stenosis, HTN, chronic
back pain iso spinal stenosis, depression, and alcohol abuse
disorder who presents as a transfer from ___ where he
initially was evaluated iso increased falls and weakness at
home.
Imaging obtained subsequently demonstrated a hepatic mass,
pleural effusion, and ascites. Decision was made to transfer
patient to ___ for further evaluation/management.
Patient says that he has had four or so falls at home over the
past several weeks. He lives alone in an apartment in ___ and ___ otherwise been able to be up and about without
the assistance of a cane or walker. Patient denies any
lightheadedness/dizziness prior to falling, rather his 'legs
just
give out.' The most recent fall was this past ___. Patient
called his brother who came to help him get up. Ultimately,
patient's brother was able to convince patient to present to ___ ___.
Patient endorses 42lbs weight loss over the past ___,
intentional he says iso strict portion control to prevent the
progression of prediabetes-->diabetes. For the last two weeks,
however, patient has had very poor appetite, which is unusual
for
him. +Intermittent nausea with dry heaves. No fevers/chills.
About 1.5 weeks ago, patient describes five days of self-limited
diarrhea, which was quite dark in color (no blood, but described
as 'black'). Patient notes that his urine has been quite dark
in
color as well for the past three weeks. Patient denies any
dysuria or worsening back pain (chronically has issues related
to
spinal stenosis). Patient further denies any abdominal pain.
He
has had persistent abdominal distention, he was surprised that
his abdomen did not recede with his ongoing weight loss.
Of note, patient currently has two drinks nightly. He was a
previous heavy drinking from his teens into his sixth decade
___ drinks daily). Patient denies any prior history of EtOH
withdrawal or seizures.
Upon presentation to ___, labs were notable as follows: Hb
13, plts 218, INR 4.22, Troponin-T <.01, UA with small
___
WBCs/3+ Bacteria/rare Epis.
Patient was administered CTX given concern for UTI. Imaging was
obtained as outlined below. Decision was made to transfer
patient to ___ ED further evaluation/management.
In the ___ ED, initial VS were: 98.4 92 149/96 20 96% RA
Exam notable for:
Abdomen distended, mildly tender in the right upper quadrant, no
rebound or guarding
ECG: Normal axis, irregular rhythm without clearly discernible
Pwaves, T wave flattening inferolaterally, no acute ischemic ST
changes.
Labs showed:
CBC 6.5>12.___.2<165 (MCV 101, 75.1% PMNs)
BMP ___
___ 45, PTT 38, INR 4.2
Urine tox POS opiates
Imaging showed (OSH):
CT A/P, CHEST
Conclusion:
1. No definite acute posttraumatic process in the chest. Small
to
moderate left pleural effusion and passive left base
atelectasis.
2. Small mediastinal lymph nodes, most of which are unchanged
since
___ however there are 3 enlarged 8-9 mm short axis para-aortic
lymph
nodes below left hilum, which are potentially concerning.
3. Incidental findings of thoracic spine with no acute skeletal
process seen in the chest, no definite acute displaced rib
fracture
seen.
4. Oval enhancing 2.3 x 1.9 cm liver lesion in central segment
IVb, in
front of IVC, highly suspicious for hepatoma. New since prior
imaging.
Correlation with serum AFP advised.
4. Cirrhosis. Large volume ascites in all 4 quadrants of the
abdomen.
Potentially suspicious aortocaval, para-aortic sub-CM lymph
nodes.
5. Uncomplicated colonic diverticulosis. Evidence of prominent
hemorrhoidal portosystemic collateral vessels. Other incidental
nonacute findings as listed above.
CT CERVICAL SPINE
CONCLUSION:
1. No acute cervical fracture or misalignment.
2. Ankylosis of the C6-T1 vertebral bodies, C6/7 facets.
3. Developmentally small canal with multilevel central,
foraminal
stenosis.
4. Other incidental nonacute findings as outlined above.
CT HEAD
Conclusion:
1. Mild involution, minimal small vessel ischemic
leukoencephalopathy.
Otherwise Normal noncontrast CT scan of the head.
2. No acute hemorrhage, acute infarction, edema, mass, mass
effect, or
fracture.
Consults: Hepatology
Patient received: NOTHING
Transfer VS were: 98.1 69 114/71 18 96% RA
Past Medical History:
Atrial fibrillation on warfarin
Aortic stenosis
HTN
Chronic back pain iso spinal stenosis
Depression
Alcohol abuse disorder
Social History:
___
Family History:
Mother and father, also aunts with CAD/MI.
Brother recently died of melanoma.
No known family history of liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2 143/96 74 18 96 Ra
GENERAL: NAD, pleasant in conversation.
HEENT: Faint scleral icterus, MMM, poor dentition, halitosis.
NECK: No JVP elevation.
CV: Regular rate, irregular rhythm, S1/S2, systolic murmur at
the
RUSB with radiation to clavicles, no gallops or rubs.
PULM: Decreased breath sounds at the bilateral bases L>R.
GI: NABS, abdomen soft, +distention, nontender in all quadrants,
no rebound/guarding, palpable liver edge below the costal
margin.
EXTREMITIES: No cyanosis, clubbing, or edema.
PULSES: 1+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric.
DERM: Warm and well perfused, healing skin breaks on L forearm
and R elbow with dried blood.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0 PO |132 / 80 |91 |18 |97 RA
General: Thin, alert and cooperative, and appears to be in no
acute distress.
HEENT: Normocephalic, atraumatic. Pupils are equal, round, and
reactive to light and accommodation. EOMI in all cardinal
directions of gaze without nystagmus. Vision is grossly intact,
hearing grossly intact. Nares patent with no nasal discharge.
Oral cavity and pharynx are without inflammation, swelling,
exudate, or lesions. Teeth and gingiva in poor general
condition.
Cardiac: Normal S1 and S2. There is a IV/VI systolic
crescendo-decrescendo murmur heard throughout precordium. Rhythm
is irregular.
Pulmonary: Clear to auscultation without rales, rhonchi,
wheezing
or diminished breath sounds.
Abdomen: Normoactive bowel sounds. Soft, distended, nontender.
No guarding or rebound. No masses.
Musculoskeletal: ROM intact in spine and extremities. No joint
erythema or tenderness. Muscle bulk and tone appropriate for age
and habitus.
Neuro: Alert and oriented x3. No gross focal deficits.
Skin: Skin type III. Skin normal color, texture and turgor with
no lesions or eruptions.
Pertinent Results:
___ 11:37PM BLOOD WBC-6.5 RBC-3.70* Hgb-12.8* Hct-37.2*
MCV-101* MCH-34.6* MCHC-34.4 RDW-13.0 RDWSD-48.1* Plt ___
___ 11:37PM BLOOD Neuts-75.1* Lymphs-13.4* Monos-9.9
Eos-0.3* Baso-0.5 Im ___ AbsNeut-4.88 AbsLymp-0.87*
AbsMono-0.64 AbsEos-0.02* AbsBaso-0.03
___ 11:37PM BLOOD ___ PTT-38.0* ___
___ 11:37PM BLOOD Glucose-113* UreaN-11 Creat-0.7 Na-140
K-3.3* Cl-95* HCO3-31 AnGap-14
___ 11:37PM BLOOD ALT-30 AST-80* AlkPhos-256* TotBili-2.7*
DirBili-1.5* IndBili-1.2
___ 06:00AM BLOOD Albumin-2.7* Calcium-8.5 Phos-2.5*
Mg-1.4*
___ 11:37PM BLOOD calTIBC-166* Ferritn-1461* TRF-128*
___ 11:37PM BLOOD HCV Ab-NEG
___ 06:31AM BLOOD AMA-NEGATIVE Smooth-POSITIVE*
IMAGING:
MRI LIVER W/ WO CONTRAST:
IMPRESSION:
2.6 cm avidly arterially enhancing mass with rapid washout just
superior to the middle of attic vein, predominantly in segment
4A but also in segment 8 is consistent with hepatocellular
carcinoma (OPTN class 5B). No additional liver lesions
identified. Patent portal vein. Conventional hepatic arterial
anatomy.
Stable appearance of left pleural effusion and large volume
ascites. No
splenomegaly. There are esophageal varices.
5 mm pancreatic tail cystic lesion is likely a side branch IPMN.
No further follow-up is indicated in a patient of this age
without symptoms or increased risk for pancreatic cancer.
Cholelithiasis within folded gallbladder without evidence of
acute
cholecystitis.
TTE:
IMPRESSION: Moderate calcific aortic valve stenosis. Normal left
ventricular wall thickness, cavity size and
regional/global systolic fucntion. Mild mitral regurgitation.
Mild tricuspid regurgitation. Left pleural effusion is
present.
EGD:
Normal mucosa. No evidence of varices.
DISCHARGE LABS:
================
___ 05:55AM BLOOD WBC-6.1 RBC-3.82* Hgb-13.4* Hct-39.1*
MCV-102* MCH-35.1* MCHC-34.3 RDW-13.2 RDWSD-49.6* Plt ___
___ 05:55AM BLOOD ___ PTT-29.2 ___
___ 05:55AM BLOOD Glucose-112* UreaN-20 Creat-0.7 Na-139
K-4.0 Cl-98 HCO3-29 AnGap-12
___ 05:55AM BLOOD Albumin-2.3* Calcium-8.6 Phos-3.5 Mg-1.5*
Brief Hospital Course:
___ with history of atrial fibrillation on warfarin, aortic
stenosis, HTN, chronic back pain iso spinal stenosis,
depression, and alcohol abuse disorder who presents as a
transfer from ___ where he initially was evaluated i.s.o
increased falls and weakness at home, subsequently found to have
a liver mass concerning for new malignancy, also ascites and L
pleural effusion. MRI study was consistent with hepatocellular
carcinoma.
ACUTE ISSUES:
================
#HEPATOCELLULAR CARCINOMA:
Patient presented with liver mass concerning for evolving
malignancy, either primary
HCC vs. less likely metastatic disease. MRI liver results were
c/w HCC. Paracentesis was performed and cytology did not show
any malignant cells. EGD was done and was normal and wihtout
evidence of varices. Follow up was arranged with the
multidisciplinary liver tumor program.
#CIRRHOSIS WITH PLEURAL EFFUSION AND ASCITES:
#COAGULOPATHY:
On warfarin for pAF, he says that his INR has been difficult to
control over the past several months (often supratherapeutic)
suggestive of synthetic dysfunction. He presented with INR 4.2
and recieved vitamin K and home warfarin was held. Patient with
heavy EtOH history and evidence of cirrhosis on CT A/P. Large
ascites as well, no abdominal pain or fevers to suggest SBP.
Hepatitis serologies negative. EGD without evidence of varices.
Patient was started on Lasix 20mg/spironolactone 50mg for
ascites tis admission. At time of dicharge patient with TBili
1.5 / Cr 0.7 / INR 1.2 with MELD 10. Patient will need HAV/HBV
vaccines as transitional issue as outpatient.
#ALCOHOL USE DISORDER:
He did not score on CIWA. Continued vitamin supplementation.
#MACROCYTIC ANEMIA:
Secondary to underlying liver disease and EtOH abuse.
#GUAIAC POSITIVE STOOL:
Patient described self resolved diarrhea week prior to
admission, stools were
quite dark and Guaiac positive intially concerning for slow
upper GI bleed. He had no other
clinical signs of bleeding. No varices on EGD.
#COMPLICATED URINARY TRACT INFECTION:
UA at ___ consistent with UTI, patient denied any urinary
symptoms. Empirically treated with ceftriaxone and finished CTX
(last day ___ for ___ culture finalized
with >100,000 CFU ENTEROCOCCUS spp. Repeated UA showed small
leuks, few bacteria, 5 WBC.
#POSITIVE DRUG SCREEN:
Patient denies any history of opiate use, he was surprised by
the test results. Unclear if he received any opiates at ___
___.
CHRONIC ISSUES:
==========================
#ATRIAL FIBRILLATION:
- Rate control: held home Cardizem iso possible GIB, continued
home ___ restart cardizem for discharge.
- AC: Held home warfarin iso supratherapeutic INR, received VitK
as above, chads2vasc is 2 and so there is no indication to
bridge. His home warfarin was resumed and will need to be
titrated to INR goal ___.
#AORTIC STENOSIS:
Last TTE ___. Repeated on ___ showing moderate calcific aortic
stenosis with valve area 1.0-1.5 cm2.
#HYPERTENSION:
- Held home Cardizem/iso possible GIB restarted for discharge.
- Restarted home metoprolol as patient has BB withdrawal
tachycardia.
#DEPRESSION:
- Continued home cymbalta
CODE STATUS: DNAR/DNI
TRANSITIONAL ISSUES:
[ ] Patient will need HAV/HBV vaccines as outpatient.
[ ] INR on discharge 1.2 (goal ___. Patient will need repeat
INR daily until therapuetic with adjustement made to warfarin
dosing as necessary.
[ ] Patient initiated on diuretics this hospitalization, please
monitor electrolytes and volume status.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Warfarin 5 mg PO EVERY OTHER DAY
3. Cardizem CD 240 mg oral DAILY
4. DULoxetine 60 mg PO QAM
5. DULoxetine 30 mg PO QPM
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Spironolactone 50 mg PO DAILY
5. Thiamine 100 mg PO DAILY
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Cardizem CD 240 mg oral DAILY
8. DULoxetine 60 mg PO QAM
9. DULoxetine 30 mg PO QPM
10. Metoprolol Succinate XL 100 mg PO DAILY
11. Warfarin 5 mg PO EVERY OTHER DAY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hepatocellular carcinoma
Alcoholic liver cirrhosis
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 ___ because you were having falls,
becoming more weak, and a mass concerning for cancer was found
on your liver.
While you were in the hospital, you had an MRI of your liver
which showed liver cancer. You also had an EGD done which was
normal. You had a procedure called a paracentesis to remove
fluid called ascites from your abdomen.
When you leave the hospital, please review your upcoming doctor
appointments below along with your medication list for any
changes.
It was a pleasure caring for you!
Your ___ team
Followup Instructions:
___
|
19745809-DS-3
| 19,745,809 | 24,242,993 |
DS
| 3 |
2150-04-06 00:00:00
|
2150-04-06 19:55:00
|
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:
None
attach
Pertinent Results:
ADMISSION LABS
===============
___ 12:00PM BLOOD WBC-8.9 RBC-3.20* Hgb-10.0* Hct-30.5*
MCV-95 MCH-31.3 MCHC-32.8 RDW-14.4 RDWSD-49.0* Plt ___
___ 12:00PM BLOOD Neuts-77.8* Lymphs-10.4* Monos-9.9
Eos-0.7* Baso-0.2 Im ___ AbsNeut-6.89* AbsLymp-0.92*
AbsMono-0.88* AbsEos-0.06 AbsBaso-0.02
___ 03:44PM BLOOD ___ PTT-30.2 ___
___ 12:00PM BLOOD Glucose-203* UreaN-24* Creat-1.3* Na-128*
K-5.5* Cl-96 HCO3-22 AnGap-10
___ 12:00PM BLOOD ALT-111* AST-116* AlkPhos-142*
TotBili-0.9
___ 12:00PM BLOOD Albumin-2.9* Calcium-8.8 Phos-3.6 Mg-1.9
DISCHARGE LABS
===============
___ 06:19AM BLOOD WBC-6.8 RBC-3.49* Hgb-10.6* Hct-33.7*
MCV-97 MCH-30.4 MCHC-31.5* RDW-14.7 RDWSD-51.0* Plt ___
___ 06:19AM BLOOD ___ PTT-35.8 ___
___ 06:19AM BLOOD Glucose-149* UreaN-16 Creat-1.0 Na-135
K-5.0 Cl-100 HCO3-23 AnGap-12
___ 06:19AM BLOOD ALT-66* AST-66* AlkPhos-131* TotBili-1.3
___ 06:19AM BLOOD Albumin-3.3* Calcium-9.0 Phos-3.3 Mg-1.8
IMAGING STUDIES
================
CXR ___
Small left and trace right bilateral pleural effusions. Patchy
opacities in lung bases may reflect atelectasis though infection
is difficult to exclude in the correct clinical setting.
LEFT SHOULDER XRAY ___. No acute fracture or dislocation.
2. Moderate acromioclavicular and mild glenohumeral joint
degenerative changes.
3. Minimal periarticular calcifications suggestive of calcific
tendinopathy.
NCHCT ___
No acute intracranial process
CT A/P w/ contrast ___. Expected post ablation changes within the liver with
increased moderate volume nonhemorrhagic perihepatic ascites.
2. No acute intra-abdominal process.
3. Stable moderate left and new small right pleural effusion
with associated bibasilar atelectasis.
MICROBIOLOGY
==============
URINE CULTURE NEGATIVE
BLOOD CULTURES NGTD
Brief Hospital Course:
___ year old man with afib (on warfarin), aortic stenosis, HTN,
spinal stenosis and liver cirrhosis decompensated by portal
hypertension in the form of ascites/pleural effusion and
multifocal HCC now s/p recent thermal ablation who presents with
visual/tactile hallucinations c/f possible HE vs. medication
side effects.
TRANSITIONAL ISSUES:
====================
[] Duloxetine -- may accumulate in patients with hepatic
dysfunction. Consider tapering.
[] Continue to monitor for hallucinations and consider
neurologic evaluation if they persist despite treatment of his
hepatic encephalopathy.
[] Spironolactone was held for ___ on presentation. Furosemide
was continued. This diuretic regimen should continue to be
reassessed based on labs and volume status.
ACUTE ISSUES:
=============
# Visual/Tactile Hallucinations
Pt presented w/ increasing confusion and hallucinations s/p
recent thermal ablation. Head imaging and neuro exam
unremarkable. Concerning for hepatic encephalopathy given
constipation in the last week and improvement with starting
lactulose. Also considered medication side effect (Robitussin,
duloxetine. Duloxetine may have accumulated given hepatic
dysfunction. His symptoms improved with increased stooling and a
mild decrease in the dose of his duloxetine (from 60mg qAM and
30mg qPM to 30mg BID). Continuing to taper this medication can
be considered by his outpatient providers.
# EtoH Cirrhosis - MELD 22
Patient had 2 prior para in ___, 5L and 2 L, 1x thoracentesis
on low dose diuretics, no history of varices, no SBP or previous
HE. Per CT scan on ___ there was expected post ablation
changes within the liver with increased moderate volume
nonhemorrhagic perihepatic ascites. No gastric or esophageal
varices on ___. Worsening LFTs likely secondary to
ablation, now improving. Infectious workup negative. Continuing
rifaximin 550mg PO BID, lactulose TID titrate to ___ BMs/day.
#Localized HCC
He was diagnosed with 2.6cm HCC in ___ S/P ablation to seg 4
on ___ and s/p microwave ablation of 3 hepatic lesions in
segment VII and IV A + paracentesis of
approximately 50 cc of serosanguineous perihepatic ascites on
___. Most recent MRI from ___ showing 4 lesions, 2
of which HCC size 1cm and 1.1cm and 2 suspicious lesions less
than cm. In addition there is intrahepatic ductal dilation
likely ___ prior intervention. CT chest without concerning lung
lesions.
# Hyponatremia - resolved. Thought to be secondary to
hypovolemia, improved with IV albumin.
# ___ on CKD - resolved. Most likely in setting of poor PO
intake, improved after 75g albumin on admission.
CHRONIC ISSUES:
===============
# Lt pleural effusion, diagnostic thoracentesis done in ___:
transudate, negative cytology. Cardiac vs hepatic origin. Per
CXR on ___, small left and trace right bilateral pleural
effusions. No respiratory distress during this admission.
# Atrial fibrillation
- Rate control: Continued home dilt 120mg ER, metoprolol
succinate 25mg PO daily
- AC: warfarin (4.5mg daily)
# Aortic stenosis
Last TTE ___ with moderate calcific aortic stenosis with
valve area 1.0-1.5 cm2.
- Per last cards note, patient will be seen in ___ for
re-evaluation and will likely proceed with AVR at that time
# Depression
- Duloxetine taper per above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Metoprolol Succinate XL 25 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Spironolactone 25 mg PO DAILY
7. Thiamine 100 mg PO DAILY
8. Warfarin 4.5 mg PO Frequency is Unknown
9. Diltiazem Extended-Release 120 mg PO DAILY
10. DULoxetine ___ 60 mg PO DAILY
11. DULoxetine ___ 30 mg PO QHS
12. GuaiFENesin-Dextromethorphan 10 mL PO Q4H:PRN cough
13. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
14. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
15. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Third
Line
16. Fleet Enema (Saline) 1 Enema PR Q72HR PRN constipation
Discharge Medications:
1. Lactulose 30 mL PO TID
2. rifAXIMin 550 mg PO BID
3. DULoxetine ___ 30 mg PO BID
4. Warfarin 4.5 mg PO DAILY16
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Fleet Enema (Saline) 1 Enema PR Q72HR PRN constipation
9. FoLIC Acid 1 mg PO DAILY
10. Furosemide 20 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Third
Line
13. Multivitamins 1 TAB PO DAILY
14. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=====================
HEPATIC ENCEPHALOPATHY
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 ___ from ___.
WHY WERE YOU ADMITTED?
========================
- You were admitted because you were seeing things that others
weren't.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
==============================================
- We started medications to remove toxins from your body (that
are caused by your liver disease).
- We stopped some medications.
WHAT SHOULD YOU DO AFTER YOU LEAVE THE HOSPITAL?
=================================================
- Take all of your medications as prescribed.
- Follow up with your doctors as listed below.
It was a pleasure caring for you!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19746177-DS-19
| 19,746,177 | 26,998,922 |
DS
| 19 |
2169-11-08 00:00:00
|
2169-11-10 14:21:00
|
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Diplopia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old man with mitral valve repair, HLD,
prior episode of amurosis fugax, usually on plavix but
non-compliant for the past 5 days, presenting for evaluation of
transient double vision.
The patient works in ___ 5 days per week so is
frequently
traveling back and forth between ___ and ___. He ran out of
his
plavix 5 days ago and was not able to get this renewed yet due
to
his travel schedule. Today he was working remotely from ___,
and went to ___ to work. At 10 AM he was typing an email
on
his computer when he experienced sudden onset of double vision.
He describes that he saw two computer screens horizontally
doubled, with one slightly higher than the other (skew
deviation), and slightly outwardly rotated from each other. He
thinks the R image was slightly higher than the L. He tried
covering each eye and his monocular vision was normal in both
eyes, but he continued to have binocular diplopia with both eyes
open. This lasted for 4 minutes and then spontaneously
resolved.
He walked briskly home (without any gait unsteadiness) and took
his plavix immediately, then came to the ED. Code stroke was
called in the ED and NIHSS = 0.
The patient had a heart valve repair ___ years ago. He does not
know the details but states this occured at ___. He thinks it was his mitral valve which was repaired
"with my own tissues" and thinks there was ___ mechanical
component to the valve. He was on coumadin for 3 months of after
the surgery. During that time, he had 1 episode of L eye
altitiduinal visual field loss lasting for a breif moment, and
was told this was a TIA which resolved. He was unable to keep a
therapeutic INR on coumadin, needing to get his labs drawn every
other day at one point. He was switched to plavix and aspirin at
that time, it was unclear if this was because of his labile INR
or a planned switch. Later, he started to have frequent
nosebleeds, so was switched to plavix only, which he has taken
for some time. However, he ran out of this 5 days ago (See
above).
Past Medical History:
PMH/PSH:
- HLD
- mitral valve repair
- prior episode of L ameurosis fugax while on plavix
Social History:
___
Family History:
Father with CABG, sister with MS. ___ strokes in the family.
Physical Exam:
Normal exam upon discharge
General: NAD, lying in bed comfortably.
Head: NC/AT, ___ icterus, ___ oropharyngeal lesions
Neck: Supple, ___ nuchal rigidity, ___ meningismus, ___
carotid/subclavian/vertebral bruits
Cardiovascular: RRR, distant heart sounds
Neurologic Examination:
- Mental Status -
Awake, alert. Attentive to examiner and able to relate history
without difficulty. Speech is fluent, able to describe stroke
card well, name all stroke objects, follow commands. ___
dysarthria. ___ evidence of hemineglect.
- Cranial Nerves -
I. not tested
II. Equal and reactive pupils (5mm to 3mm). Visual fields were
full to finger counting, finger wiggling, and red desaturation.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus.
V. facial sensation was intact, muscles of mastication with full
strength
VII. face was symmetric with full strength of facial muscles
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
Muscule bulk and tone were normal. ___ pronation, ___ drift. ___
tremor or asterixis.
Delt Bic Tri ECR Fext Fflx IP Quad Ham TA Gas
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
Intact to light touch throughout with ___ extinction to DSS.
- DTRs -
Bic Tri ___ Quad Gastroc
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response flexor bilaterally.
- Cerebellar -
___ dysmetria with finger to nose or HTS testing bilaterally.
- Gait -
Normal stance and stride
Pertinent Results:
___ 04:50AM BLOOD WBC-7.6 RBC-4.63 Hgb-13.2* Hct-40.6
MCV-88 MCH-28.5 MCHC-32.5 RDW-12.8 RDWSD-40.6 Plt ___
___ 04:50AM BLOOD ___ PTT-29.8 ___
___ 04:50AM BLOOD Glucose-89 UreaN-19 Creat-1.2 Na-141
K-4.0 Cl-103 HCO3-28 AnGap-14
___ 01:54PM BLOOD ALT-85* AST-46* AlkPhos-55 TotBili-0.7
___ 04:50AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:50AM BLOOD %HbA1c-6.1* eAG-128*
___ 04:50AM BLOOD Triglyc-145 HDL-47 CHOL/HD-3.1 LDLcalc-69
___ 04:50AM BLOOD TSH-5.7*
HCHCT/CTA (___): ___ acute intracranial pathology. Vessels
clean. Prominent left posterior communicating artery. Left
vertebral artery originates from the aorta. Bovine arch.
Brain MRI (___): Unremarkable except for paranasal sinus
disease.
TTE (___): Mildly dilated LA, EF normal, ___ interatrial shunt
despite agitated saline injection, Well-seated mitral
annuloplasty ring with normal transvalvular gradients
Brief Hospital Course:
#Neuro: Patient was admitted to ___ stroke service given
transient horizontal diplopia x4min, with resolution of symptoms
in the hospital. Imaging was negative for acute infarct, with
subsequent diagnosis of TIA of cryptogenic etiology. TTE showed
___ evidence of interatrial shunt and intact mitral
valvuloplasty.
The patient's antithrombotic regimen on admission was:
-Clopidogrel 75mg daily
For discharge, he was continued on Clopidogrel 75mg daily
Discharge exam notable for: benign exam
Risk factor labs: TSH 5.7 (high) ; HbA1c 6.1 (pre-DM) ; LDL 69
on statin
#CV: Telemetry was unremarkable. Home metoprolol was continued.
#Transitional Issues:
-Outpatient SBP goal <140
-Encourage weight loss and improved nutrition given pre-diabetic
status as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. Metoprolol Succinate XL 100 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Atorvastatin 40 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
TIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of double vision
resulting from a possible TRANSIENT ISCHEMIC ATTACK (TIA), a
condition where a blood vessel providing oxygen and nutrients to
the brain is briefly 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.
TIAs 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 cholesterol
We are not changing your medications. Please take your other
medications as prescribed. The Plavix will decrease your risk of
future stroke.
Please followup with Neurology and your primary care physician
as listed below.
It was a pleasure meeting you!
Your ___ Neurology Team
Followup Instructions:
___
|
19746404-DS-7
| 19,746,404 | 27,200,743 |
DS
| 7 |
2173-08-29 00:00:00
|
2173-08-29 17:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right leg swelling and pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M PMH NIDDM, HTN, CKD presenting with RLE deep venous
thrombosis. Patient states that 1 week ago he developed right
calf pain which resolved in ___ days. He states that pain
returned in his right medial thigh yesterday. He went to the PCP
today and had an US showing a R thigh DVT. Patient referred here
for eval. Patient denies chest pain or shortness of breath. He
states he has had a dry cough for one week. He denies fevers or
chills. He denies lightheadedness. Patient denies ever having
"clot" before. Has been sedentary for 2 weeks in between jobs.
Mother had blood clot at ___ yo.
In the ED, initial vitals were:
Temp. 98.0, HR 65, BP 155/77, RR 18, 100% RA
Exam notable for CTAB, RRR, abdomen soft, RLE swollen with mild
erythema and ttp
Labs notable for: CBC within normal limits. Chemistry notable
for potassium of 2.8.
Imaging notable for:
1. Extensive acute deep venous thrombosis involving the right
calf veins, popliteal vein, and femoral vein extending to the
level of the upper thigh.
2. No evidence of deep venous thrombosis in the left lower
extremity veins.
Patient was given: IV heparin and 40 mEQ potassium x2
VS on transfer: 70 143/70 24 98% RA
On the floor, the patient reports persistent pain in RLE and
non-productive cough. He denies chest pain, dyspnea.
Review of systems: (+) Per HPI, all other ROS otherwise negative
up imaging.
Past Medical History:
Asthma
Type II Diabetes
Hyperlipidemia
Hypertension
Obesity
GERD
Atypical Chest Pain
CKD
Recurrent UTI
Social History:
___
Family History:
Mother: DM, HTN, DVT ___ yo)
Father: MI (___), glaucoma
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 98.3 BP 168/76 HR 75 18 95 RA
Gen: well appearing, no acute distress
HEENT: JVP not visualized
CV: RRR, nl S1 S2, no murmurs/rubs/gallops
Pulm: clear to auscultation bilaterally, no wheeze/rales/rhonchi
Abd: soft, NT, ND, NABS
GU: no foley
Ext: WWP, 1+ edema on RLE > LLE, TTP on medial knee
Skin: no rash
Neuro: CN ___ grossly intact, moving all extremities
spontaneously
Psych: normal mood and affect
DISCHARGE PHSYCIAL EXAM:
========================
VS: T 98.3, BP 155/76, HR 70, RR 20, O2 94% RA
GENERAL: NAD, alert, interactive
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation bilaterally, otherwise no w/r/r
HEART: RRR, normal S1/S2, no MRG
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP, RLE without notable swelling, edema, or
erythema; moderate TTP of R posterior upper calf with normal
sensation & motor function of RLE..
NEURO: awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
===============
___ 11:13PM ___ PO2-41* PCO2-42 PH-7.28* TOTAL
CO2-21 BASE XS--6
___ 11:13PM LACTATE-1.6
___ 03:50PM estGFR-Using this
___ 03:50PM estGFR-Using this
___ 03:50PM cTropnT-<0.01 proBNP-38
___ 03:50PM WBC-7.1 RBC-5.01 HGB-14.3 HCT-44.1 MCV-88
MCH-28.5 MCHC-32.4 RDW-12.7 RDWSD-40.5
___ 03:50PM NEUTS-58.5 ___ MONOS-11.1 EOS-3.8
BASOS-0.8 IM ___ AbsNeut-4.18 AbsLymp-1.82 AbsMono-0.79
AbsEos-0.27 AbsBaso-0.06
___ 03:50PM PLT COUNT-154
___ 03:50PM ___ PTT-32.8 ___
DISCHARGE LABS:
==============
___ 06:24AM BLOOD WBC-7.4 RBC-4.69 Hgb-13.7 Hct-41.3 MCV-88
MCH-29.2 MCHC-33.2 RDW-12.9 RDWSD-41.2 Plt ___
___ 06:24AM BLOOD Plt ___
___ 06:24AM BLOOD PTT-31.0
___ 06:24AM BLOOD Glucose-181* UreaN-36* Creat-1.6* Na-143
K-5.1 Cl-105 HCO3-21* AnGap-22*
___ 06:24AM BLOOD Calcium-10.2 Phos-4.0 Mg-1.9
___ 06:24AM BLOOD
IMAGING:
=======
BILAT LOWER EXT VEINS ___. Extensive acute deep venous thrombosis involving the right
calf veins,
popliteal vein, and femoral vein extending to the level of the
upper thigh.
2. No evidence of deep venous thrombosis in the left lower
extremity veins.
CTA CHEST ___. Multiple bilateral pulmonary emboli without CT evidence of
right heart
strain or signs of infarction.
2. Small pulmonary nodules which are size stable from ___ CT,
requiring no additional followup imaging.
ECHOCARDIOGRAM ___
IMPRESSION: Suboptimal image quality. Mild right ventricular
cavity dilatation with preserved contractile function. Mild
pulmonary hypertension. Mild symmetric left ventricular
hypertrophy with preserved regional/global systolic function.
Mild aortic regurgitation. Thoracic aortic dilation.
Brief Hospital Course:
Patient is a ___ yo man with PMH of NIDDM, HTN, CKD who was
admitted ___ with RLE deep venous thrombosis c/b bilateral
pulmonary embolism.
# Acute Proximal RLE DVT and Acute Pulmonary Embolism:
Patient presented with RLE pain/swelling and was found to have
an extensive RLE DVT (involving femoral vein to upper thigh) and
multiple bilateral, asymptomatic PE. No evidence of R heart
strain on echo or BNP/troponin. Considered to be an unprovoked
thromboembolism, given lack of preceding trauma or surgery
leading to immobility. Received IV heparin for 24h ___ aft -
___ aft), reaching therapeutic PTT by ___ morning. Since
eGFR>30, started on rivaroxaban ___ morning, to be taken 15mg
BID for 3 wks followed by 15mg daily thereafter.
# Non-gap metabolic acidosis:
The patient had an asymptomatic metabolic acidosis with normal
anion gap for the duration of his hospitalization, likely from
impaired renal ammoniagenesis in the setting of CKD (although
his HCO3 has been wnl prior to this admission). HCO3 was
measured as 12 in the ED (___), but this may have been a
measurement error as it was the same blood sample that yielded a
Cr of 0.9 (below the pt's baseline Cr of ~1.5, and returning to
1.5-1.6 on subsequent measurements). After receiving IVF, VBG on
___ showed pH 7.28, pCO2 42, HCO3 21. Urine anion gap was +64
and the pt had no recent h/o diarrhea, thereby implicating a
renal etiology--more likely CKD than RTA in absence of hypo- or
hyperkalemia.
---------------
CHRONIC ISSUES:
---------------
# CKD (Cr 1.4-1.6): Electrolytes were monitored regularly,
nephrotoxins avoided.
# Asthma: without exacerbations during hospital course.
Continued PRN albuterol, held symbicort 80 mcg-4.5 mcg 1 inhaled
BID as NF.
# HTN: Pt never became hypotensive, but antihypertensives held
initially until RH strain r/o on echo and out of initial concern
for ___ (later thought just to be continuation of baseline Cr
from CKD). Resumed carvedilol after normal echo ___. SBP
peaked at 178 on ___ AM without symptoms; subsequently resumed
amlodipine & chlorthalidone once ___ ruled out. Did not restart
valsartan given K of 5.1 and wanting to avoid restarting too
many antihypertensives simultaneously.
# IDDM: held home glipizide and metformin, used Humalog insulin
sliding scale.
# HLD: continued home atorvastatin 20.
TRANSITIONAL ISSUES:
===================
# NEW MEDICATIONS: Xarelto (15 mg twice a day for 3 weeks until
___ and then decrease to 15 mg daily.)Dose renally adjusted
given GFR per discussion with pharmacy
# MEDICATIONS STOPPED: aspirin 81 mg given initiation of xarelto
as above, Valsartan 320 mg PO DAILY (iso slightly elevated Cr
1.6 and K 5.1 on discharge)
[] DVT/PE: Review age-appropriate cancer screening & consider
hypercoag workup as an outpatient.
[] Please check chem 7 before resuming valsartan at follow up on
___
[] Please consider outpatient hypercoagulable work-up
[] Please continue to discuss duration of anticoagulation. If no
clear provoking factor is found, should consider ongoing
lifelong anticoagulation
[] Please prescribe compression stockings 30 mmHg as outpatient.
# DISCHARGE Cr 1.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
5. Carvedilol 12.5 mg PO BID
6. Chlorthalidone 25 mg PO DAILY
7. ciclopirox 0.77 % topical BID
8. GlipiZIDE XL 10 mg PO DAILY
9. Valsartan 320 mg PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Rivaroxaban 15 mg PO BID
take twice daily until ___ then decrease to once daily with
dinner
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth twice a day
Disp #*51 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
3. amLODIPine 5 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
6. Carvedilol 12.5 mg PO BID
7. Chlorthalidone 25 mg PO DAILY
8. ciclopirox 0.77 % topical BID
9. GlipiZIDE XL 10 mg PO DAILY
10. HELD- Valsartan 320 mg PO DAILY This medication was held.
Do not restart Valsartan until told by your Cardiologist or PCP
___:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Proximal DVT
Pulmonary Embolism
Acute Kidney Injury
Secondary Diagnosis;
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were in the hospital because you had clots in your legs. You
had imaging of your lungs which showed you also had clots in
your lungs. You were given a medicine to help prevent clot
formation. You can resume regular activity as long as you do not
have symptoms of shortness of breath, dizziness, chest pain, or
feeling lightheaded. Please do not undergo any prolonged travel
with immobility in the next month as your body recovers from
these blood clots.
Now that you are going home, please take your Xarelto exactly as
prescribed. It is important to take this medication with food.
This medicine is very important in preventing future clots.
Please seek medical care immediately if you have recurrence of
symptoms or sudden onset of bleeding.
Please do not take any medications that increase risk of
bleeding including aspirin or NSAIDs such as ibuprofen.
Please follow-up with your PCP and cardiologist. These
appointments have been scheduled for you!
We wish you the best!
- Your ___ Team
Followup Instructions:
___
|
19746404-DS-8
| 19,746,404 | 20,506,630 |
DS
| 8 |
2174-10-16 00:00:00
|
2174-10-16 13:51:00
|
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 trimalleolar ankle fracture
Major Surgical or Invasive Procedure:
Open reduction internal fixation of left ankle fracture ___,
___
History of Present Illness:
___ year old male with history of DVT/PE on Xarelto, DM2, HLD
presenting with a left ankle fracture s/p slip and fall on black
ice earlier tonight. Denies HS/LOC. Denies pain in other
extremities. Denies n/t in the left foot.
Past Medical History:
ASTHMA
DIABETES TYPE II
HYPERLIPIDEMIA
HYPERTENSION
OBESITY
GASTROESOPHAGEAL REFLUX
CHRONIC KIDNEY DISEASE
DEEP VENOUS THROMBOPHLEBITIS
PULMONARY EMBOLISM
DYSPNEA
COUGH
H/O RIGHT LATERAL ___
H/O COLONIC ADENOMA
H/O DIPLOPIA
H/O RECURRENT PNEUMONIA
H/O RECURRENT URINARY TRACT INFECTION
H/O ATYPICAL CHEST PAIN
H/O BENIGN POSITIONAL VERTIGO
Social History:
___
Family History:
non-contributory
Physical Exam:
Vitals:
___ 0449 Temp: 98.5 PO BP: 148/67 R Sitting HR: 85 RR: 16
O2
sat: 96% O2 delivery: Ra
General: Well-appearing, breathing comfortably
MSK:
LLE:
In splint
Fires ___, FHL
Sensation intact over exposed toes
WWP
Pertinent Results:
___ 06:20AM BLOOD WBC-6.6 RBC-4.07* Hgb-12.0* Hct-37.3*
MCV-92 MCH-29.5 MCHC-32.2 RDW-13.2 RDWSD-44.5 Plt ___
___ 06:20AM BLOOD Glucose-343* UreaN-39* Creat-1.6* Na-140
K-4.9 Cl-103 HCO3-22 AnGap-15
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 trimalleolar 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 was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the left lower extremity, and will be
discharged on his home xarelto 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. Omeprazole 20 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough, sob
3. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
4. amLODIPine 5 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Carvedilol 12.5 mg PO BID
7. Chlorthalidone 25 mg PO DAILY
8. ciclopirox 0.77 % topical daily rash
9. Desonide 0.05% Cream 1 Appl TP TID rash
10. GlipiZIDE XL 10 mg PO DAILY
11. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
12. PredniSONE 40 mg PO DAILY asthma flare
13. Valsartan 320 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth q8hr Disp #*80
Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth q4hr
Disp #*30 Tablet Refills:*0
4. Rivaroxaban 20 mg PO DAILY
5. Senna 8.6 mg PO BID constipation
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tablet by
mouth twice a day Disp #*60 Tablet Refills:*0
6. Tamsulosin 0.4 mg PO DAILY
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough, sob
8. amLODIPine 5 mg PO DAILY
9. Atorvastatin 20 mg PO QPM
10. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
11. Carvedilol 12.5 mg PO BID
12. Chlorthalidone 25 mg PO DAILY
13. ciclopirox 0.77 % topical daily rash
14. Desonide 0.05% Cream 1 Appl TP TID rash
15. GlipiZIDE XL 10 mg PO DAILY
16. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
17. Omeprazole 20 mg PO DAILY
18. PredniSONE 40 mg PO DAILY asthma flare
19. Valsartan 320 mg PO DAILY
20.Standard manual wheelchair
Rx: Standard Manual wheelchair with seat back cushion, elevating
leg rests, anti tip, break extensions
Dx: Left ankle fracture
Px: Good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left trimalleolar ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing to the left lower extremity in a splint
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take your home Xarelto
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. ___,
in 2 weeks. Call ___ to schedule appointment upon
discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Physical Therapy:
nonweightbearing to the left lower extremity in a splint
Treatments Frequency:
Please keep splint in place until the followup appointment.
Sutures to remain for at least two weeks postoperatively.
Please keep splint dry. If you have any concerns regarding the
splint, please call the clinic at the number provided.
Followup Instructions:
___
|
19746570-DS-5
| 19,746,570 | 22,642,752 |
DS
| 5 |
2123-02-24 00:00:00
|
2123-03-06 15:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
meperidine
Attending: ___
Chief Complaint:
Fall
Mild TBI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ female on Plavix for cardiac stents who
presents to ___ on ___ with a mild TBI. Patient
was walking in her neighbor's driveway when she tripped and
fell,
striking her head. Denies LOC. Was able to get up herself and
presented to OSH ED with R forehead laceration. NCHCT was
performed which showed small L frontal SAH. The patient was
transferred to ___ for further evalution.
Past Medical History:
HTN
HLD
Cardiac stent x ___ yrs on Plavix
Social History:
___
Family History:
N/A
Physical Exam:
Exam on admission:
O: T: 98.1 BP: 126/80 HR: 71 RR: 18 O2 Sat: 100% RA
GCS at the scene: 15
GCS upon Neurosurgery Evaluation:
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: R forehead laceration with DSD
Neck: Supple
Extrem: warm and well perfused
Neuro:
Mental Status: Awake, alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech is fluent with good comprehension.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
3mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Exam on discharge:
___ x 3. NAD. PERRLA. CN II-XII intact.
LS clear.
RRR.
Abdomen soft, NTND.
___ BUE and BLE. No drift.
Pertinent Results:
___ Head CT
Two smaqll foci of hyperdense tSAH within the left frontal lobe
without mass effect or MLS. She show mild redistribution and no
interval increase in the size of hemorrhage.
Brief Hospital Course:
#Fall/Mild TBI/tSAH:
___ yo patient presents after a trip and fall. Heac CT at OSH
showed small tSAH in the left frontal lobe. She was
Neurologically intact with GCS of 15. Her exam was stable on ED
evaluation and she was admitted to the floor given her history
of Plavix use. Repeat CT is stable as is her exam. She was
discharged home on ___. She may restart Plavix on ___.
Medications on Admission:
Atorvastatin 80mg daily
Plavix 75mg daily
diltiazem ER (dose unknown)
Lisinopril 10mg daily
Metoprolol 125mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Atorvastatin 80 mg PO QPM
3. Diltiazem Extended-Release 300 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Tartrate 100 mg PO BID
6. Plavix 75mg daily - may restart this medication on ___
Discharge Disposition:
Home
Discharge Diagnosis:
Traumatic Subarachnoid Hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage without Surgery
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 may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
19746907-DS-9
| 19,746,907 | 28,501,892 |
DS
| 9 |
2195-07-09 00:00:00
|
2195-07-11 10:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye / Keflex / heparin / Compazine
/ Darvon
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD, colonoscopy
History of Present Illness:
___ presents with h/o breast ca s/p bilateral mastectomy,
cervical cancer s/p hysterectomy, multiple abdominal surgeries
including CCY, appy, Hx, stab wound s/p bowel resection p/w
acute on chronic abdominal pain. She has had ongoing chronic
abdominal pain which acutely worsen approximately 3 days prior
to presentation. The pain is primarily located in the
epigastrium and LUQ with p.o. intake. At baseline, she also has
suprapubic and RLQ pain. It occasionally radiates to her back.
Her abdominal pain is exacerbated by p.o. intake. She reports
painful defecation, and some transient relief of the pain after
BM. Diarrhea a/w eating for the last few days plus on and off
for several years, some stool incontinence, reports seeing
undigested food. She notes one episode of grossly blood stools
with clots several months ago, none since, per pt report has
been anemic in the past. She avoids hot and acidic foods, which
exacerbate the pain. Denies lactose intolerance sx. Has a
associated nausea, no vomiting but no F/C, CP, SOB. Reports a
50lb weight loss over the last several months a/w decreased
appetite. Her workup to this point has included EGD, ___ and
___ study per pts report, as well as some imaging (pt unclear
on details).
She was treated at ___ approximately 3 month
prior to presentation with an ERCP for chronic abdominal pain,
procedure was complicated by pancreatitis. She reports a
"bacterial instestinal infection" ___ year ago after returning
from a trip to ___.
In the ED, initial vitals: 98 106 166/96 20 100% ra. Guiac was
negative. Labs were without abnormalities including lipase,
LFTs, WBC, Hct, albumnin. GI was consulted in ED, decided no
urgent need for cross-sectional imaging. She received 5mg IV
morhpine x2 for pain.
On arrival to the floor she is tearful and complains of
abdominal pain. She is accompanied by her husband.
Past Medical History:
Anxiety
Depression
Domestic violence
bilateral TRAM flap reconstructions ___ Dr. ___ pancreatitis (ERCP for sphincter of Oddi dysfunction
with Dr. ___ ___.
Interstitial cystitis
Back surgery - disc fusion ___ years ago
Breast cancer, per pt noninvasive, but required bilateral
mastectomy
Cervical cancer, per pt treated with hysterectomy, pap smears
reportedly UTD and negative.
Divirticulitis s/p partial colectomy.
GERD, ___ esophagus
Social History:
___
Family History:
Mother: lung cancer, ? IBS, DM
Grandmother: lung cancer
Sister, Brother: DM
Does not know father's ___
Physical ___:
ADMISSION EXAM
Vitals- 98.4 70 ___ 97% RA Pain ___
General- Alert, oriented, in pain, at times tearful, accompanied
by husband
___ 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- TTP diffusely, most prominently in LUQ, RLQ, suprapubic
region. Rebound tenderness in RLQ. NT/ND. Palpable peristalsis,
hyperactive bowel sounds. No organomegaly.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Face symmetric, motor function grossly normal
DISCHARGE EXAM
Vitals- 98.1 97.2 116/61 63 18 99%RA
General- Alert, oriented, in visible discomfort
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- TTP diffusely, most prominently in LUQ, RLQ, suprapubic
region. Mild rebound tenderness in RLQ. NT/ND. Hyperactive bowel
sounds. No organomegaly.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Face symmetric, motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 12:30PM GLUCOSE-99 UREA N-9 CREAT-0.8 SODIUM-138
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-27 ANION GAP-15
___ 02:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 12:30PM ALT(SGPT)-9 AST(SGOT)-17 LD(LDH)-175 ALK
PHOS-86 TOT BILI-0.2
___ 12:30PM LIPASE-16
___ 12:30PM ALBUMIN-4.6 CALCIUM-8.8 PHOSPHATE-3.2
MAGNESIUM-2.0
___ 12:30PM WBC-7.5 RBC-4.80 HGB-14.3 HCT-43.5 MCV-91
MCH-29.7 MCHC-32.8 RDW-13.8
___ 12:30PM NEUTS-62.2 ___ MONOS-3.1 EOS-2.2
BASOS-0.5
___ 12:30PM PLT COUNT-155
DISCHARGE LABS
___ 09:11AM BLOOD Folate-GREATER TH
___ 04:50PM BLOOD CA125-8.6
C. difficile DNA amplification assay (Final ___: Negative
for toxigenic C. difficile by the Illumigene DNA amplification
assay.
___ 10:03 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
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.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ 4:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
IMAGING STUDIES
Abdominal Xray ___:
FINDINGS: AP supine and upright views of the abdomen were
obtained. There is a non-obstructive bowel gas pattern. No
large air-fluid levels are seen. There is no evidence of free
air. There is high-density material within the pelvis, which
appears to be intraluminal which may be within small bowel from
a recent prior ingestion/study. The lung bases are clear.
Degenerative changes are seen along the spine with lateral
osteophyte formation at at least L4/L5 and L2/L3.
IMPRESSION: No evidence of bowel obstruction or free air.
High-density
material in what appears to be loops of small bowel in the
pelvis may be from recent prior contrast study.
Transvaginal ultrasound ___:
The patient is status post hysterectomy and left oophorectomy.
The right ovary
is not definitely visualized. No adnexal masses are seen. The
urinary bladder
is partially filled and appears unremarkable. There is no pelvic
free fluid.
IMPRESSION:
1. Status post hysterectomy and left oophorectomy.
2. Nonvisualized right ovary. No adnexal masses.
MRI ABDOMEN W/O & W/CONTRAST Study Date of ___ 5:06 ___
MRI ABDOMEN: The liver is normal in signal intensity, aside from
a small area of focal fat adjacent to the falciform ligament.
Mild intra and extrahepatic bile duct dilation predominant in
the left hepatic lobe is noted in this patient post
cholecystectomy. Pneumobilia within the bile ducts, relates to
prior sphincterotomy. No intraductal obstructing stones are
seen. The adrenal glands and spleen are normal. The pancreas is
normal. Both kidneys are unremarkable, without hydronephrosis or
renal masses. No pathologic retroperitoneal or mesenteric
lymphadenopathy seen. Mild abdominal aortic atherosclerosis is
seen, without aneurysmal dilation. The celiac trunk, superior
mesenteric and bilateral renal arteries are patent. Incidental
more note is made of retroaortic left renal vein. The portal,
splenic and superior mesenteric veins are patent.
The stomach, small and large bowel loops are unremarkable,
except for a
moderate size duodenum diverticulum. The ascending and
transverse colon are decompressed with a redundant transverse
colon. Few scattered diverticula are seen, without evidence of
active diverticulitis.
MRI PELVIS: The urinary bladder is decompressed and appears
unremarkable.The rectum and sigmoid colon normal. The patient is
status post hysterectomy. No adnexal masses are seen. No pelvic
free fluid or adenopathy seen.
There is mild S-shaped scoliosis of lumbar spine. Mild
degenerative changes are seen at L4-L5 and L5-S1 levels.
Extensive postsurgical changes are seen in the anterior
abdominal/ pelvic wall. Focal area of thinning or defect is seen
in the midline anterior pelvic wall (14:41), without evidence of
a ventral hernia.
IMPRESSION:
No acute abdominal or pelvic pain to explain the patient's
symptoms.
SCOPES:
EGD ___:
Irregular z-line in the GEJ (biopsy)
Linear erythema and erosions in the antrum compatible with
erosive gastritis (biopsy, biopsy)
Otherwise normal EGD to third part of the duodenum
Gastrointestinal mucosal biopsies from EGD ___:
1. Gastroesophageal junction:
- Cardiac-type mucosa, within normal limits.
- No squamous mucosa or intestinal metaplasia seen.
2. Body:
- Corpus mucosa, within normal limits.
3. Antrum:
- Antral mucosa with prominent regeneration of gastric pits,
most
consistent with a chemical-type gastropathy, and focal
intestinal
metaplasia.
- Immunohistochemical stain for Helicobacter will be performed
and
reported in a revised report.
Colonoscopy ___:
Diverticulosis of the sigmoid colon. Normal mucosa in the whole
colon. There was no evidence of colitis. Otherwise normal
colonoscopy to cecum.
Colonic mucosal biopsies, six:
1. Cecum:
Colonic mucosa with no diagnostic abnormalities recognized.
2. Ascending colon:
Colonic mucosa with no diagnostic abnormalities recognized.
3. Transverse colon:
Colonic mucosa with no diagnostic abnormalities recognized.
4. Descending colon:
Colonic mucosa with no diagnostic abnormalities recognized.
5. Sigmoid colon:
Colonic mucosa with no diagnostic abnormalities recognized.
6. Rectum:
Colonic mucosa with no diagnostic abnormalities recognized.
Brief Hospital Course:
Mrs. ___ is a ___ year old woman with a history of multiple
abdominal surgeries including a cholecystectomy, appendectomy,
hysterectomy with left oopherectomy, and a stab wound status
post partial bowel resection who presented with acute on chronic
abdominal pain. She presented with new severe right
lower-quadrant and suprapubic abdominal pain, worse with eating,
on top of chronic epigastric pain and diarrhea. Workup here
included abdominal MRI, esophagoduodenoscopy, colonoscopy,
transvaginal ultrasound, fecal cultures and c-diff testing. The
EGD revealed erosive gastritis, abdominal MRI showed possible
mild colitis but colonoscopy was unremarkable except for mild
diverticulosis. The workup did not identify any abnormalities to
account for her pain. The cause of her pain remains unclear, but
our differential includes potential mild hernia, abdominal
adhesions from prior surgeries, small intestinal bacterial
overgrowth or irritable bowel syndrome. Reportedly, she had a
negative workup at an outside hospital for celiac disease as
well as unrevealing colonoscopies, abdominal CTs and a pill
endoscopy study within the last few years.
ACTIVE ISSUES
# Abdominal pain: Pt presented with acute RLQ/suprapubic pain on
chronic epigastric pain, possibly multifactorial. IBS seems
possible given diarrhea, although she has tried dicyclomine in
the past without improvement. H/o abdominal surgeries suggest
adhesions or possibly incisional hematoma. Stool cultures were
negative for C diff or bacterial colitis. Ischemic colitis
unlikely with lactate 0.7 and no known atherosclerotic risk
factors or comorbidities. She has a history or pancreatitis
___, but lipase non-elevated. Given h/o breast and
cervical cancer, mets were considered, but none were seen on
MRI. CA-125 non-elevated. On speculum exam, no discharge,
cystocele or other abnormality, bimanual deferred due to extreme
tenderness to suprapubic palpation. MRI, colonoscopy with
biopsies and TVUS did not show clear cause of RLQ pain. We
ultimately did not identify the cause of her pain. Her pain was
treated with her home methadone 10mg BID as well as oxycodone
15mg q4hr as needed and standing Tylenol. At time of discharge,
fecal fat and ova/parasite studies are pending. In addition,
colonic mucosa biopsies from colonoscopy are pending. We
recommended further outpatient studies looking into small bowel
bacterial overgrowth and potential consideration of repair of
possible small midline hernia.
# Orthostasis: Pt was initially orthostatic, with heart rate
increase from ___ supine to ___ with standing, likely in the
setting of decreased food intake. Orthostasis resolved after the
first hospital day, and pt was able to tolerate small amounts of
solid and liquid food.
# Weight loss: Pt reports poor PO intake for weeks. Albumin and
phosphate were within normal limits. There was no evidence of
underlying malignancy on the abdominal/pelvic MRI performed
here. Nutrition was consulted, and recommended
Ensure/Ensure Clear three times daily and a multivitamin with
minerals.
# Nausea: Controlled with Zofran
CHRONIC ISSUES
# Anxiety/depression: Continued home clonazepam and fluoxetine
TRANSITIONAL ISSUES
-CODE STATUS: Confirmed Full
-CONTACT: ___, husband, ___
-would recommend urease breath test for small intestinal
bacterial overgrowth as an outpt.
-results pending at discharge: fecal fat
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO TID
2. Fluoxetine 20 mg PO DAILY
3. Methadone 10 mg PO BID
4. Nicotine Patch 14 mg TD DAILY
5. Estrogens Conjugated 0.625 mg PO DAILY
6. Zolpidem Tartrate ___ mg PO HS
Discharge Medications:
1. ClonazePAM 1 mg PO TID
2. Estrogens Conjugated 0.625 mg PO DAILY
3. Fluoxetine 20 mg PO DAILY
4. Methadone 10 mg PO BID
5. Nicotine Patch 14 mg TD DAILY
6. Zolpidem Tartrate ___ mg PO HS
7. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN abdominal
pain
Do not drive or drink alcohol while on this medication. Do not
take more than the prescribed amount
RX *oxycodone 10 mg 1 tablet(s) by mouth every 4 hours PRN Disp
#*30 Tablet Refills:*0
10. Simethicone 40-80 mg PO QID:PRN flatulence/GI upset
Take this as needed for stomach upset/gas
RX *simethicone 80 mg 1 tab by mouth four times a day Disp #*30
Tablet Refills:*0
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Please use as needed for constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 powder(s)
by mouth daily Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain: gastritis versus adhesions versus gas pains.
Mild diverticulosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you during your hospitalization
at ___. You were admitted with belly pain. We performed
several test to try to find the cause of your pain, including a
colonoscopy, upper GI endoscopy, an abdominal and pelvic MRI and
a transvaginal ultrasound.
The endoscopy showed gastritis (inflammation of your stomach).
The ultrasound and colonoscopy were unremarkable. The MRI
showed no concerning findings that would specifically explain
the pain. Unfortunately, these tests otherwise did not identify
a cause for the pain in your lower belly, however, this doesn't
mean that the pain will not eventually resolve. One thought is
that this is bacterial overgrowth in the small intestine which
you can please discuss with Dr. ___. Also possible is
a small hernia from your incision which you should please see
your plastic surgeon about. Again, there is no dangerous cause
of the pain that we could find at this point.
We would like you to follow up with Dr. ___ Dr. ___
as detailed below, as well as with your primary care doctor and
your pain specialist. In addition, we would recommend that you
see your plastic surgeon Dr. ___ to evaluate your bladder sling.
We wish you all the best!
Sincerely,
The SIRS4 team
Followup Instructions:
___
|
19747003-DS-10
| 19,747,003 | 20,445,463 |
DS
| 10 |
2151-03-13 00:00:00
|
2151-03-13 13:32:00
|
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:
___ Exploratory laparotomy with lysis of adhesions
History of Present Illness:
___ F, prev healthy presents with sudden onset abd pain. Pt
awoke at noon today and after breakfast developed sudden onset
abd pain. Pain sharp, continuous, along right side, and
epigastric. Associated nausea and vomiting. Denies hematemesis,
BRBPR, melena. Last BM yesterday, denies passing flatus since
onset of pain. Is experiencing associated chills.
Past Medical History:
PMH: HLD, migraines
PSH: C section x 2 and tubal ligation
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
VS: 97.0 56 145/78 22 99 RA
GEN: A&O, in extreme discomfort
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, TTP along epigastrum and along right
side, with rebound and guarding, normoactive bowel sounds, no
palpable masses, well healed midline infraumbilical incision
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Abd/Pelvis CT:
IMPRESSION: Findings concerning for closed loop obstruction or
transmesenteric internal hernia complicated by small bowel
ischemia.
___ 07:10AM BLOOD WBC-12.6* RBC-4.47 Hgb-12.8 Hct-39.5
MCV-88 MCH-28.5 MCHC-32.3 RDW-13.2 Plt ___
___ 08:55AM BLOOD WBC-5.0 RBC-4.07* Hgb-11.5* Hct-35.5*
MCV-87 MCH-28.4 MCHC-32.5 RDW-12.9 Plt ___
___ 09:17PM BLOOD ___ PTT-19.8* ___
___ 08:55AM BLOOD Glucose-127* UreaN-8 Creat-0.6 Na-142
K-3.6 Cl-107 HCO3-26 AnGap-13
___ 08:55AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.2
Brief Hospital Course:
She was admitted to the Acute Care Surgery team and underwent CT
imaging of her abdomen showing closed loop obstruction or
transmesenteric internal hernia complicated by small bowel
ischemia. She was made NPO and given IV fluids. It was discussed
with her that operative repair was indicated; she was prepped,
consented and taken to the operating room on her first hospital
day for exploratory laparotomy with lysis of adhesions. There
were no complications.
Postoperatively she progressed slowly in terms of return of
bowel function. Her NG was removed on POD# 2 and she was kept
NPO for 24 hours. Her diet was advanced very slowly starting
with sips and eventually to solids for which she was able to
tolerate.
She did have urinary retention after Foley catheter removal on
POD#2 requiring that her catheter be replaced. Another voiding
trial was attempted on the POD#3 and she voided on her own
initially. On POD #4 she was noted with very little urinary
output with bladder distention and was bladder scanned for >800
cc's; the Foley was replaced again. Flomax was started as well.
She was started on Unasyn for blood cultures that grew
CORYNEBACTERIUM SPECIES; repeat blood cultures were sent and
there was no growth as of ___. The antibiotics were discontinued
on ___.
Her pain was well controlled with oral narcotics and she is
ambulating independently.
She is being discharged to home and will follow up with her PCP
and in the Acute Care Surgery clinic as scheduled. Patient
will be sent home with foley in place and plan to f/u with
urology as an outpatient. Appointment was provided at time of
discharge. Foley care teaching was provided and patient
declined ___ services.
Medications on Admission:
Denies
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
4. senna 8.6 mg Tablet Sig: ___ Tablets PO once a day as needed
for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with an obstruction in your
intestines that required an operation to alleviate.
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.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
You have staples that will need to be removed in the next ___
days when you return to the surgical clinic for follow up.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
___
|
19747015-DS-19
| 19,747,015 | 29,784,780 |
DS
| 19 |
2184-10-11 00:00:00
|
2184-10-11 16:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Percocet
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old male with h/o multiple myeloma who presents with
fever 101.6 and cough. He is s/p stem cell transplant ___, on
revlimid maintenance. Symptoms began with URI last week, for
about 4 days, now 2 days fever, chills. Denies any sick
contacts.
Denies any nausea, diarrhea, dysuria, or constipation.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Mr. ___ is a ___ yo gentleman who presented to his PCP ___
___ which persistent upper and lower back pain for several
weeks. He described this pain as aching and pressure like of
moderate to severe intensity. Pain is increased with any
movement. He had tried ibuprofen without complete relief of
symptoms. He at one time had felt a snap in his back while
lifting a suitcase. CXR of the throacic and lumbar spine was
done, which showed a compression fracture at T8. Labs were
subsequently drawn which show anemia with a hemoglobin of 13.0,
calcium of 10.7. SPEP showed a 1.8 g/dL IgG kappa monoclonal
band. Immunoelectrophoresis was not done. Serum free light
chains
showed a very elevated free kappa at 871. ESR was 30. Creatinine
was normal at 1.1. UPEP was not drawn.
___ Bone marrow biopsy aspirite with 58% abnormal plasma
cells, consistent with MM. Cytogenetics and surgical pathology
not available yet.
___ Skeletal survey: Likely 3.8 cm expansile lesion left
seventh posterior rib, rib films can be obtained for
confirmation. Mild compression fracture superior endplate one of
the lower thoracic vertebral body probably T9. Degenerative
changes spine. 4 mm focus of sclerosis right humeral head.
___ Spine MRI: Focal abnormalities within T6, T9, T12, L2
and L3 vertebral bodies and andsacrum are suggestive of
infiltrative process which can be due to metastasis.There is no
cord compression seen. Minimal epidural soft tissue changes are
seen on the right at T6 and T12 level.
___: C1 RVD
___: C4 RVD. Cytoxan added.
___: C6
___: Auto stem cell transplant BWH.
___: restarted RVD and zometa for maintenance
PAST MEDICAL/SURGICAL HISTORY:
Hypercholesterolemia
Social History:
___
Family History:
Father with HTN. MGM with colon CA.
Physical Exam:
Vitals: T 98.2 BP 134/86 HR 77 RR 18 O2 96%RA
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple
CV: Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: Soft, NT, ND.
EXT: No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3. No focal deficits.
Pertinent Results:
___ 03:41AM BLOOD WBC-3.7* RBC-4.57* Hgb-14.4 Hct-42.6
MCV-93 MCH-31.5 MCHC-33.8 RDW-13.0 RDWSD-44.0 Plt Ct-98*
___ 06:35AM BLOOD WBC-3.2* RBC-4.14* Hgb-13.1* Hct-39.1*
MCV-94 MCH-31.6 MCHC-33.5 RDW-12.8 RDWSD-44.0 Plt Ct-87*
___ 06:35AM BLOOD Glucose-119* UreaN-10 Creat-0.9 Na-140
K-3.7 Cl-104 HCO3-27 AnGap-13
___ 06:35AM BLOOD ALT-40 AST-37 AlkPhos-68 TotBili-0.7
___ 06:35AM BLOOD Calcium-8.6 Phos-2.2* Mg-1.9
CXR: No acute intrathoracic abnormality.
Brief Hospital Course:
___ yo male with a history of multiple myeloma on revlimid who is
admitted with a cough and fever.
Upper Respiratory Infection
- While admitted the patient remained afebrile and cultures had
no growth to date. He felt much better on the day of discharge
after IV Fluids. Chest X-ray did not show a clear pneumonia.
Discussed with his primary oncology team and will continue
levofloxacin as an outpatient to finish a seven day course.
Multiple myeloma
- Continued home revlimid. Will follow up with his primary
oncologist as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lenalidomide 5 mg PO DAILY
2. Gabapentin 600-900 mg PO TID
3. OxyCODONE SR (OxyconTIN) 10 mg PO QAM
4. Multivitamins 1 TAB PO DAILY
5. Aspirin 325 mg PO DAILY
6. Loratadine 10 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
8. Vitamin D 1000 UNIT PO DAILY
9. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Gabapentin 600-900 mg PO TID
3. Loratadine 10 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
6. OxyCODONE SR (OxyconTIN) 10 mg PO QAM
7. Vitamin B Complex 1 CAP PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Lenalidomide 5 mg PO DAILY
10. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Upper Respiratory Infection
Multiple Myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fevers and cough and thought to have an
upper respiratory infection. You were started on levofloxacin
which you will continue as an outpatient.
Followup Instructions:
___
|
19747096-DS-5
| 19,747,096 | 21,560,631 |
DS
| 5 |
2179-02-09 00:00:00
|
2179-02-13 20:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
___ with RVR
Major Surgical or Invasive Procedure:
___ Cardioversion
History of Present Illness:
___ man with a prior history
of COPD and hypertrophic cardiomyopathy, pancreatic
adenocarcinoma currently undergoing treatment with neutropenia
and thrombocytopenia, Type II DM, temporal lobe epilepsy who
presented from clinic with atrial fibrillation with RVR with HR
in 130s. For his pancreatic adenocarcinoma Mr. ___ is
currently being treated with phase 2 randomized study of
___ with or without PEGPH20 IV
hyaluronidase. Currently C1D15 of ___. The pt states that the
only symptom that he felt was shortness of breath when he walked
to get weighed this morning at clinic. He had no other symptoms
like diaphoresis or chest pain or pressure. He had one episode
of diarrhea over the weekend. He said he felt clammy and cold
but now feels warm.
In the ED, initial vitals were 98.4 135 98/62 18 96% 2L. ECG
showed afib with RVR. Patient was seen by cardiology who felt
that this was likely secondary to dehydration, poor PO intake
and diarrhea. Pulsus noted to be 8. Bedside ultrasound showed
mild to moderate pericardial effusion without tamponade
physiology. Plan to admit to ___ for IV metoprolol as patient
has failed diltiazem in the past, also has hx of cardioversion.
Plan discussed with Dr. ___ agrees with admission to
___ for cardiology. In the ED, Pt received 2L of IV
fluids.
Patient denies any cough, shortness of breath, chest pain,
abdominal pain, nausea or vomiting.
On arrival to the floor, the pt had HR in 130s with SBPs
___. Pt asymptomatic and without complaints. He was given 1L
NS bolus.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
Pancreatic adenocarcinoma, dx ___
Type 2 diabetes mellitus
COPD
BPH
Hypercholesterolemia
History of temporal lobe epilepsy, last seizure in the ___
Hypertrophic cardiomyopathy. Echocardiogram on ___
showed an ejection fraction of 65%, grade 1 diastolic
dysfunction and moderate left atrial enlargement.
___ ICD/pacemaker implanted after Holter showing VT (per
son)
History of atrial fibrillation status post cardioversion,
status post pacemaker and AICD placement
History of left upper extremity DVT
Status post left shoulder surgery
Status post deviated septum surgery
Status post right toe surgery
Social History:
___
Family History:
The patient's mother lived to her ___ with hypertension. His
father died in his ___. A sister died of tobacco associated
lung cancer at ___ years. A sister died of alcohol abuse at ___
years. He has one biologic son who has
cardiovascular disease. He has three adopted children.
Physical Exam:
Admission Physical Exam:
VS: 98.3 95/71 136 96% RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: tachycardic, irregularly irregular
Lungs: CTAB, no w/r/r
Abdomen: distended, soft, NT/ND, BS+
Ext: WWP, +1 pedal pitting edema bilaterally, 1+ distal pulses
bilaterally
Neuro: moving all extremities grossly
Discharge:
VS: 98, ___, 120, 18, 96% RA tele a fib with rates in
120's, PVCs
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: regular rate and rhythm, no mrg
Lungs: decreased breath sounds on R base and mild crackles
Abdomen: distended, soft, NT/ND, BS+
Ext: WWP, no edema in legs, 2+ edema in arms b/l, pulses 2+
extremities
Neuro: CN ___ intact
Pertinent Results:
Admission:
___ 08:45AM ___ ___
___ 08:45AM PLT ___ LOW PLT ___
___ 08:45AM ___
___
___
___ 08:45AM ___
___
___ 08:45AM ___
___
___ 08:45AM ___
___ 08:45AM ALT(SGPT)-27 AST(SGOT)-15 ALK ___ TOT
___
___ 08:45AM ___ this
___ 08:45AM UREA ___
___ TOTAL ___ ANION ___
___ 08:45AM ___
___ 12:00PM PLT ___ LOW PLT ___
___ 12:00PM ___
___
___ 12:00PM ___
___
___ 12:00PM ___
___
___ 12:00PM ___
___ 12:00PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 12:14PM ___
Discharge:
___ 08:59AM BLOOD ___
___ Plt ___
___ 08:59AM BLOOD ___
___
___ 08:59AM BLOOD ___
___
___ 08:59AM BLOOD ___ ___
___ 08:59AM BLOOD ___
___
___ 08:59AM BLOOD ___
Portable TTE (Complete) Done ___ at 2:27:25 ___ FINAL
Conclusions
The left atrium is elongated. No left atrial mass/thrombus seen
(best excluded by transesophageal echocardiography). The
estimated right atrial pressure is ___ mmHg.Left ventricular
wall thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF ___. Right ventricular chamber size is
normal with mild free wall hypokinesis. The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a prominent fat
pad.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with low normal global systolic function (may be
related to rapid ventricular rate). Mild mitral regurgitation
with normal valve morphology. No pericardial effusion. Right
ventricular free wall hypokinesis (may be related to ventricular
rate).
Radiology Report CHEST (PORTABLE AP) Study Date of ___
9:45 ___
FINDINGS: The lung volumes are low. There are bilateral small
areas of
atelectasis at the lung bases. Moderate cardiomegaly without
overt pulmonary edema. Left pectoral pacemaker with correct
position of the leads. No evidence of larger pleural effusions.
No pulmonary edema. No pneumothorax.
Cardiovascular Report ECG Study Date of ___ 9:33:42 AM
Atrial fibrillation with a rapid ventricular response.
Anterolateral
___ wave changes are ___ but cannot rule out
myocardial schemia. Clinical correlation is suggested. Low
voltage in the precordial leads. Early R wave transition.
Compared to the previous tracing of ___ there is no
diagnostic interval change.
Brief Hospital Course:
___ man with a prior history of COPD and hypertrophic
cardiomyopathy, pancreatic adenocarcinoma currently undergoing
treatment with neutropenia and thrombocytopenia, Type II DM who
presented from clinic with atrial fibrillation with rate of 135.
# A fib with RVR: Patient presented with atrial fibrillation
with rapid ventricular response and BP 90's/50's. Initial
differential diagnosis includes infection, structural heart
disease- has dilated left atrium on echo and dehydration
secondary to poor PO intake and diarrhea. An ECHO was performed
due to concern for pericardial effusion in the ER, and this
showed a normal LVEF with no pericardial effusion. HR remained
in the 120's with SBP in the low 100's. Patient denied any
palpitations, lightheadedness, chest pain, dyspnea, PND or
orthopnea. Due to concern for sepsis given immunocompromised
state he was started on ceftazidime and vancomycin which was
narrowed to cefepime and subsequently discontinued as there were
no signs of infection and cultures negative. He was
successfully cardioverted on ___ and returned to sinus
rhythm. An interrogation of his PPM/ICD at the time of
cardioversion revealed he had been in ___ for much of the time
since ___. He has required two cardioversions in the past
as well at an OSH. We restarted his home metoprolol and
continued him on norpace. Amiodarone may be an option if he
goes back in to A fib with RVR, however this is contraindicated
with norpace.
# Hypertrophic cardiomyopathy - He is s/p ICD ___ for
reported VT on Holter monitor. He was continued on norpace and
metoprolol.
# Metastatic Pancreatic adenocarcinoma: C1D15 of ___ of
phase 2 randomized study of ___ with or
without PEGPH20 IV hyaluronidase. He will likely resume
chemotherapy upon discharge. WBC count trended and antibiotics
given as described above.
# Hyperlipidemia: Continued pravastatin.
# Diabetes: Placed on insulin sliding and transitioned to home
insulin on discharge.
# Temporal lobe epilepsy: Continued on home keppra.
# COPD: Continued spiriva.
Transitional Issues:
- recheck ___ on ___ and faxed to primary care physician
- could consider transition to amiodarone if recurrent ___,
would require d/c norpace
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. LeVETiracetam 500 mg PO BID
3. Disopyramide Phosphate 100 mg PO HS
4. ___ (magnesium gluconate) 27 mg (500 mg) oral BID
5. Metoprolol Succinate XL 100 mg PO HS
6. Metoprolol Succinate XL 125 mg PO QAM
7. Pravastatin 40 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Furosemide 20 mg PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
11. Potassium Chloride 10 mEq PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Tamsulosin 0.8 mg PO HS
14. Finasteride 5 mg PO HS
15. Warfarin 2 mg PO DAILY16
16. ___ 1 TAB PO Q6H:PRN pain
17. Ondansetron 8 mg PO Q8H:PRN nausea
18. NPH insulin human recomb 20 units subcutaneous BID
19. NovoLOG (insulin aspart) 100 unit/mL subcutaneous TID w/
meals
20. Clotrimazole 1 TROC PO ASDIR
Discharge Medications:
1. Disopyramide Phosphate 100 mg PO HS
2. Finasteride 5 mg PO HS
3. ___ 1 TAB PO Q6H:PRN pain
4. LeVETiracetam 500 mg PO BID
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Pantoprazole 40 mg PO Q24H
7. Pravastatin 40 mg PO DAILY
8. Tamsulosin 0.8 mg PO HS
9. Tiotropium Bromide 1 CAP IH DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Furosemide 20 mg PO DAILY
12. ___ (magnesium gluconate) 27 mg (500 mg) oral BID
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Metoprolol Succinate XL 100 mg PO HS
15. Metoprolol Succinate XL 125 mg PO QAM
16. NovoLOG (insulin aspart) 100 unit/mL subcutaneous TID w/
meals
17. NPH insulin human recomb 20 units subcutaneous BID
18. Potassium Chloride 10 mEq PO DAILY
19. Clotrimazole 1 TROC PO ASDIR
20. Outpatient Lab Work
Please check ___ on ___ and fax results to
___ Phone: ___ Fax: ___.
21. Silver Sulfadiazine 1% Cream 1 Appl TP BID
RX *silver sulfadiazine 1 % apply small amount to apply to
affected area twice a day Disp #*1 Tube Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: atrial fibrillation with rapid ventricular response,
hypotension
Secondary: neutropenia, pancreatic adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with a fast and irregular heart rhythm called atrial
fibrillation. You were given medications to slow your heart down
and you were also given an electrial shock (cardioversion) to
put your heart back into a normal rhythm. The interrogation of
your pacemaker showed that you have been in this since ___
so you may go back into this rhythm. Your cardiologist may want
to consider a medication called amiodarone if this happens
again. You had a very high INR when you were admitted and should
have this rechecked after discharge on ___ if possible.
Please do not take your coumadin today or tomorrow and recheck
your INR on ___.
Followup Instructions:
___
|
19747343-DS-17
| 19,747,343 | 23,178,217 |
DS
| 17 |
2152-10-30 00:00:00
|
2152-11-02 12:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Endometrial biopsy on ___
History of Present Illness:
Patient is a ___ y/o woman with a history of bipolar d/o,
dysfunctional uterine bleeding, Severe OA of the left knee for
which she takes opiates who presents with 3 days of abdominal
pain. Pain started abruptly, is "intense", worsens with any
movement. She has had little po intake so difficult to assess
if it is worse with food. No fevers, nausea, vomiting, chest
pain or shortness of breath. She had an endometrial biopsy two
days ago for evaluation of a polyp and her pain did not worsen
after this.
Past Medical History:
Bipolar d/o
Hypertension
Obesity
OA of the left knee
S/P TKA of right knee
Asthma or COPD
Social History:
___
Family History:
DM in mother
___ cancer in grandmother
Physical ___ 105-122/50-60s ___
Gen: Obese female, initially appearing very uncomfortable, but
by the afternoon she appeared at ___: CTA B
CV: RRR
Abd: Nabs, diffuse tenderness over abdomen, most notably left
of umbilicus
Ext: No edema
Pertinent Results:
___ 10:22PM BLOOD WBC-15.6* RBC-4.03 Hgb-11.8 Hct-37.5
MCV-93 MCH-29.3 MCHC-31.5* RDW-12.6 RDWSD-42.9 Plt ___
___ 10:22PM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-138
K-3.8 Cl-107 HCO3-21* AnGap-14
___ 10:22PM BLOOD ALT-24 AST-19 AlkPhos-146* TotBili-0.3
___ 10:22PM BLOOD Albumin-4.0
___ 10:36PM BLOOD Lactate-1.8
___ 10:22PM BLOOD HCG-<5
Discharge labs
___ 06:10AM BLOOD WBC-10.4* RBC-3.71* Hgb-10.8* Hct-34.9
MCV-94 MCH-29.1 MCHC-30.9* RDW-12.2 RDWSD-42.4 Plt ___
___ 06:10AM BLOOD Glucose-85 UreaN-7 Creat-0.7 Na-139 K-4.1
Cl-106 HCO3-22 AnGap-___. A 2.8 cm small bowel diverticulum in the left abdomen with
surrounding fat stranding likely represents mild acute
diverticulitis with no evidence of perforation. The
diverticulum is filled with food residue/fecal material, from
stasis.
2. Endometrial polyp.
3. Colonic diverticulosis without diverticulitis.
Transvaginal ultrasound.
An endometrial polyp again noted measuring 1.0 x 1.2 x 1.2 cm
with a
vascularized stalk and adjacent small amount of endometrial
cavity fluid. A small uterine fibroid is again noted measuring
2.6 x 2.4 x 2.0 cm. Small volume free fluid appears simple.
The left ovary is normal in grayscale appearance and size. The
right ovary is not clearly visualized.
IMPRESSION:
Endometrial polyp again seen. Uterine fibroid. Small volume
free pelvic
fluid, simple. Nonvisualized right ovary.
Brief Hospital Course:
___ y/o woman with obesity, hypertension, bipolar disorder,
recent endometrial biopsy admitted with abdominal pain that
precedes biopsy, imaging shows acute small bowel diverticulitis.
She has a leukocytosis as well.
1. Small bowel diverticulitis: Her pain initially appeared to
be out of proportion to the extent of diverticulitis seen on
imaging on presentation. ? contribution of anxiety. Her
symptoms improved significantly and her leukocytosis improved as
well. She was advised to follow a clear liquid diet for ___
days and to advance her diet gradually. She will finish a
course of ciprofloxacin and flagyl for one week as well and will
use the oxycodone that she has at home for pain control.
2. Abdominal Pain: Presumably due to small bowel
diverticulitis. Her dose of oxycodone was increased to 15 mg
during her first day of hospitalization and then a dose of 10 mg
every six hours as needed was continued. She was put on
standing tylenol and told to take oxycodone prn.
3. Bipolar d/o: Continue Topamax, prn Seroquel.
4. Back pain: Continue gabapentin
5. Hypertension: BP is low normal, amlodipine held. Advised
to f/u with PCP prior to restart.
6. Knee pain due to OA on the left knee: Continue oxycodone.
7. ? ADD: Hold Adderall while she is in the hospital.
8. Constipation: Patient with stool in the diverticulum and
stasis near diverticulum seen on CT scan. Patient appears to
have some limited health literacy, but we discussed at length
need to limit opiates and to discuss with PCP expediting surgery
for her knee. She was started on miralax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
2. Amlodipine 5 mg PO DAILY
3. Amphetamine-Dextroamphetamine 20 mg PO DAILY:PRN need to
concentrate
4. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
5. Gabapentin 300 mg PO TID
6. Omeprazole 20 mg PO DAILY
7. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia
8. Topiramate (Topamax) 200 mg PO BID
Discharge Medications:
1. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
2. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
3. Gabapentin 300 mg PO TID
4. Omeprazole 20 mg PO DAILY
5. QUEtiapine Fumarate 25 mg PO QHS:PRN insomnia
6. Topiramate (Topamax) 200 mg PO BID
7. Acetaminophen 1000 mg PO Q8H pain in abdomen or knee
8. Ciprofloxacin HCl 750 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
9. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
10. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN abdominal
pain or knee pain
take this only if the Tylenol does not help your pain
11. Amphetamine-Dextroamphetamine 20 mg PO DAILY:PRN need to
concentrate
12. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 gm
powder(s) by mouth daily Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Diverticulitis
2. Hypertension
3. Bipolar disorder
4. Knee pain due to chronic osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain and were found to have
inflammation in the small intestine due to diverticulitis.
Please finish 5 more days of the antibiotics ciprofloxacin and
flagyl. Please stay on clear liquids (broth, jello, juices,
soups) at home for the next day and then start to eat more solid
foods.
Please take Tylenol ___ mg every 8 hours for pain in your
abdomen and then only take oxycodone if you cannot manage the
pain.
We expect that your abdominal pain will continue to improve
gradually over the next several days.
Please try to minimize your use of oxycodone and discuss with
your PCP use of other medications such as tramadol to control
your symptoms.
Your blood pressures have been normal here in the hospital, so
hold your blood pressure medication amlodipine for now.
Please avoid constipation. I am sending you home with a
medication called miralax so that you have regular bowel
movements.
Followup Instructions:
___
|
19747459-DS-19
| 19,747,459 | 28,514,274 |
DS
| 19 |
2127-01-13 00:00:00
|
2127-01-14 20:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a h/o HTN, post-op A-Fib
___, HLD, BPH, CKD 3, who presents following a fall, found to
have a subdural hematoma and SAH.
He says that earlier today he was attempting to walk upstairs
after returning from the grocery store. He had bags of
groceries
in both hands. He missed his footing on the stairs and fell to
the ground, landing on cement, striking his head. There were no
preceding symptoms, no loss on consciousness, no chest pain, no
palpitations. He reports several falls over the preceding
weeks,
also mechanical, though denies headstrike with these. He denies
chest pain, shortness of breath, fever/chills, nausea/vomiting,
diarrhea, headache.
EMS was called, and on arrival they found him to be hypertensive
with a systolic of 200. He was taken at ___.
At
___ he was noted to be in atrial fibrillation,
and CT scan showed SDH and SAH. He was started on Nicardipine
drip for BP control but this was later stopped. He was
transferred to ___.
Past Medical History:
ALLERGY, DOG DANDER
AORTIC REGURGITATION
ARTHRITIS
ASTHMA
BPH
DEPRESSION
ELEVATED PROSTATE SPECIFIC ANTIGEN
HYPERCHOLESTEROLEMIA
HYPERTENSION
INGUINAL HERNIA
MITRAL REGURG
Social History:
___
Family History:
Father - died of MI age ___
Mother died in her ___, Alzheimer
2 Brothers - 1 with mitral valve disease, other with HTN
Daughter with ___
Oldest son died of cancer
Physical Exam:
Admission Exam:
VS: 98.0, 129/68, HR 70, 88 RA, RR 20
GENERAL: NAD, tired/drowsy but easily arousable and answers
questions appropriately, hard of hearing
HEENT: EOMI, PERRL, anicteric sclera, OP clear, MM dry
NECK: supple, no LAD
HEART: RRR, no murmurs, no rubs
LUNGS: CTAB, increased WOB on room air improved with
supplemental
O2
ABDOMEN: nondistended, nontender
EXTREMITIES: bilateral ___ edema with venous stasis changes
PULSES: 2+ radial pulses bilaterally
NEURO: A&Ox3, moving all extremities. ___ strength in bilateral
upper and lower extremities. CN ___ intact
Discharge Exam:
VS: 98.5 PO 166 / 73 63 18 94 2l
GENERAL: NAD, hard of hearing, AOX3.
HEENT: EOMI except vertical gaze palsy, PERRL,
anticteric sclera, dry MM
Lungs: CTAB. decreased breath sounds throughout and at bases, no
crackles
HEART: RRR, III/VI systolic RUSB murmur, no r/g.
ABDOMEN: nondistended, non tender
EXTREMITIES: ___ pitting edema +2 (improved with stocking)
NEURO: A&O x3 moving all extremities, upper and lower extremity
strength ___, CN ___ intact. Vertical gaze palsy, finger to
nose
dysmetria. Action tremor seen when holding arms out. No resting
tremor. fast alternating hand movements intact.
Pertinent Results:
Admission labs:
================
___ 05:17PM BLOOD WBC-10.9* RBC-4.09* Hgb-12.0* Hct-37.1*
MCV-91 MCH-29.3 MCHC-32.3 RDW-12.0 RDWSD-39.8 Plt ___
___ 05:17PM BLOOD Neuts-89.3* Lymphs-6.9* Monos-2.7*
Eos-0.3* Baso-0.2 Im ___ AbsNeut-9.77* AbsLymp-0.75*
AbsMono-0.30 AbsEos-0.03* AbsBaso-0.02
___ 05:17PM BLOOD ___ PTT-33.6 ___
___ 05:17PM BLOOD Glucose-142* UreaN-35* Creat-1.3* Na-147
K-4.6 Cl-107 HCO3-25 AnGap-15
___ 05:17PM BLOOD CK(CPK)-68
___ 05:17PM BLOOD CK-MB-4 proBNP-313
___ 05:17PM BLOOD cTropnT-0.03*
___ 05:17PM BLOOD Calcium-8.9 Phos-4.0 Mg-2.4
___ 05:27PM BLOOD Lactate-1.2 K-4.3
Discharge labs:
=================
___ 06:25AM BLOOD WBC-7.5 RBC-3.56* Hgb-10.5* Hct-32.7*
MCV-92 MCH-29.5 MCHC-32.1 RDW-11.9 RDWSD-40.4 Plt Ct-93*
___ 06:25AM BLOOD Plt Smr-LOW* Plt Ct-93*
___ 06:25AM BLOOD Glucose-111* UreaN-24* Creat-1.2 Na-146
K-4.1 Cl-106 HCO3-27 AnGap-13
Imaging:
=================
___ CT head:
1. Overall slightly less prominent right-sided and left frontal
subdural
hematoma. Stable inferior left frontal intraparenchymal
hemorrhage. Right temporal subarachnoid hemorrhage with
layering blood in the occipital horns of the bilateral lateral
ventricles consistent with redistribution of subarachnoid blood.
No new intracranial hemorrhage.
2. Stable mass effect with 3 mm midline shift and effacement of
the left
lateral ventricle.
___ CXR:
Heart size is prominent but stable. There is again seen a small
left-sided pleural effusion and bibasilar atelectasis. There is
mild prominence of the pulmonary interstitial markings without
overt pulmonary edema. There are no pneumothoraces.
___ CT chest w/o contrast:
1. No acute findings in the chest. No fracture, pneumothorax,
or pneumonia.
2. Scattered 1-2 mm pulmonary nodules.
3. Mild bronchial wall thickening suggestive of chronic small
airways disease.
4. Trace left-sided pleural effusion.
5. Bilateral probable proteinaceous/hemorrhagic renal cyst. If
confirmation is warranted, renal ultrasound can be performed.
Brief Hospital Course:
Patient Summary:
=================
Mr. ___ is a ___ y/o M with a h/o HTN, post-op A-Fib in ___
(with one recurrent episode on admission), HLD, BPH and CKD 3,
who presents following a fall, found to have SDH and SAH, as
well as new O2 requirement. SAH/SDH remained stable on repeat CT
head and headache improved. No surgical intervention was
necessary. He had new O2 requirement with CT chest showing
evidence of chronic small airway disease without acute causes of
hypoxia. He had Well's score of 0, without EKG changes
concerning for right heart strain, tachycardia, pleuritic chest
pain or history of immobility or surgeries concerning for
pulmonary embolism. O2 weaned down to 2L by discharge with plan
for continued incentive spirometry and follow up with
pulmonology.
#Hypoxia: Patient had new O2 requirement with CT chest showing
evidence of chronic small airway disease without acute causes of
hypoxia. He had Well's score of 0, without EKG changes
concerning for right heart strain, tachycardia, pleuritic chest
pain or history of immobility or surgeries concerning for
pulmonary embolism. Exam and chronic airway disease with 90 pack
year smoking history concerning for chronic lung disease
requiring outpatient PFT. Likely cause of hypoxia is atelectasis
with a component of chronic lung disease. Will continue on O2
with plan to wean down in rehab by continued incentive
spirometry. Follow up with pulmonology for outpatient PFT.
#Subdural hematoma, SAH: traumatic bleed in the setting of
recent fall. Evaluated by neurosurgery without indication for
surgery as repeat NHCT remained stable. Stopped Aspirin. He was
started on Keppra 500mg BID x 7 days for seizure ppx ___ -
___. Can follow up with concussion clinic as needed.
#Fall: Multiple recent mechanical falls. Possible triggers
deconditioning, a-fib, ___ edema, ?Parkinsonian sx. No evidence
of UTI or other infection. Tele with intermittent bigeminy but
no other concerning findings for cardiac cause. ___ have a
component of early ___ disease given patient's vertical
gaze palsy but no evidence of rigidity or bradykinesia on exam.
Evaluated by ___ and will have outpatient neurology consultation.
#Thrombocytopenia- Baseline Plt of 147 in ___ with decrease
this admission and stable anemia. Thrombocytopenia likely in the
setting of SAB and subdural hematoma. Not on heparin. Will trend
labs at rehab facility.
Chronic/Resolved Issues:
==========================
#Vertical gaze palsy- Concern for possible supernuclear gaze
palsy in association with ___ disease. Has had multiple
recent falls without resting tremor or cogwheel rigidity. Will
have outpatient follow up with neurology.
#Hypernatremia- Likely in the setting of dehydration with ~3.7L
water deficit. Clinically dry on exam with improvement of
dizziness with fluids. Hypernatremia resolved s/p 1L D5W.
#HTN- Continued on home Terazosin, amlodipine, and losartan as
inpatient instead of Irbesartan as it was not on formulary.
#Atrial fibrillation: H/o paroxysmal a fib post prostatectomy in
___. Found to be A fib at presentation but now in sinus rhythm.
Could have developed secondary to stress of fall/bleed.
Currently in sinus rhymthm with bigeminy at times. Defer
Anticoag for now given intracranial hemorrhages.
#Dizziness: Dizziness on admission that was likely related to
intravascular dehydration (hypernatremia, dry MM). Less likely
due to evolving neurologic process (mild reduction of bleeding
in CT and stable neuro exam). Dizziness resolved with IV fluid
hydration.
___ Edema: Familial lower extremity edema. Improved with
compression stockings. Held home Lasix in the setting of
dehydration and hypernatremia but restarted on discharge.
#HLD - continue home atorvastatin
#CKD 3 - currently 1.3, baseline 1.4-1.8
#Glaucoma - continue home latanoprost
#Supplementation - continue home MVI, B12
TRANSITIONAL ISSUES:
- New Meds: Keppra 500mg BID until ___
- Stopped/Held Meds: Aspirin 81mg
- Changed Meds: None
- Post-Discharge Follow-up Labs Needed: CBC (trend
thrombocytopenia)
- Incidental Findings: scattered 1-2mm nodules in lungs, mild
bronchial wall thickening suggestive of small airway disease,
Bilateral probable proteinaceous/hemorrhagic renal cyst.
# CODE STATUS: Full code (attempt resuscitation)
# CONTACT: Wife ___ ___
() Continue Keppra 500mg BID until ___
() Follow up with pulmonology to consider PFT testing given CT
findings and 30pack year smoking history
() Primary care follow up to discuss possible anticoagulation
given paroxysmal Afib but not eligible at this point given
recent SAH/subdural hematoma
() F/u labs to trend thrombocytopenia thought to be related to
recent SAH/subdural hematoma
() Neurology consult for evaluation of ___ plus syndrome
given vertical gaze palsy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Furosemide 40 mg PO DAILY
4. irbesartan 300 mg oral DAILY
5. Terazosin 2 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) ASDIR
10. Triamcinolone Acetonide 0.1% Cream 1 Appl TP ASDIR
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. LevETIRAcetam 500 mg PO Q12H
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*10 Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Cyanocobalamin 1000 mcg PO DAILY
5. Furosemide 40 mg PO DAILY
6. irbesartan 300 mg oral DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) ASDIR
9. Multivitamins 1 TAB PO DAILY
10. Terazosin 2 mg PO BID
11. Triamcinolone Acetonide 0.1% Cream 1 Appl TP ASDIR
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Subarachnoid hemorrhage
Subdural hemorrhage
Hypoxia
Secondary diagnosis
Thrombocytopenia
vertical gaze palsy
Hypernatremia
Hypertension
Atrial fibrillation
Chronic lower extremity edema
Chronic kidney 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. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
- you fell and hit your head causing a small brain bleed
WHAT HAPPENED IN THE HOSPITAL?
- You had imaging of your head that showed the bleeding in the
brain had stopped and was improving
- You received Intravenous fluids as you were very dehydrated
- you had imaging of your lungs that didn't show any acute cause
of shortness of breath but some chronic changes that you will
need to follow up about with your primary care doctor
WHAT SHOULD YOU DO AT HOME?
- Please follow up with your primary care doctor in 1 week
- Please report to the ER if you have increase shortness of
breath, chest pain, dizziness, weakness, numbness, tingling,
changes in vision, or any other acute concerning changes
- Please continue to use incentive spirometry at rehab to help
open up your lungs
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
19747612-DS-2
| 19,747,612 | 23,418,462 |
DS
| 2 |
2158-07-18 00:00:00
|
2158-07-18 22:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ speaking F interviewed with phone
interpreter w PMH HTN and palpitations who presents with
increasing frequency of syncope. She reports she had been in
good
health until about one hear ago when she got the shingles
vaccine
and she began having dizziness, palpitations, and syncope.
Recently the syncope has been increasing in frequency. She had
an
event on ___ and another two today. She reports she has
overall "not felt right in the head" and has been more fatigued.
She denies headache. She does feel that these episodes happen
more frequently when she is standing and she feels the need to
sit and get acclimated before she gets out of bed but they seem
to happen anytime. She reports frequent palpitations with
exertion and when she gets dizzy. She denies any other symptoms.
No chest pain, dyspnea, shortness of breath, ___ swelling, visual
changes, numbness or weakness, no fevers, weight changes.
Patient had an outpatient EKG in early ___ that showed
tachycardia with irregular rhythm, read as sinus tachycardia
with
frequent PACs and SVT. EKG here today is more consistent with
atrial flutter with variable conduction.
In the ED, initial VS were: T 98, HR 98, BP 157/110, RR16,
SaO2100% RA
Exam notable for:
patient is awake and alert. No evidence of traumatic injury.
Neurologic exam nonfocal.
ECG: Atrial flutter, rate of 96, normal axis, normal intervals
Labs showed:
Trop-T: <0.01
9.8 >15.8/46.8<230
Imaging showed:
CXR:
Patchy bibasilar opacities which likely reflect atelectasis
though
superimposed pneumonia cannot be excluded in the appropriate
clinical setting.
CT Head:
No acute intracranial abnormality
CT Spine:
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes.
Transfer VS were: T___.7, HR 96, BP136/87, RR14, SaO2 99% RA
On arrival to the floor, patient reports the above via phone
interpreter. Son joins at bedside and verifies.
Past Medical History:
HYPERTENSION
VENOUS STASIS DERMATITIS
ITCHY EYES
Social History:
___
Family History:
Non-contributory
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VS: BP122/70 L Standing HR93 RR18 SaO294%RA
GENERAL: NAD, laying in bed, son at bedside
___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: irreg. irreg., S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, CN ___
intact. Sensation in tact to light touch, ___ and ___ grossly
symmetric and WNL.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
=========================
DISCHARGE PHYSICAL EXAM
=========================
GENERAL: NAD, laying in bed
___: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: Normal rate, regular rhythm, S1/S2, no murmurs, gallops,
or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, CN ___
intact. Sensation in tact to light touch, ___ and ___ grossly
symmetric and WNL.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
==============
ADMISSION LABS
==============
___ 06:15PM BLOOD WBC-8.8 RBC-5.27* Hgb-15.8* Hct-46.8*
MCV-89 MCH-30.0 MCHC-33.8 RDW-12.3 RDWSD-40.0 Plt ___
___ 06:15PM BLOOD Neuts-53.7 ___ Monos-9.1 Eos-2.6
Baso-0.8 Im ___ AbsNeut-4.71 AbsLymp-2.95 AbsMono-0.80
AbsEos-0.23 AbsBaso-0.07
___ 06:15PM BLOOD Plt ___
___ 11:58PM BLOOD ___ PTT-27.3 ___
___ 09:08PM BLOOD Glucose-105* UreaN-21* Creat-0.8 Na-134*
K-4.9 Cl-100 HCO3-20* AnGap-14
___ 06:15PM BLOOD cTropnT-<0.01
___ 09:08PM BLOOD Calcium-9.7 Phos-3.5 Mg-2.1
___ 11:58PM BLOOD D-Dimer-2977*
___ 09:08PM BLOOD TSH-0.82
___ 09:08PM BLOOD CEA-4.4*
==============
DISCHARGE LABS
==============
___ 06:12AM BLOOD WBC-7.5 RBC-4.82 Hgb-14.6 Hct-43.8 MCV-91
MCH-30.3 MCHC-33.3 RDW-12.3 RDWSD-40.5 Plt ___
___ 06:12AM BLOOD Plt ___
___ 06:12AM BLOOD ___ PTT-27.2 ___
___ 06:12AM BLOOD Glucose-121* UreaN-20 Creat-0.8 Na-133*
K-4.4 Cl-97 HCO3-23 AnGap-13
___ 06:12AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.9
==================
IMAGING/PROCEDURES
==================
___ Chest X-ray
FINDINGS:
AP and lateral views of the chest provided.
Patchy bibasilar opacities, most prominent in the retrocardiac
region likely
reflect atelectasis though superimposed pneumonia cannot be
excluded in the
appropriate clinical setting. There is no pleural effusion or
pneumothorax.
The cardiomediastinal silhouette is normal. No acute osseous
abnormality
identified.
IMPRESSION:
Patchy bibasilar opacities which likely reflect atelectasis
though
superimposed pneumonia cannot be excluded in the appropriate
clinical setting.
___ CT C-Spine w/o contrast
FINDINGS:
Alignment is normal. No fractures are identified.Multilevel
degenerative
changes are seen notable for uncovertebral hypertrophy and
posterior
osteophyte formation resulting in up to mild canal narrowing.
There is no
prevertebral edema.
The thyroid is unremarkable. Pleural based apical scarring is
visualized in
the lungs bilaterally.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes.
___ CT Head W/o Contrast
FINDINGS:
There is no evidence of acute large territory infarction,
hemorrhage, edema,
or mass. The ventricles and sulci are prominent compatible with
age-related
involutional changes. Periventricular and subcortical white
matter
hypodensities are nonspecific, but likely reflect sequelae of
chronic small
vessel ischemic disease.
No fractures are identified. Aerosolized secretions are
visualized in the
right sphenoid sinus with additional mucosal thickening of the
bilateral
ethmoidal air cells. Otherwise the visualized paranasal
sinuses, mastoid air
cells, and middle ear cavities are clear. The orbits are
unremarkable.
IMPRESSION:
No acute intracranial abnormality.
___ 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.
Mild-to-moderate atherosclerotic calcifications of the aortic
arch, great
vessels, and descending aorta.
The pulmonary arteries are well opacified to the subsegmental
level, with no
evidence of filling defect within the main, right, left, lobar,
segmental or
subsegmental pulmonary arteries. The main and right pulmonary
arteries are
normal in caliber, and there is no evidence of right heart
strain.
There is no supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no
pleural effusion.
Evaluation of the lung parenchyma is mildly limited by
respiratory motion.
Within this limitation, there is probable biapical pleural
scarring. Mild,
bilateral dependent atelectasis. Otherwise, there is no
evidence of pulmonary
parenchymal abnormality. The airways are patent to the
subsegmental level.
Limited images of the upper abdomen are unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is
identified.
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
___ TTE
CONCLUSION:
The left atrial volume index is normal. The right atrium is
mildly enlarged. There is normal left ventricular wall thickness
with a normal cavity size. There is normal regional left
ventricular systolic function. The visually estimated left
ventricular ejection fraction is 55-60%. There is no resting
left ventricular outflow tract gradient. Normal right
ventricular cavity size with normal free wall motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal. The
aortic valve leaflets (3) appear structurally normal. There is
no aortic valve stenosis. There is no aortic regurgitation. The
mitral leaflets are mildly thickened with no mitral valve
prolapse. There is mild [1+] mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: No structural cardiac cause of syncope identified.
Normal biventricular cavity sizes, regional/global systolic
function. Mild mitral regurgitation.
Brief Hospital Course:
========
SUMMARY
========
Ms. ___ is an ___ woman with PMH of HTN, palpitations, and
stasis dermatitis who presented with three syncopal episodes in
the last week and ongoing palpitations. She was found on cardiac
workup to have new diagnosis of atrial fibrillation and was
started on metoprolol for rate control and warfarin for
anticoagulation. Discharged on ___ of ___ Monitor and
follow-up with PCP and ___ for further evaluation.
==============================
ACUTE MEDICAL ISSUES ADDRESSED
==============================
# Syncope
Patient presented with three syncopal events in a one week
period and ongoing sensation of palpitations. Had TTE without
structural or valvular disease, CTA without evidence of
pulmonary embolism. EKG obtained demonstrated atrial
fibrillation and given associated symptoms of palpitations with
syncope, raised concern for arrythmogenic cause of syncope.
Electrophysiology consulted and felt syncope unlikely related to
atrial fibrillation as converted to sinus rhythm on telemetry
WITHOUT conversion sinus pauses or signs of sick sinus. Patient
did not have any syncopal events or presyncopal symptoms during
hospitalization so could not rule out ventricular arrhythmia as
potential cause. She will be discharged on ___ of Hearts
Monitor with plan to follow-up with cardiology for continued
outpatient workup.
# Paroxysmal Atrial fibrillation
Found to have new atrial fibrillation on EKG not previously
documented. Unclear precipitant. TSH normal, CTA negative for
PE, trops normal and no evidence of ischemia on EKG.
Electrophysiology consulted and recommended rate control Started
on metoprolol succinate 25mg daily with good control of heart
rate to ___. CHADSVASC of 4. Given patient is Jehovah's
Witness and unable to receive blood products so started on
warfarin as it is a more easily reversible agent and not all
hospitals have praxbind idracizumab. Received warfarin 5mg ___
and ___. Had close follow-up with primary care nurse
practitioner on ___ for INR check and warfarin adjustment. Will
be followed at ___ w/PCP.
# Elevated CEA
CEA spuriously checked at found to be slightly elevated at 4.4.
Unclear significance of this as an isolated check without
evidence of symptoms of malignancy. However, given also with
elevated D-dimer in absence of pulmonary embolism, would
consider further workup. CTA here without any concerning pulm
nodules. Would ensure age appropriate screening for breast,
colorectal (thyroid and pancreas also associated with CEA
elevations)
#Erythrocytosis:
Slightly elevated to 15.8 on admission, resolved with check. If
persistent as outpatient, consider work up for OSA, polycythemia
___ etc as outpatient
#Hypertension:
Restarted HCTZ and lisinopril at reduced doses 50% 12.5 and 10mg
respectively.
===================
TRANSITIONAL ISSUES
===================
[] Jehovah's Witness
[] Syncope: Discharged on ___ of Hearts Monitor with plan to
follow-up with cardiology for continued outpatient workup.
[] Paroxysmal A-fib: Discharged on metop succinate 25mg daily
and warfarin 5mg daily. Patient has next day follow-up for INR
check ___. Warfarin will be titrated per primary care.
- If INR on ___ <1.5, suggest increasing warfarin dose by 50%
(inc to 7.5mg).
- If INR between 1.5 and 2.0, keep dose at 5mg. Decrease by 50%
- If INR ___, decrease dose to 2.5mg
- If INR 2.5-2.99, decrease dose to 1mg
- If INR >3, hold warfarin
[] restarted HCTZ at 50% dose 12.5mg and lisinopril at 10mg (50%
dose)
[] Elevated CEA: would ensure age appropriate screening for
breast, colorectal (thyroid and pancreas also associated with
CEA elevations)
[] Erythrocytosis: Resolved without intervention. If persistent
as outpatient, consider work up for OSA, polycythemia ___ etc
as outpatient
Restarted home antihypertensives
#CODE: Full
#CONTACT:
Name of health care proxy: ___
Relationship: dtr
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Warfarin 5 mg PO DAILY16
RX *warfarin 1 mg ___ tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5.Outpatient Lab Work
Dx: Atrial Fibrillation ICD 10: ___
Lab: INR
Fax results to:
___, MPH
Location: ___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
==================
PRIMARY DIAGNOSIS
==================
Syncope
New Diagnosis Atrial fibrillation on coumadin
===================
SECONDARY DIAGNOSIS
===================
Hypovolemic Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were fainting at home and were admitted to the hospital
for further evaluation.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had an imaging test called an echocardiogram which was
normal.
- You had a CT scan of you lungs which did not show any evidence
of blood clots.
- Your heart rhythm was monitored and was found to be irregular
and fast. We diagnosed you with a condition called atrial
fibrillation and you were started on a medication to control
your heart rate.
- Because atrial fibrillation can increase your risk of stroke,
you were started on a blood thinner called warfarin that you
need to take everyday
- We discussed risks and benefits of blood thinners given that
you would not want blood products as a Jehovah's Witness. You
understood these risks and agreed that you would take this
medication and monitor it closely.
- You were seen by our physical therapy team who felt you were
safe to go home and did not require rehab.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- You will be discharged on a medication called metoprolol
succinate which will help to decrease your heart rate and
prevent you from going into the fast rhythm.
- You will be discharged on a medication called warfarin which
is a blood thinner to prevent a stroke that can be caused by
your irregular heart beat.
- You will need to be monitored closely by your primary care
clinic after your leave the hospital to make sure your INR level
(blood thinning level) is at the right range on the warfarin. We
scheduled an appointment for you to see a nurse practitioner at
the ___ Clinic tomorrow, ___, as listed
below to check up on you and check an INR level. Please wait
until that appointment before taking your warfarin dose for that
day.
- You will be discharged with a special heart monitor called a
___ of Hearts monitor. Anytime you feel like you are going to
faint, please press the button on the monitor so this can be
reviewed by your heart doctor.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19747837-DS-14
| 19,747,837 | 26,182,662 |
DS
| 14 |
2184-12-11 00:00:00
|
2184-12-15 18:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right Sided Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with extensive past medical
history including prior CVA (___), MI, hx. multiple DVTs with
PE in ___ (in setting of ongoing treatment for malignancy), CKD
(stage III) who presents with acute onset chest pain. Pt. states
that he was in his usual state of health until 2 days prior to
presentation when he woke up with acute onset CP localized to
the right lower thorax 3-5 cm anteromedial to the right axillary
line. Pain described as sharp and is made worse with movement,
inspiration, and palpation. Pt. denies subjective fevers/chills
although does endorse night sweats over the last ___ weeks. He
also endorses new malaise and shortness of breath over the last
few days with speaking and on exertion. Pt. denies any nausea,
vomiting, abdominal pain, or changes in his stool recently. He
did note some dysuria approximately 1 week ago which has since
resolved. He also reports episodic lower extremity leg swelling
over the last ___ months typically on days that he is more
active. He also c/o chronic posterior calf pain which is
intermittent. Pt. denies rhinorrhea, sore throat, nasal
congestion or recent sick contacts. He does note some chronic
___ which on occassion stimulates what sounds like a cough in
order for him to clear his through. Pt. denies hx. of exertional
CP, orthopnea, or PND. He also denies any trauma or recent
falls.
Past Medical History:
# Left pontine lacunar CVA - ___
# Seizure disorder - began following CVA, on Keppra, reports
ongoing seizure episodes manifested by staring episodes and
facial droop
# Status post MI - ___
# Status post left parietal occipital hemorrhage secondary to
hypertension - ___
# Afib - documented by ECG in ___ in setting of DVT/PE
# Hypertension
# Hypercholesterolemia
# History of DVT in the setting of hospitalization - ___
# History of small-bowel obstruction - ___
# Chronic kidney disease stage III with a baseline creatinine
in the mid to high 1 range
# Falls
# Status post right rotator cuff injury
# DVTs and PEs - ___
# Vocal cord cancer
# Urinary retention
# Sciatica
# Osteoarthritis
Social History:
___
Family History:
Father hx. of MI/CAD and died ___ complications of prostate
cancer. Pt.' sister had hx of cancer; unsure what type.
Otherwise, denies other family members with hx. of heart or lung
disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.4 147/104 P86 RR20 94% 2L
GENERAL: NAD, A&Ox3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: irregularly irregular, no murmurs, gallops, or rubs
LUNG: CTABL, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
========================
Vitals: 98.1 141/89 78 18 98% RA
GENERAL: NAD, A&Ox3
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, patent nares, MMM
NECK: Supply, no LAD, no JVD
CARDIAC: irregularly irregular, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
ADMISSION LABS
==============
___ 03:30AM BLOOD WBC-5.6 RBC-4.88 Hgb-15.1 Hct-44.1 MCV-90
MCH-31.0 MCHC-34.3 RDW-14.0 Plt ___
___ 03:30AM BLOOD Neuts-65.2 ___ Monos-10.3 Eos-2.8
Baso-0.6
___ 03:30AM BLOOD Glucose-115* UreaN-21* Creat-1.6* Na-136
K-3.4 Cl-99 HCO3-27 AnGap-13
___ 03:30AM BLOOD ALT-16 AST-20 AlkPhos-78 TotBili-0.7
___ 03:30AM BLOOD Digoxin-0.7*
NOTABLE LABS
============
___ 07:55AM BLOOD WBC-7.3 RBC-4.63 Hgb-13.7* Hct-42.6
MCV-92 MCH-29.7 MCHC-32.2 RDW-14.5 Plt ___
___ 07:15AM BLOOD WBC-5.2 RBC-4.48* Hgb-13.8* Hct-41.0
MCV-92 MCH-30.7 MCHC-33.6 RDW-14.0 Plt ___
___ 06:30AM BLOOD ___ PTT-67.9* ___
___ 07:35AM BLOOD ___ PTT-36.3 ___
___ 07:55AM BLOOD Glucose-102* UreaN-15 Creat-1.4* Na-142
K-3.5 Cl-106 HCO3-23 AnGap-17
___ 07:15AM BLOOD Glucose-84 UreaN-15 Creat-1.4* Na-141
K-3.3 Cl-105 HCO3-25 AnGap-14
___ 07:35AM BLOOD Glucose-113* UreaN-17 Creat-1.4* Na-138
K-3.6 Cl-104 HCO3-23 AnGap-15
___ 12:36AM BLOOD D-Dimer-982*
___ 06:30AM BLOOD TSH-4.0
___ 06:30AM BLOOD Digoxin-0.8*
___ 07:15AM BLOOD Digoxin-0.6*
___ 07:35AM BLOOD Digoxin-0.6*
DISCHARGE LABS
==============
___ 07:30AM BLOOD Glucose-105* UreaN-15 Creat-1.2 Na-137
K-3.8 Cl-105 HCO3-23 AnGap-13
___ 07:30AM BLOOD Calcium-9.9 Phos-2.8 Mg-1.9
STUDIES
========
RIB SERIES (___): IMPRESSION: 1. No displaced rib
fracture. 2. Multifocal airspace opacities, most prominant at
the right lung base.
Findings may represent aspiration, atelectasis, or potentially
infection in
the appropriate clinical setting.
CXR (___): Consolidation at the base of the right lung is
more pronounced, consistent with worsening pneumonia. Small
bilateral pleural effusions, right greater than left, should be
followed to see if the right-sided component is related to
infection. Mild cardiomegaly is stable. No pulmonary edema.
CT CHEST W/O CONTRAST (___): IMPRESSION: 1. Right lung
base consolidation with adjacent ground-glass opacities,
compatible with pneumonia given patient's clinical symptoms. 2.
Moderate right and trace-to-small left non-hemorrhagic pleural
effusions. 3. Small pericardial effusion.
ECG (___): Atrial fibrillation with rapid ventricular
response. A single ventricular premature contraction or
aberrantly conducted ventricular complex is present. Compared to
the previous tracing of ___ the ventricular response has
slowed. The findings are otherwise similar.
Brief Hospital Course:
BRIEF SUMMARY STATEMENT: Mr. ___ is a ___ year old male with
extensive past medical history including prior CVA (___), MI,
hx. multiple DVTs with PE in ___ (in setting of ongoing
treatment for malignancy), CKD (stage III) who presents with
acute onset chest pain found to have right lower lobe pneumonia.
Hospital course complicated by new afib with RVR, started on
coumadin for anticoagulation and metoprolol for rate control.
Pt. was bridged onto coumadin with lovenox. He had a bedside
speech and swallow evaluation which revealed no clear risk of
aspiration.
ACTIVE ISSUES
=============
# Right lower lobe community acquired pneumonia: Pt. presented
with acute onset right sided lower thoracic pleuritic chest
pain. CXR and CT Chest w/o contrast revealed right lung base
consolidation with adjacent ground-glass opacities likely
consistent with pneumonia. He was started on
ceftriaxone/azithro with resolution of fever. Transitioned to
levofloxacin on ___ with continued improvement in his
symptoms. Pt's caregiver described ___ possible aspiration hx.,
as such speech and swallow evaluated the pt. They found no
clear evidence of aspiration on bedside swallow test. Given
hx., pulmonary embolus was considered as a possible contributor
to pt's chest pain and hypoxia, however baseline CKD and the
decision to anticoagulate for afib, CTA of Chest was deferred.
Pt's hypoxia resolved with treatment and he was discharged to
complete a 7 day course of antibiotics for CAP (Day #1 ___.
#Afib: Pt. with hx. of afib in ___ in the setting of DVT/PE.
However, since this time, had not been noted to be in atrial
fibrillation. Pt. presented with Afib with periods of RVR.
After discussions with the pt. and the pt's PCP, anticoagulation
on coumadin was imitated given CHADS2 of 4. His known seizure
hx. was considered, however his seziures episodes are typically
focal and do not typically result in loss of consciousness or
tonic-clonic jerks. Pt. was discontinued off of labetalol and
started on metoprolol for improved rate control. His digoxin
was continued at a reduced frequency.
CHRONIC ISSUES
===============
#Seizure disorder: ___ prior stroke in ___. ? of seizure
episode in ED. No additional seizure events noted during
hospitalization. Pt. was continued on his home keppra.
#CKD: Stable. Baseline creatinine 1.5-1.7.
#HTN: Stable. Continued on amlodipine, HCTZ, and metoprolol.
#CAD: Stable. Continued on metoprolol, crestor, and aspirin 81
(reduced from 325 as coumadin was initiated on this
hospitalization).
#BPH: Stable. Continued on tamsulosin
# Chronic Pain: Stable. Continued on gabapentin
# GERD: Stable. Continued on omeprazole and ranitidine.
# Vitamin D Deficiency: Stable. Continued on vitamin D.
TRANSITIONAL ISSUES
=====================
# Speech and Swallow: Bedside evaluation performed which
revealed no clear risk of aspiration. Would recommend video
swallow in order to complete work-up for aspiration in the
setting of a person with an aspiration history and previous
laryngeal radiation.
# New Bilateral Pleural Effusions: Given pt's cardiac hx, he
would benefit from repeat TTE as outpatient.
# Digoxin: Reduced in the setting of CKD to every other day.
Given pt's known CKD, would reevaluate the utility vs. potential
harm of digoxin as outpatient.
# Afib: New dx on this admission. CHADS2 of 4. Discussed
anticoagulation with PCP who was in favor. Discharged on
coumadin, lovenox (for bridge), digoxin, and metoprolol. Aspirin
reduced to 81mg PO Daily (from 325mg daily).
# Code: FULL confirmed with pt. (no long-term life support)
# Emergency Contact: ___ caretaker (cell
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 100 mg PO QID
2. LeVETiracetam 1500 mg PO BID
3. Labetalol 600 mg PO BID
4. Digoxin 0.125 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Senna 8.6 mg PO BID:PRN constipation
7. Amlodipine 5 mg PO DAILY
8. Ranitidine 300 mg PO HS
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Aspirin 325 mg PO DAILY
12. Tamsulosin 0.4 mg PO HS
13. albuterol sulfate 90 mcg/actuation inhalation q4hrs prn
wheezing
14. Hydrochlorothiazide 25 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. Fish Oil (Omega 3) 1000 mg PO TID
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 100 mg PO QID
5. Hydrochlorothiazide 25 mg PO DAILY
6. LeVETiracetam 1500 mg PO BID
7. Omeprazole 40 mg PO DAILY
8. Ranitidine 300 mg PO HS
9. Rosuvastatin Calcium 10 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Tamsulosin 0.4 mg PO HS
12. Vitamin D 1000 UNIT PO DAILY
13. Enoxaparin Sodium 80 mg SC Q12H Duration: 5 Days
RX *enoxaparin 80 mg/0.8 mL 0.8 ML SC twice a day Disp #*10 Unit
Refills:*0
14. albuterol sulfate 90 mcg/actuation inhalation q4hrs prn
wheezing
15. Fish Oil (Omega 3) 1000 mg PO TID
16. Warfarin 2.5 mg PO DAILY16
Goal INR ___
RX *warfarin 1 mg 0.5 (One half) tablet(s) by mouth Daily Disp
#*90 Tablet Refills:*0
RX *warfarin 2 mg 1 tablet(s) by mouth Daily Disp #*90 Tablet
Refills:*0
17. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*4
Tablet Refills:*0
18. Digoxin 0.125 mg PO EVERY OTHER DAY
19. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 50 mg 3 tablet extended release 24
hr(s) by mouth daily Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
==================
1. Community Acquired Pneumonia
2. Atrial Fibrillation with Rapid Ventricular Rate
3. Bilateral Pleural Effusions
SECONDARY DIAGNOSES:
====================
1. Seizure Disorder
2. Chronic Kidney Disease
3. Hypertension
4. Coronary Artery Disease
5. BPH
6. GERD
7. Vitamin D Deficiency
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 meeting and caring for you during your most
recent hospitalization. You were admitted with chest pain. We
found that you had a pneumonia which we treated with
antibiotics. We also found that you were in an abnormal heart
rhythm called atrial fibrillation. This rhythm causes your
heart to beat fast, but you did not have any symptoms from this.
We started you on a blood thinner, coumadin, to reduce your
risk of stroke. Because Coumadin takes a few days to build up
in your system, you were also discharged on lovenox, a
medication that will thin your blood.
All the best,
Your ___ Care Team
Followup Instructions:
___
|
19747837-DS-15
| 19,747,837 | 23,181,068 |
DS
| 15 |
2185-03-16 00:00:00
|
2185-03-21 17:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left hand numbness, left sided dysmetria
Major Surgical or Invasive Procedure:
na
History of Present Illness:
___ is a ___ year-old right-handed man with history of
HTN,
HLD, Afib DVT/PE on coumadin (INR 3.1) with prior left pontine
lacunar infarct in ___ and CKD who presents with episodic left
hand numbness and concern for new dysmetria.
The patient is an extremely poor historian and the specific
details of his account of the story changed on 3 separate
examiner histories. To the best of my understanding the patient
first developed LEFT hand numbness and tingling upon waking up
on
the morning of ___. This is described as a tingling and burning
sensation involving only the left hand not involving the forearm
or leg. He was not particularly weak but found it difficult to
use the hand due to sensory changes. The episode resolved
within
1 hour and he had no further symptoms. The patient cannot
accurately determine if the right hand was involved and he
changes his story on repeat questioning, and asks his wife what
she thinks. They both agree that he following day ___ he was
completely without symptoms but this afternoon around 1PM he
again developed another 10 minute episode of paresthesias only
in
the left hand. This time he may have had a mild posterior HA in
association. So far as I can tell, he had no speech difficulty,
weakness, lightheadedness or vision change associated with these
events. He does not endorse gait instability worse than
baseline.
He denies a history of N/T related to sleep of position-related
peripheral neuropathy of the hand.
Despite his history of stroke, he appears to have a reasonably
good functional status with mild memory deficits, left
hemianopsia, normal motor strength, narrow based but slow gait
noted on recent ___ notes. Of note his seizures are described
as brief <30 second episodes of slurred speech and staring, last
one in ___ and then ___ years before that. Interestingly Epilepsy
notes also document seizures which begin with left hand and foot
numbness and a funny smell, followed by GTC. He denies
olfactory
hallucinations or convulsions, and is stable on keppra 1500mg
BID.
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:
- Left pontine lacunar CVA - ___
- Left parietal occipital hemorrhage secondary to
hypertension - ___
- Seizure disorder - began following CVA, on Keppra, reports
ongoing seizure episodes manifested by staring episodes and
facial droop. Followed by Dr. ___
- ___ MI - ___
- Afib - documented by ECG in ___ in setting of DVT/PE
- Hypertension
- Hypercholesterolemia
- History of DVT in the setting of hospitalization - ___
- History of small-bowel obstruction - ___
- Chronic kidney disease stage III with ___ baseline Crt ___
- Recurrent falls
- Status post right rotator cuff injury
- DVTs and PEs - ___
- Vocal cord cancer
- Urinary retention
- Sciatica
- Osteoarthritis
Social History:
___
Family History:
Father hx. of MI/CAD and died ___ complications of prostate
cancer. Pt.' sister had hx of cancer; unsure what type.
Otherwise, denies other family members with hx. of heart or lung
disease.
Physical Exam:
Physical Exam:
Vitals: T: 98.9 76 177/100 16 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: irregularly irregular. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Somewhat inattentive, 2
errors with ___ backward. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Some difficulty with complex commands. Pt was able to
register 4 objects and recall ___ spontaneously at 5 minutes.
There was no evidence of neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. Specifically no
deficits in sensation when testing the cutaneous areas of the
left or right hand. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 2
R 3 3 3 3 2
Plantar response was upgoing on the right, possibly bilateral.
-Coordination: Left arm with dysmetria on FNF and H2S. He has
difficulty tapping on the shin bone in a specific spot.
-Gait: Normal base but appears unsteady with some stumble to the
left on one occasion. Romberg negative.
Pertinent Results:
___ 09:10PM BLOOD WBC-4.9 RBC-5.84 Hgb-17.7 Hct-53.7*
MCV-92 MCH-30.3 MCHC-33.0 RDW-15.1 Plt ___
___ 09:10PM BLOOD Neuts-56.6 ___ Monos-9.9 Eos-2.5
Baso-2.4*
___ 10:10PM BLOOD ___ PTT-43.0* ___
___ 09:10PM BLOOD Glucose-111* UreaN-19 Creat-1.5* Na-138
K-3.6 Cl-101 HCO3-23 AnGap-18
___ 09:10PM BLOOD cTropnT-<0.01
___ 07:53AM BLOOD Triglyc-174* HDL-54 CHOL/HD-3.6
LDLcalc-105
___ 07:53AM BLOOD TSH-5.2*
___ 07:53AM BLOOD %HbA1c-6.1* eAG-128*
STUDIES
NCHCT ___:
1. No acute intracranial process.
2. Small 8 mm fusiform aneurysm in the left vertebral artery
(2:7), which has been stable from multiple priors back to ___.
Recommend clinical correlation.
MRI/MRA ___:
1. No acute abnormality on the brain MRI. Chronic
encephalomalacic changes in the right parietal lobe. No
significant stenosis in the intracranial or neck vasculature.
2. No acute abnormality on the brain MRI. Chronic
encephalomalacic changes in the right parietal lobe. No
significant stenosis in the intracranial or neck vasculature.
Brief Hospital Course:
___ is a ___ year-old right-handed man with history of
HTN, HLD, Afib DVT/PE on coumadin (INR 3.1) with prior left
pontine lacunar infarct in ___ and CKD who presents with
episodic left hand numbness and concern for new dysmetria. The
clinical history was difficult to ascertain, but given the
patient's overwhelming vascular risk factors and apparent
worsened coordination on exam, the concern was for another small
ischemic event involving the cerebellum or along cerebellar
pathways. He was found to be therapeutic on warfarin. MRI/MRA
was negative for stroke. Ddx at discharge was TIA vs seizure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Amiodarone 200 mg PO BID
4. Amlodipine 5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Finasteride 5 mg PO DAILY
9. Gabapentin 100 mg PO Q6H
10. Hydrochlorothiazide 25 mg PO DAILY
11. LeVETiracetam 1500 mg PO BID
12. Losartan Potassium 100 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Rosuvastatin Calcium 10 mg PO DAILY
15. Ranitidine 300 mg PO HS
16. Sodium Chloride Nasal ___ SPRY NU DAILY:PRN dry
17. Senna 8.6 mg PO BID:PRN constipiation
18. Vitamin D 1000 UNIT PO DAILY
19. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Amiodarone 200 mg PO BID
4. Amlodipine 5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Finasteride 5 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Gabapentin 100 mg PO Q6H
10. Hydrochlorothiazide 25 mg PO DAILY
11. LeVETiracetam 1500 mg PO BID
12. Losartan Potassium 100 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Ranitidine 300 mg PO HS
15. Rosuvastatin Calcium 10 mg PO DAILY
16. Senna 8.6 mg PO BID:PRN constipiation
17. Sodium Chloride Nasal ___ SPRY NU DAILY:PRN dry
18. Vitamin D 1000 UNIT PO DAILY
19. Warfarin 2 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
paresthesia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted to the hosptial due to your symptoms of left
hand numbness. We performed an MRI which showed that you did not
have a stroke. We believe that this symptom may have been the
result of a brief seizure. You should continue all of your
medications as you were prior to coming to the hospital.
Followup Instructions:
___
|
19747837-DS-17
| 19,747,837 | 27,747,084 |
DS
| 17 |
2186-04-23 00:00:00
|
2186-04-23 09:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Bactrim
Attending: ___
Chief Complaint:
breakthrough seizures, status epilepticus
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Mr. ___ is a ___ RH M with an extensive PMHx including
Afib, DVT/PE (on coumadin), SCC of R vocal cord, L pontine
lacunar CVA (___), L parietal occipital hemorrhage ___ HTN
(___), and seizure disorder who presents from home following a
prolonged seizure without return to baseline concerning for
focal
motor status epilepticus (epilepsia partialis continua). The
below history was obtained from Ms. ___, Mr. ___
caregiver.
Mr. ___ had been in his usual state of health prior to this
event - though he had complained of vague fatigue for the
previous three days. Ms. ___ denies that Mr. ___ had any
fevers, chills, cough, N/V/D, or preceding illness. She denies
that he missed any medication doses. Mr. ___ went to an eye
appointment at ___ where he had some drops but in his eyes to
dilate them. He had no difficulties during this appointment and
appeared well when the two returned home.
Around dinner time asked Ms. ___ for some fruit, but only ate
a
few bites. Ms. ___ reports that Mr. ___ was sitting in a
chair and staring off into the distance, up and too the left.
She
asked him what he was looking at and he said "the curtains, they
are so pretty." After that he became quite silent, and she
stated
that she "knew something wasn't right." He was quiet and
starting
off for around 10 minutes. He then began to complain that his
LUE
felt weak. Around this time, Ms. ___ called ___ because his
behavior seemed quite atypical to her. EMS instructed her not to
give him any of the sublingual benzo that she had at home. Prior
to EMS arriving, Mr. ___ began to have rhythmic twitching of
his left arm that quickly spread to include his face and leg.
Upon arrival to the ___ ED, Mr. ___ was having was reported
as having rhythmic twitching of the left face, arm, leg at ~4Hz.
He was reportedly following commands on presentation. He was
given ativan 2mg IV followed by 2mg IV without resolution of his
symptoms. He was given another 2mg IV and subsequently became
quite somnolent and stopped following any commands.
By the time this examiner reached the bedside, Mr. ___ was in
the process of being intubated for course breath sounds and
concern for poor airway protection. Propofol was initially
started for sedation and seizure control but resulted in sBP
drop
into the ___. Sedation was subsequently changed to midazolam.
Past Medical History:
- Left pontine lacunar CVA - ___
- B/L occipital hemorrhage secondary to HTN
-- R side in ___
-- L side in ___
- Seizure disorder - on Keppra, follows with Dr. ___
-- ___ detailed in OMR, include L sided symptoms
-- ___ admission for complex partial status epilepticus
(shaking of the left arm and leg)
--- trigger: decreased sleep, infection, Bactrim use
- Status post MI - ___
- Hypertension
- Hypercholesterolemia
- History of DVT in the setting of hospitalization - ___
- History of small-bowel obstruction - ___
- Chronic kidney disease stage III with ___ baseline Crt ___
- Recurrent falls
- Status post right rotator cuff injury
- DVTs and PEs - ___
- Afib - ___ in setting of DVT/PE
- Vocal cord cancer
- Urinary retention
- Sciatica
- Osteoarthritis
Social History:
___
Family History:
Father - MI/CAD and died ___ complications of prostate Ca
sister - hx of cancer; unsure what type
Physical Exam:
ON ADMISSION:
VS T97.4 HR69 BP154/95 RR21 Sat100%
GEN - intubated, midazolam held x5 minutes
HEENT - supple, no meningismus
CV - RRR
RESP - intubated, coarse upper airway sounds
ABD - soft, NT, ND
EXTR - atraumatic, WWP
NEUROLOGICAL EXAMINATION
MS - intubated, sedated on midazolam, no commands
CN - PERRL, +corneals B/L, face symmetric around ETT, no grimace
observed
SENSORIMOTOR - briskly withdraws RUE to nox; withdraw RLE to
nox;
no response in LUE or LLE to deep nox
REFLEXES - 2+ and symmetric, toes are mute
Pertinent Results:
LABS:
On Admission:
___ 06:58PM BLOOD WBC-5.8 RBC-5.13 Hgb-15.1 Hct-45.8 MCV-89
MCH-29.4 MCHC-33.0 RDW-15.0 RDWSD-49.2* Plt ___
___ 06:58PM BLOOD Neuts-47.4 ___ Monos-13.5*
Eos-1.2 Baso-0.5 Im ___ AbsNeut-2.73 AbsLymp-2.14
AbsMono-0.78 AbsEos-0.07 AbsBaso-0.03
___ 06:58PM BLOOD ___ PTT-40.2* ___
___ 06:58PM BLOOD Glucose-122* UreaN-16 Creat-1.5* Na-134
K-8.4* Cl-95* HCO3-23 AnGap-24*
___ 06:58PM BLOOD ALT-190* AST-168* CK(CPK)-322 AlkPhos-67
TotBili-0.9
___ 06:58PM BLOOD Lipase-30
___ 06:58PM BLOOD cTropnT-<0.01
___ 06:58PM BLOOD Albumin-4.7 Calcium-10.4* Phos-3.8#
Mg-2.2
___ 01:11AM BLOOD TSH-1.4
___ 06:58PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:00PM BLOOD Lactate-7.8* K-6.7*
IMAGING:
CXR ___: No acute cardiopulmonary process.
NCHCT ___: No acute intracranial process.
CT C-Spine ___: No acute fracture or traumatic malalignment.
Brief Hospital Course:
___ is a ___ year old man with a h/o HTN, HLD, Afib and
PEs (on coumadin), prior infarcts and multiple IPHs c/b
epilepsy, who presented with a 45 min breakthrough seizure and a
history consistent with focal motor status epilepticus.
# STATUS EPILEPTICUS:
He became somnolent after 6mg Ativan in the ED, requiring
intubation, after which he was sedated with Versed. Per his
recent outpatient epilepsy clinic note, he recently stopped
lamotrigine (b/c of sedation) and gabapentin (because it make
him "loopy") and this may have been the trigger for his
breakthrough seizure. This may be exacerbated by UTI (final
urine culture is pending) In the ED Mr. ___ was intubated,
loaded with phenytoin, and started on a midazolam drip, and his
clinical seizures stopped. He was extubated the following day
and has had no further seizures. He continued his home Keppra
1500mg BID. He was loaded on phenytoin but developed elevated
LFTs and a junctional cardiac rhythm - both are felt to be side
effects from PHT toxicity. His phenytoin was stopped and keppra
was started at 1500mg BID and zonisamide was started at 100mg
qhs. Needs to increase the dose of zonisamide to 200mg on
___. Dr. ___ see him in clinic on ___ at 8am and
titrate his medications from there.
# Atrial Fibrillation, with junctional rhythm:
Patient was continued on coumadin for afib. He developed a
junctional rhythm on tele that may be from PHT toxicity. His
home amiodarone was held initially while intubated and stopped
due to acute liver injury with LFTs in the 1000s. Coumadin was
also held because his INR became supratherapeutic likely ___
acute liver injury. INR trending down, will need INR checks
while at acute rehab.
# History of PE:
COumadin held while INR supratherapeutic, will need to restart
in rehab.
# Recent right eye surgery:
continued home eye drops
# UTI: needs 10 day course of cefpodoxime
# Elevation of LFTs
Patient developed acute on chronic elevated on LFTs. This was
felt to be from PHT toxicity. His LFTs were trended and
decreased. Liver ultrasound was normal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation 2 puffs every
four (4) hours as needed wheezing
2. Amiodarone 200 mg PO BID
3. Benzonatate 100 mg PO QPM cough
4. dorzolamide-timolol 22.3-6.8 mg/mL ophthalmic 1 drop both
eyes, BID
5. Finasteride 5 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QPM
8. LeVETiracetam 500 mg PO BID
9. losartan 100 mg oral DAILY
10. mometasone 50 mcg inhalation 1 spray, BID
11. Omeprazole 20 mg PO DAILY
12. Klor-Con 10 (potassium chloride) 10 mEq oral every other day
13. rosuvastatin 5 mg oral DAILY
14. Ascorbic Acid ___ mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Docusate Sodium 100 mg PO BID
18. Fish Oil (Omega 3) 1000 mg PO TID
19. Senna 8.6 mg PO BID:PRN constipation
20. Warfarin 2 mg PO BID
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation inhalation 2 puffs every
four (4) hours as needed wheezing
2. Ascorbic Acid ___ mg PO DAILY
3. Benzonatate 100 mg PO QPM cough
4. Docusate Sodium 100 mg PO BID
5. dorzolamide-timolol 22.3-6.8 mg/mL OPHTHALMIC 1 DROP BOTH
EYES, BID
6. Finasteride 5 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO TID
8. Hydrochlorothiazide 25 mg PO DAILY
9. Klor-Con 10 (potassium chloride) 10 mEq oral every other day
10. mometasone 50 mcg inhalation 1 spray, BID
11. Omeprazole 20 mg PO DAILY
12. rosuvastatin 5 mg oral DAILY
13. Senna 8.6 mg PO BID:PRN constipation
14. Vitamin D 1000 UNIT PO DAILY
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QPM
16. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 7 Days
17. Warfarin 2 mg PO BID
hold until INR in goal range of ___, then restart
18. Keppra XR (levETIRAcetam) 1500 mg oral BID
19. Tobramycin-Dexamethasone Ophth Susp 1 DROP RIGHT EYE QAM
20. Zonisamide 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizures
Discharge Condition:
voiding, taking po, afebrile, needs acute rehab to help with
strength and ambulation, alert and oriented to person/place/time
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for seizure breakthrough consistent
with focal motor status epilepticus. You were somnolent in the
ED after receiving ativan, so you required intubation and
sedation. This seizure likely occurred because you have been off
your lamotrigine and gabapentin in the setting of a urinary
tract infection. You were extubated the next day and had no
further issues. Unfortunately, your liver suffered some damage
likely from some of the medications you required to help with
your seizure. Your liver enzymes are improving, but it is still
having some effect on your INR levels. As a result, you will
need your INR checked reguarly while at rehab, and the
physicians there will dose your coumadin appropriately.
You are currently on Keppra XR 1500mg BID and zonisamide 100mg
daily. Please increase the dose of your zonisamide to 200mg on
___. Dr. ___ see you in clinic on ___ at 8am and
titrate your medications from there.
It was a pleasure taking care of you while you were in the
hospital, and we wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19747837-DS-18
| 19,747,837 | 25,082,027 |
DS
| 18 |
2186-11-14 00:00:00
|
2186-11-17 18:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Bactrim / phenytoin
Attending: ___
Chief Complaint:
left arm weakness and numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ right-handed man with seizures
secondary to bilateral occipital hemorrhages, multiple medical
problems including atrial fibrillation, small cell carcinoma of
the right vocal cord, DVT/PE on Coumadin, left pontine lacunar
stroke who presented with left arm weakness and disco
ordination.
He was having problems controlling the left arm, and it felt
numb. This started at 4 pm. He could not use it normally and it
seemed unsteady. He was concerned, since he has multiple
neurological problems, so his wife brought him to the ED. In the
ED, he now feels better than before. He has never had this
before and this is not like his known seizures.
He has been sleeping a lot for the past 2 days but otherwise has
felt well.
He last had a seizure 1 month ago, with lip smacking and altered
consciousness.
Per chart review:
Seizure types:
1. Complex partial: Episodes of slurred speech associated with
staring and lip smacking movements, but says he is able to hear
his surroundings, is unable to respond appropriately, followed
by
confusion for 15 minutes and somnolence. These events can be
triggered by increased physical activities. The most recent was
in late ___.
2. Secondarily generalized tonic-clonic: Episodes of left hand
and foot numbness and a funny smell, possibly followed by a
generalized convulsion. Last in ___, then ___.
3. Complex partial: Staring, unresponsiveness, then left arm,
face, and leg rhythmic clonus, prolonged. ___.
4. Undetermined: Episodes of strange sensation on the top of
his
head, burning or crawling inside his head, no loss of
consciousness or confusion, lasting ___ seconds. Often
associated with anxiety.
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. 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:
- Left pontine lacunar CVA - ___
- B/L occipital hemorrhage secondary to HTN
-- R side in ___
-- L side in ___
- Seizure disorder - on Keppra and Zonisamide, follows with Dr.
___
-- ___ admission for complex partial status epilepticus
(shaking of the left arm and leg)
-- triggers: decreased sleep, infection, Bactrim use
- Status post MI - ___
- Hypertension
- Hypercholesterolemia
- History of DVT in the setting of hospitalization - ___
- History of small-bowel obstruction - ___
- Chronic kidney disease stage III with ___ baseline Crt ___
- Recurrent falls
- Status post right rotator cuff injury
- DVTs and PEs - ___
- Afib - ___ in setting of DVT/PE, on Coumadin
- Vocal cord squamous cell cancer
- Urinary retention
- Sciatica
- Osteoarthritis
Social History:
___
Family History:
Father - MI/CAD and died ___ complications of prostate Ca
sister - hx of cancer; unsure what type
Physical Exam:
ADMISSION PHYSICAL EXAM:
97.7 120 163/00 18 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple, no nuchal rigidity.
Pulmonary: CTABL
Cardiac: irregularly irregular, tachycardic
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: venous stasis changes.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Attentive, able to name ___
backward without difficulty. There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. left field cut (baseline).
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ 4+ 5 4+ 4+ ___ 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
-Plantar response was flexor bilaterally.
-Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick. proprioception
diminished in great toes.
-Coordination: Left dysmetria on FNF and HKS.
-Gait: not tested.
================================================================
DISCHARGE PHYSICAL EXAM:
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Attentive, able to name ___
backward without difficulty.
-Cranial Nerves:
I: Olfaction not tested.
II: Right pupil 4->3mm, left pupil 5-> 4mm.
III, IV, VI: Right ptosis. Left homonymous hemianpsia. EOMI
without nystagmus. Normal saccades. No overshoot on saccadic
testing.
V: Facial sensation intact to light touch in all distributions
VII: Mild left NLFF, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted. Pain limited exam of the right deltoid.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L ___ ___ ___ 5 5 5
R 4* ___ ___ ___ 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
-Plantar response was flexor bilaterally.
-Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch.
-Coordination: Left dysmetria on FNF and mirroring. Normal FNF
on right. Good finger tap bilaterally. Normal HTS in bilateral
LEs.
-Gait: Stands unassisted. Narrow based gait, unsteady, needs 1
person assist or walker to walk.
Pertinent Results:
ADMISSION LABS:
___ 07:05PM BLOOD WBC-4.2# RBC-4.82 Hgb-13.1* Hct-42.3
MCV-88 MCH-27.2 MCHC-31.0* RDW-15.7* RDWSD-50.2* Plt ___
___ 07:05PM BLOOD Neuts-37.8 ___ Monos-12.5 Eos-3.4
Baso-1.0 Im ___ AbsNeut-1.58*# AbsLymp-1.88 AbsMono-0.52
AbsEos-0.14 AbsBaso-0.04
___ 07:05PM BLOOD ___ PTT-33.0 ___
___ 07:05PM BLOOD Glucose-84 UreaN-20 Creat-1.5* Na-139
K-4.6 Cl-107 HCO3-18* AnGap-19
___ 07:05PM BLOOD ALT-19 AST-35 AlkPhos-50 TotBili-0.4
___ 07:05PM BLOOD Lipase-25
___ 07:05PM BLOOD cTropnT-<0.01
___ 06:05AM BLOOD Calcium-9.5 Phos-2.4* Mg-2.0 Cholest-PND
___ 07:05PM BLOOD Albumin-4.3
___ 07:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
CXR ___:
No acute cardiopulmonary process.
CTA HEAD AND NECK ___:
1. Unchanged 8 mm aneurysm of the left mid V4 segment. No new
aneurysms.
2. Patent vasculature in the neck with no evidence of internal
carotid artery stenosis by NASCET criteria.
3. No acute intracranial abnormality.
4. Unchanged encephalomalacia of the right parietal lobe.
DISCHARGE LABS:
___ 06:05AM BLOOD TSH-4.9*
___ 06:05AM BLOOD Triglyc-153* HDL-39 CHOL/HD-4.8
LDLcalc-118
___ 06:05AM BLOOD %HbA1c-6.1* eAG-128*
Brief Hospital Course:
Mr. ___ is a ___ right-handed man with seizures
secondary to bilateral occipital hemorrhages with residual left
homonymous hemianposia, multiple medical problems including
atrial fibrillation, small cell carcinoma of the right vocal
cord, DVT/PE on Coumadin, left pontine lacunar stroke who
presents with left arm and leg weakness, parasthesiaes and
discoordination, with likely an acute ischemic stroke.
His exam was initially notable for left homonymous hemianopsia,
left wrist extensor, finger extensor weakness, and left sided
dysmetria on exam. The weakness resolved, but he continued to
have left sided ataxia with finger-nose and mirroring. He
underwent CT scan which showed unchanged encephalomalacia of the
right parietal lobe without acute intracranial abnormality. He
also had CTA head and neck which showed an unchanged 8 mm
aneurysm of the left mid V4 segment. There was no flow limiting
stenosis or thrombus. Unfortunately, he was unable to get an MRI
due to recent surgical procedure of his right eye involving
metal. However, given the sudden onset symptoms and change in
neurologic exam, etiology of his symptoms was thought to be
acute ischemic stroke. Labs were notable for a subtherapeutic
INR to 1.8, though embolism secondary to afib is unlikely the
cause of his symptoms given the minimal deficits on exam. The
more likely etiology is small vessel disease given his extensive
vascular risk factors and atherosclerotic disease.
His aspirin was continued and he was started on Apixaban given
recent subtherapeutic INR. In he past year, his Cr has been less
than 1.5, so the team felt comfortable starting on Apixaban 5mg
po BID in accordance with recommended guidelines. Warfarin was
discontinued. Intracranial bleeding risk is less with Apixaban
than Warfarin and this was taken into account given his history
of IPH. Stroke risk factors were checked including: A1C of 6.1,
LDL of 118. His Pravastatin was increased from 10 to 20mg.
He will have TTE as an outpatient and his cardiologist will
follow-up the results.
He was evaluated by ___ who recommended home with supervision
with walker given his unsteady gait.
He will follow-up with neurology and cardiology and these
appointments were set prior to discharge.
Transitional issues:
-f/u TTE
-starting apixaban, d/c warfarin
-continue aspirin
=
=
=
=
=
=
================================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - warfarin () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 118) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - home ___ () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - aspirin (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - apixaban() No - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
2. Docusate Sodium 100 mg PO BID
3. LeVETiracetam 1500 mg PO BID
4. Nasonex (mometasone) 50 mcg/actuation nasal BID:PRN nasal
symptoms
5. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN dyspnea
6. Aspirin 81 mg PO DAILY
7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
8. Finasteride 5 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. LORazepam 2 mg/mL oral DAILY:PRN motor seizure > 3 mins
11. Losartan Potassium 50 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Pravastatin 10 mg PO QPM
14. Zonisamide 200 mg PO QHS
15. Warfarin 4 mg PO 5X/WEEK (___)
16. Warfarin 6 mg PO 1X/WEEK (TH)
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*5
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Finasteride 5 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. LeVETiracetam 1500 mg PO BID
8. LORazepam 2 mg/mL oral DAILY:PRN motor seizure > 3 mins
9. Pravastatin 20 mg PO QPM
RX *pravastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*5
10. Zonisamide 200 mg PO QHS
11. albuterol sulfate 90 mcg/actuation INHALATION Q4H:PRN
dyspnea
12. Losartan Potassium 50 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Nasonex (mometasone) 50 mcg/actuation nasal BID:PRN nasal
symptoms
15. Vitamin D 1000 UNIT PO DAILY
16. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice a day Disp #*13 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of left sided weakness and
parasthesiaes 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:
-atrial fibrillation
-high cholesterol
-high blood pressure
We are changing your medications as follows:
-STOP WARFARIN
-START APIXABAN
-CONTINUE ASPIRIN
-INCREASE PRAVASTATIN
Please take your other medications as prescribed.
Additionally, on routine workup, you were found to have a
urinary tract infection (UTI), which may explain why you have
been urinating more frequently lately. We have prescribed an
antibiotic to treat the UTI. Please make sure to take the
entire course of medication, even if your symptoms resolve
before you have finished.
You will have an ultrasound of your heart as part of the stroke
work-up. The appointment is scheduled below for ___ @ 9:30am.
There are no dietary restrictions prior to this test.
Please followup with the physicians listed below, including your
neurologist and your primary care physician.
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:
___
|
19747837-DS-20
| 19,747,837 | 29,475,369 |
DS
| 20 |
2188-07-29 00:00:00
|
2188-07-29 12:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Bactrim / phenytoin
Attending: ___.
Chief Complaint:
Abdominal distension, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of constipation, atrial fibrillation and
DVT/PE on anti-coagulation, strokes, laryngeal cancer who
presents with three days of right lower quadrant pain and
malaise. He reports acute onset of RLQ pain that is sharp,
stabbing and severe in nature and has not resolved. He endorses
nausea and poor PO intake but denies emesis. He denies fevers
and chills. He has chronic constipation at baseline and has not
had a bowel movement in approximately one week but reports that
he has been intermittently passing gas. He has a history of
urinary incontinence which has been exacerbated in the setting
of this new RLQ pain, but denies urinary urgency or
foul-smelling urine.
The patient was brought to the ED by his caretaker ___
(___). He was noted to be febrile and tachycardic upon
presentation but defervesced and stabilized with IVF And IV
antibiotics.
Patient was admitted for almost 3 months during which he
underwent exploratory laparotomy, extensive lysis of adhesions,
right colectomy and small bowel resection, and temporary
abdominal closure and ileocolic anastomosis, partial colectomy,
loop jejunostomy, abdominal closure with wound vac. His clinical
course was complicated with failure to thrive, atrial
fibrillation, gastroparesis, and inability to take PO nutrition
due to not absorbing and high residuals.
On ___, patient was stable enough on PO medications, afib rate
controlled and tolerating TPN so the patient was discharged to a
long term care facility with plans to follow up in the ___
clinic
in the next 2 weeks.
At the long term care facility the patient started having
projectile vomiting x3 and his abdomen was noted more distended
so the patient was sent back to the Emergency department at
___
for evaluation and recommendations. ACS evaluated the patient in
the ED and given his recent discharge (less than 24 hours ago)
patient was re-admitted for workup.
Past Medical History:
- Left pontine lacunar CVA - ___
- B/L occipital hemorrhage secondary to HTN
-- R side in ___
-- L side in ___
- Seizure disorder - on Keppra and Zonisamide, follows with Dr.
___
-- ___ admission for complex partial status epilepticus
(shaking of the left arm and leg)
-- triggers: decreased sleep, infection, Bactrim use
- Status post MI - ___
- Hypertension
- Hypercholesterolemia
- History of DVT in the setting of hospitalization - ___
- History of small-bowel obstruction - ___
- Chronic kidney disease stage III with ___ baseline Crt ___
- Recurrent falls
- Status post right rotator cuff injury
- DVTs and PEs - ___
- Afib - ___ in setting of DVT/PE, on LVX
- Vocal cord squamous cell cancer
- Urinary retention
- Sciatica
- Osteoarthritis
- Perforated appendicitis failed conservative management (___)
PSH:
___: Exploratory laparotomy, extensive lysis of adhesions,
right colectomy and small bowel resection, and temporary
abdominal closure.
___: Ileocolic anastomosis, partial colectomy, loop
jejunostomy, abdominal closure with wound vac.
___: Trach/PEG
Social History:
___
Family History:
Father - MI/CAD and died ___ complications of prostate Ca
sister - hx of cancer; unsure what type
Physical Exam:
PHYSICAL EXAM ON DISCHARGE:
GEN: NAD, oriented to person, place
RESP: Trach in place, no respiratory distress
CV: Irregularly irregular
ABD: Moderately distended, G-tube in place to gravity with
bilious drainage. LLQ JP in place with dark scant ouptut,
midline incision well healed
EXT: WWP
Pertinent Results:
___ 12:13AM BLOOD WBC-12.1* RBC-2.84* Hgb-7.3* Hct-25.2*
MCV-89 MCH-25.7* MCHC-29.0* RDW-20.0* RDWSD-65.3* Plt ___
___ 01:26AM BLOOD WBC-9.6 RBC-2.99* Hgb-7.6* Hct-25.9*
MCV-87 MCH-25.4* MCHC-29.3* RDW-19.9* RDWSD-62.4* Plt ___
___ 07:25AM BLOOD WBC-15.4*# RBC-2.77* Hgb-7.0* Hct-23.6*
MCV-85 MCH-25.3* MCHC-29.7* RDW-19.8* RDWSD-62.0* Plt ___
___ 02:15PM BLOOD Glucose-117* UreaN-48* Creat-1.7* Na-135
K-3.9 Cl-97 HCO3-24 AnGap-14
___ 01:26AM BLOOD Glucose-141* UreaN-44* Creat-1.5* Na-135
K-3.5 Cl-98 HCO3-26 AnGap-11
___ 07:25AM BLOOD Glucose-140* UreaN-37* Creat-1.3* Na-139
K-3.5 Cl-102 HCO3-24 AnGap-13
___ 02:15PM BLOOD Calcium-9.2 Phos-4.4 Mg-2.3
___ 01:26AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.2
___ 07:25AM BLOOD Calcium-9.2 Phos-2.3* Mg-2.1
CT A/P (___)
1. Slight increase in degree of diffuse small-bowel distension
without
transition point likely represents ileus. However, early or
partial small
bowel obstruction cannot be excluded given the presence few
normal caliber
distal small bowel loops.
2. Slight interval decrease in small bilateral pleural
effusions.
3. Interval decrease in size of left psoas abscess with pigtail
catheter in appropriate position. No evidence of new fluid
collections or discrete
abscess.
4. Slight interval decrease in abdominopelvic free fluid.
CXR (___)
Compared to chest radiographs ___ through ___.
Relative symmetry of bibasilar opacification argues for
pulmonary edema at
hilar alone or perhaps in conjunction with pneumonia, but is
unlikely to be pneumonia alone. Findings are relatively
unchanged since ___. Small right pleural effusion is
likely. No pneumothorax. Moderate cardiomegaly stable.
Left PIC line ends at the origin of the SVC. Tracheostomy tube
midline.
Brief Hospital Course:
Hospital course ___
Patient was stable and sent to a Long Term Facility on ___
after being stable for some weeks. While in the facility, there
was some confusion with the diet order. Patient was restarted on
his Tube feeds (that were supposed to be held) and his G-tube
was not vented so the patient backed up and vomited 3 times and
sent back to the ED and ___. He was admitted to the ___ for
close monitoring and evaluation. Patient was admitted and
observed. TF were discontinued and patient restarted in TPN.
Patient did well and tolerated this regimen for 3 days. Patient
is now stable enough again and will be discharged back to his
Long term facility with scheduled follow up in the ___ clinic.
N: Patient continues to have AMS. He is to continue Keppra 1gm
PO BID. No seizure activity noted during this admission.
R: Patient is maintained on and off TM during this
hospitalization via the tracheostomy and should continue to be
maintained on and off the vent as tolerated.
CV: Patient continues to have A. fib that is difficult to rhythm
control. He continues on Diltiazem 90mg PO TID, Metop 25mg PO
Q6H, and Amiodarone 400BID and will need to follow up with
cardiology/PCP outpatient to continue management.
GI: His tube feed continues to be held. G-tube is placed to
gravity and clamped while meds are given. He continues on the
aggressive bowel regimen and has daily bowel movements.
Abdominal distension improved.
In summary, despite an extensive work-up, the cause of his
intolerance to tube feeds was unclear. We have had several
attempts to advance his tube feed rate, but the patient would
not tolerate rates higher than 20 cc/h. THEREFORE IT WAS DECIDED
THAT THE PATIENT SHOULD CONTINUE HIS NUTRITION EXCLUSIVELY WITH
TPN AND HOLD TUBE FEEDS INDEFINITELY. Also, G-tube should be
constantly vented to prevent abdominal distention and pain. It
can be held for medication and clamped for 30 minutes during
that time. The decision to restart TF will be taken by the
surgery team during follow up visits.
GU: Patient has hx of CKD and all medication are renally dosed.
HEME: Patient was transitioned to Rivaroxaban for treatment of
A. fib. (LVX caused increased in his creatinine) LLQ JP drain in
place for drainage of Psoas hematoma from previous admission.
Removal of drain will be discussed during his follow up
appointment in the surgery clinic. Please monitor output daily.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Pravastatin 20 mg PO QPM
4. Senna 8.6 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. Metoprolol Tartrate 25 mg PO QID
7. Fleet Enema (Saline) ___AILY:PRN if no stool for >24
hrs
8. Amiodarone 400 mg PO BID
9. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Dry
eyes
10. Bisacodyl ___AILY \
11. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
12. Docusate Sodium 100 mg PO BID
13. Erythromycin 250 mg PO Q6H
14. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
15. Zonisamide 200 mg PO BID
16. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN For use with
mucomyst
17. Aspirin 81 mg PO DAILY
18. Diltiazem 90 mg PO TID
19. Enoxaparin Sodium 90 mg SC Q12H
20. Acetylcysteine 20% ___ mL NEB Q6H:PRN thick secretions
21. Famotidine 20 mg IV Q24H
22. LevETIRAcetam 1000 mg IV Q12H
23. Metoclopramide 10 mg IV Q6H
24. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
25. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
26. Vital AF 1.2 Cal (nut.tx.impaired dige fxn-fiber) 0.08 gram-
1.2 kcal/mL oral Continuous
Discharge Medications:
1. Famotidine 20 mg PO Q24H
2. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
3. LevETIRAcetam 1000 mg PO Q12H
4. Rivaroxaban 15 mg PO DAILY
RX *rivaroxaban [Xarelto] 15 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Metoprolol Tartrate 25 mg PO Q6H
6. Acetylcysteine 20% ___ mL NEB Q6H:PRN thick secretions
7. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN For use with
mucomyst
8. Amiodarone 400 mg PO BID
9. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN Dry
eyes
10. Aspirin 81 mg PO DAILY
11. Bisacodyl ___AILY \
12. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
13. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
14. Diltiazem 90 mg PO TID
15. Docusate Sodium 100 mg PO BID
16. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES TID
17. Erythromycin 250 mg PO Q6H
18. Fleet Enema (Saline) ___AILY:PRN if no stool for
>24 hrs
19. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
20. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
21. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
22. Metoclopramide 10 mg IV Q6H
23. Polyethylene Glycol 17 g PO DAILY
24. Pravastatin 20 mg PO QPM
25. Senna 8.6 mg PO DAILY
26. Zonisamide 200 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Nausea, vomiting
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after having
nausea, abdominal distension, and vomiting. You have done well
from that and is not ready to be discharged. Please follow the
instructions below to ensure a safe recovery.
You have a G-tube in place from previous admission, please
continue that to gravity and do not clamp. The G-tube will
assist in preventing your stomach from overfilled with fluid
that causes emesis. The G-tube can be clamped 30 minute during
the time medication is given through it.
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.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
19747913-DS-21
| 19,747,913 | 23,900,180 |
DS
| 21 |
2147-03-08 00:00:00
|
2147-03-10 09:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetanus
Attending: ___.
Chief Complaint:
Apnea
Major Surgical or Invasive Procedure:
Exploratory laparoscopy, lysis of adhesions, partial hiatal
hernia reduction with plication to the left crus and
percutaneous gastrostomy tube, endoscopically guided ___
___
___ of Present Illness:
___ with PMH of hypothyroidism, HTN, bipolar disorder, and
breast ca with post-breast radiation BOOP and restrictive lung
disease who originally presented to the hospital about 2 weeks
ago for repair of a large paraesophageal hernia that was thought
to potentially be contributing to her increased WOB and choking,
particularly after eating. Had a lap fundo, gastropexy, and G
tube placed on ___ that was uncomplicated. However,
intermittently had episodes of hypoxia that led to BiPap
initiation and admission to the SICU before returning to the
floor. Had increasing WBC during her admission with a CT chest
revealing LLL and RUL consolidation that was initially covered
with vanc/cefepime before being changed to ceftaz per ID
recommendations. She subsequently was triggered on the floor for
desats requiring a brief period of NRB prompting transfer to the
SICU with request for MICU transfer. At the time of transfer,
patient had been changed to face tent with improvement of her
sats to 98% though with some reports of mild SOB still. Her
breathing was noted to improve after her TFs were clamped and
drained as well as with adequate pain control.
She subsequently triggered again for reports of desats with
patient placed briefly on a NRB before being weaned to 2L NC
before arrival to the ICU. Her stomach was mildly distended on
CXR and KUB. Patient was mildly somnolent but improved at time
of arrival to the ICU. She complained of mild SOB but no other
specific concerns. No other focal complaints at that time
including f/c/s/n/v or CP.
Past Medical History:
Hiatal Hernia
HTN
Restrictive lung disease
BOOP radiation-induced, followed by pulmonology
?TIA
Breast Cancer s/p bilateral mastectomy and XRT
GERD
Bipolar disorder
Papillary thyroid cancer s/p thyroidectomy (___)
Carotid stenosis
HLD
Social History:
___
Family History:
father died ___ CAD CHF
Mother died ___ thrombosis
1 brother DM sister a/w
widow with 6 children daughter with arrythmia
Mother, daughter and son with bipolar disorder
Physical Exam:
ADMISSION EXAM:
===============
VITAL SIGNS: 97.9 131/83 66 18 96RA
GENERAL: elderly woman, no acute distress
HEENT: moist mucosa, anicteric sclerae, PERRL.
CARDIAC: RRR, normal S1, S2, no audible murmurs or rubs
LUNGS: decreased at the bases bilaterally, otherwise CTA
ABDOMEN: soft, nontender, nondistended
EXTREMITIES: warm, nontender, no edema
NEURO: grossly intact and moving all extremities spontaneously,
AOx3, can say DOWB
PSYCH: somewhat flat affect
DISCHARGE EXAM:
===============
General: elderly woman, answering questions appropriately,
lethargic
Rest of physical exam deferred given CMO
Pertinent Results:
ADMISSION LABS:
===============
___ 04:14AM BLOOD WBC-12.8* RBC-3.76* Hgb-11.0* Hct-34.2
MCV-91 MCH-29.3 MCHC-32.2 RDW-13.2 RDWSD-44.2 Plt ___
___ 04:14AM BLOOD Neuts-73.6* Lymphs-11.5* Monos-9.0
Eos-4.3 Baso-0.9 Im ___ AbsNeut-9.41* AbsLymp-1.47
AbsMono-1.15* AbsEos-0.55* AbsBaso-0.11*
___ 04:14AM BLOOD Glucose-124* UreaN-20 Creat-0.8 Na-140
K-4.3 Cl-104 HCO3-24 AnGap-16
___ 05:10AM BLOOD ALT-11 AST-17 LD(LDH)-260* CK(CPK)-19*
AlkPhos-143* TotBili-0.2
MICRO:
======
ALL BLOOD AND URINE CX'S NEGATIVE THROUGHOUT ADMISSION
CDIFF NEGATIVE ___
MRSA SCREEN NEGATIVE ___
RELEVANT IMAGING/STUDIES:
=========================
___ TTE:
IMPRESSION: Small pericardial effusion without echocardiographic
signs of tamponade. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
Mild mitral valve prolapse with mild mitral regurgitation. Mild
pulmonary artery systolic hypertension.
___ CTA chest, CT abdomen:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Consolidation in the right suprahilar region, new since the
prior study, may represent an infectious process.
Consolidation in the left lower lobe may represent a
combination of infectious process and volume loss.
3. The left-sided pleural effusion is increased compared to the
prior study.
The right-sided pleural effusion is new compared to the prior
study.
4. There has been interval placement of a gastrostomy tube.
Large right-sided hiatal hernia persists.
5. Subcutaneous emphysema extending from the axillae down to the
groin
bilaterally and a small amount of pneumoperitoneum are new since
the prior
study, likely postsurgical.
6. Moderate pericardial effusion is again seen, unchanged
compared to the
prior study.
7. Left-sided inguinal hernia contains a nonobstructed loop of
large bowel.
8. A 2.3 cm left renal cyst is mildly hyperattenuating and may
represent a
proteinaceous/hemorrhagic cyst, unchanged since ___.
9. Severe T12 compression deformity is unchanged compared to ___.
___ CXR:
1. Worsening distension, intrathoracic, herniated stomach.
2. No new focal consolidation concerning for pneumonia.
3. Stable left lower lobe collapse with associated small left
pleural
effusion.
4. Minimally improved right perihilar opacities, likely
reflecting
atelectasis.
___ ECHO:
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). with normal
free wall contractility. There is a small pericardial effusion
measuring up to 0.8 cm in greatest dimension, with preferential
fluid deposition inferolateral to the left ventricle. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade. IMPRESSION: Small pericardial effusion without
echocardiographic evidence of tamponade. Preserved biventricular
systolic function. Left pleural effusion. Compared with the
prior study (images reviewed) of ___, the findings are
simliar.
___ KUB:
G-tube projects over a portion of the stomach and may be
intraluminal however there is no second view to confirm this.
Opacification of the left lung base may represent atelectasis or
developing pneumonia. Elevation of the right hemidiaphragm with
a markedly distended stomach, similar in appearance to ___. Recommend clinical correlation.
___ CXR:
Large air-filled structure in the right lower chest consistent
with a large hiatal hernia. Mediastinal shift to the left side
with associated left basilar atelectasis. Right lung
atelectasis is also noted adjacent to the large hiatal hernia.
Superadded infection cannot be excluded. Findings are without
change from 1 day earlier.
___ CT A/P W/ CONTRAST
1. No acute intra-abdominal pathology.
2. Other unchanged findings as above, including a large hiatal
hernia and
gastrostomy tube in place, stable 0.6 cm probable IPMN in the
pancreatic tail, and severe chronic fracture deformity of the
T12 vertebral body.
___ CT CHEST W/ CONTRAST
Volume of distended stomach traversing the hiatus hernia into
the right lower paramedian chest has decreased.
Previous right upper lobe pneumonia has resolved.
New alveolar opacification superior segment left lower lobe
could be recent aspiration or early pneumonia.
Substantial bibasilar atelectasis unchanged.
___ CT A/P W/ CONTRAST
1. Small amount of free intraperitoneal air, fluid, and a
locule of air in the left rectus muscle, adjacent to the GJ
tube, is likely related to recent tube exchange.
2. New left inguinal hernia containing loops of nondilated
sigmoid colon. No evidence of surrounding inflammatory change,
wall thickening, or obstruction.
3. Persistent bilateral nonhemorrhagic pleural effusions, trace
on the right and small on the left. These have slightly
decreased since the prior study.
4. Persistent large hiatal hernia containing the gastric fundus
and body.
DISCHARGE LABS
==============
no discharge labs given CMO
Brief Hospital Course:
___ with PMH of hypothyroidism, HTN, bipolar disorder, and
breast ca with post-breast radiation BOOP and restrictive lung
disease who originally presented to the hospital for repair of a
large paraesophageal hernia, s/p MICU course after tx of PNA,
now s/p modified post-pyloric feeding tube but w/ worsening
abdominal pain and respiratory status despite all interventions.
SURGICAL COURSE
===============
Ms. ___ presented to ___ after an episode of apnea
in the setting of known large paraesophageal hernia with
previous episodes of apnea and planned repair on ___ ___. At ___, she had a CT chest which showed the hiatal
hernia, pleural effusions, and moderate pericardial effusion.
Her apnea resolved spontaneously, without intervention but
previous episodes she has required CPAP. She was transferred to
___ on ___ for interval management and operative
planning.
Medicine was consulted for risk stratification and medical
optimization in light of comorbidities and new pericardial
effusion. She was assigned intermediate risk of <5% for cardiac
complications, but surgery was not contraindicated. A TTE was
performed ___ that found mild mitral valve prolapse, mitral
regurgitation, and mild pulmonary artery systolic hypertension
with a small pericardial effusion and no signs of tamponade
physiology, please see report for further details.
Cardiology was consulted for pericardial effusion, and after
completion of TTE and evaluation of EKGs, recommendations were
made to discharge with ___ of Hearts monitor for one month
for a possible atrial fibrillation versus sinus rhythm with
multiple PACs on an EKG from ___. Also recommended was a one
month follow up TTE to evaluate for expected effusion
resolution, breast cancer follow up and monitoring, TSH
evaluation, and followup with cardiology in 2 months. There was
concern for possible malignant effusion.
In addition to consulting cardiology and medicine, she was
continued to be monitored on telemetry and continuous oxygen
saturation monitoring with surveillance labs. She was tolerating
soft mechanical regular diet, was ambulating with a walker, and
did not have further nausea, vomiting, chest pain, dyspnea, or
apnea episodes while planning for an operation.
On ___, her WBC 16.7, and she had a repeat pre-operative CXR
that found stable pleural effusions (moderate on left, small on
right) with a top normal cardiac size and previously known
hernia. She was taken to the operating room, and had an
exploratory laparoscopy, lysis of adhesions, partial hiatal
hernia reduction with plication to the left crus and
percutaneous, endoscopically guided gastrostomy tube placement.
She tolerated the procedure well, and after her stay in the PACU
was transferred to the floor after prolonged fatigue from
anesthesia. She was continued on telemetry and oxygenation
monitoring.
On ___, patient was transferred to the SICU for increased
work of breathing and found to have a RUL consolidation with WBC
of 24. A CTA was also done to rule out a PE, which was negative,
but was concerning for a RUL consolidation. She completed a
course of cefatzadime. The patient continued to have hypoxic
episodes w/ respiratory distress c/f multiple aspiration events,
went back and forth between the medicine floor and ICU for these
events. The surgery team saw her and felt that she might need
advancement of her G-tube to a G-J tube.
MEDICINE COURSE
===============
# Hypoxic Respiratory Failure
Reported baseline history of tachypnea prior to surgery thought
to be potentially related to large hiatal hernia but also has
known history of BOOP and restrictive lung disease ___ her prior
history of radiation for breast cancer therapy. Had multiple
aspiration events, completed a course of ceftaz for possible PNA
as above. Was seen by speech and swallow multiple times, was
ultimately cleared for just clear liquids for comfort. Patient
had worsening respiratory status every time tube feeds were
started, prompting discontinuation. Patient complained of
difficulty breathing throughout hospitalization w/ interval
CXR's demonstrating worsening paraesophageal hernia causing a
mediastinal shift to the left. Patient placed on low-dose
morphine w/ some improvement in symptoms.
# Abdominal pain/distension
# Hiatal hernia s/p plication and GJ tube placement: Patient
continued to have abdominal pain after the plication procedure.
G tube was modified to a GJ to allow for post-pyloric feeds
while simultaneously allowing for G tube venting, but did not
help symptoms. Tube feeds were attempted 3 times, and even
though they were started at very low rates, her pain and
abdominal distension would worsen w/in 24 hours of starting.
During hospitalization, was noted to have urinary retention, but
no pain relief from straight caths PRN, and retention
self-resolved after home oxybutynin was d/c'd. Patient was also
given aggressive bowel regimen. Despite all interventions,
patient continued to suffer from significant pain. Ultimately
decided to d/c tube feeds. Continued to leave G tube to vent,
morphine as above. Once tube feeds started, patient was placed
on TPN; however, given concerns for volume overload as well as
overall goals of care, this was stopped prior to discharge.
Family wishes to continue ongoing discussions re: TPN at ___
facility.
# Malnutriton: Pt with poor PO intake this admission ___
expansion of hernia with PO and resulting respiratory distress
as described above. Holding TFs as above, can get clear liquids
for comfort per speech and swallow recs. As above, TPN was
stopped prior to discharge.
# GOC: Patient w/ worsening respiratory and nutritional status
despite all interventions over this long hospitalization.
Multiple GOC discussions had w/ patient and family, they are
aware that further medical interventions are limited and likely
not to help. Ultimately decided on transitioning patient to
hospice care and comfort measures only. However, patient's
family not ready to d/c TPN, they are still discussing this
issue amongst themselves. Therefore, the patient was transferred
with a ___ line in place in case they opt for TPN moving
forward. Patient very lethargic during these meetings, and could
not offer much insight into how she would like to be treated.
# HTN: Continued home amlodipine
# Bipolar disorder: Continued home ___ (level 0.5), olanzapine.
# Hypothyroidism: Continued home levothyroxine
TRANSITIONAL ISSUES
===================
[ ] patient has been transitioned to ___, hospice care
[ ] family still undecided on whether to continue TPN, please
continue ongoing ___ discussions, specifically regarding this
issue
[ ] continue to keep G tube to vent, ok to clamp for 30 minutes
if administering meds
# Communication/HCP: ___ (daughter, ___)Phone
number: ___ Cell phone: ___
# Code: DNR/DNI, confirmed with patient and subsequently HCP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob, wheeze, cough spell
2. amLODIPine 5 mg PO DAILY
3. FLUoxetine 40 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
6. Levothyroxine Sodium 50 mcg PO 1X/WEEK (___)
7. Lithium Carbonate SR (Lithobid) 300 mg PO QHS
8. OLANZapine 5 mg PO DAILY
9. Omeprazole 20 mg PO BID
10. Oxybutynin 5 mg PO QAM
11. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
12. Calcium Carbonate 500 mg PO DAILY
13. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
14. Loratadine 10 mg PO DAILY:PRN allergies
15. Multivitamins 1 TAB PO DAILY
16. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PR QHS:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
5. Lithium Oral Solution 150 mg PO BID
6. Morphine Sulfate (Oral Solution) 2 mg/mL 2.5 mg PO Q6H:PRN
pain or dyspnea
RX *morphine 10 mg/5 mL 2.5 mg by mouth every 4 hours Disp #*45
Milliliter Milliliter Refills:*0
7. Pantoprazole (Granules for ___ ___ 40 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID
10. Simethicone 40 mg PO TID:PRN distension
11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
12. amLODIPine 5 mg PO DAILY
13. Calcium Carbonate 500 mg PO DAILY
14. FLUoxetine 40 mg PO DAILY
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
16. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
17. Levothyroxine Sodium 50 mcg PO 1X/WEEK (___)
18. Loratadine 10 mg PO DAILY:PRN allergies
19. OLANZapine 5 mg PO DAILY
20. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS
=================
- Paraesophageal hernia
- Recurrent aspiration pneumonia c/b hypoxic respiratory failure
- Severe Malnutrition
SECONDARY DIAGNOSIS
===================
- Right breast cancer s/p lumpectomy, XRT, arimidex
- Radiation pneumonitis/BOOP
- Bipolar disorder
- Hypertension
- Hypothyroidism
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 for abdominal pain related to
your stomach hernia. You had surgery on that hernia, but
unfortunately it did not improve your symptoms. We had a feeding
tube that bypasses the stomach placed which also did not help,
and the feeds actually seemed to make your symptoms a lot worse.
Therefore, we continued to feed you through your PICC instead.
After talking with you and your family, it was decided that it
would be best to transition to hospice in order to shift the
focus of your care to maximize your comfort and quality of life.
We wish you the best of health,
Your ___ Care Team
Followup Instructions:
___
|
19747979-DS-4
| 19,747,979 | 21,042,605 |
DS
| 4 |
2153-12-26 00:00:00
|
2153-12-27 11:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Mr. ___ is a ___ with no known PMH but heavy alcohol use who
presented to ___ reporting increased frequency of bowel
movements for the last 2 days and epigastric pain for the last
day.
Patient presented to ___ after having 2 days of increased
frequency of bowel movements. The day of admission he developed
epigastric pain and had one episode of hematemesis at home. He
then presented to ___. Per ___, pt denied having melanotic or
hematochezic stool. He does admit to drinking alcohol daily,
last drink was the night prior to admission. Vitals at ___ were:
98.0, 174/88, 75, 98% RA. CXR was normal. CT abd/pelvis showed a
nodular appearing live concerning for cirrhosis. Labs were
significant for H/H 12.7/38.8, plt 126, albumin 2.9, INR 1.1,
AST 47, ALT 33, ALP 42, lipase 267. He was given IV protonix
80mg, zofran and morphine. He received 1L IVFs. He was then
transferred to ___ for further evaluation and management.
In the ___ ED, initial vitals: 97.7, 66, 132/82, 16, 97% RA.
Labs were notable for H/H of 12.8/36.7, plts 122, AST 43, ALT
28, ALP 33, albumin 3.3, lipase 44, Cr 0.7, lactate 1.3, INR
1.1. Serum tox screen was negative. Urine tox screen was
positive for opiates, cocaine and amphetamines. UA showed large
leuks (WBC 20), 19 RBCs and no bacteria. He was given 1L IVF,
protonix gtt, zofran and IV dilaudid 0.25mg. BCx were sent.
Patient was intubated for airway protection after another
episode of hematemesis w/ clots. During intubation, patient's
blood pressure spiked to 217/107.
On transfer, vitals were: 97.7, 83, 170/83, 16, 100%
Intubation.
On arrival to the MICU, patient is intubated and sedated.
Past Medical History:
Per daughter has diagnosis of alcoholic and HCV cirrhosis, but
patient denies
-polysubstance abuse: cocaine, prescription drugs (adderall,
oxycodone), alcohol
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- T: 98.4 BP: 134/74 P: 78 R: 19 O2: 99% RA
GENERAL: Intubated and sedated, small amount of blood in mouth
HEENT: Sclera anicteric, MMM, oropharynx bloody but poorly
visualized.
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1/S2. ___ systolic murmur
heard best at the LSB. No rubs or gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No rashes, ecchymoses, or jaundice
NEURO: sedated and unable to participate in examination
DISCHARGE PHYSICAL EXAM
VS - 98.4 110-114 / 69-70 20 80s 97 RA
4Bms, 2420/ 252 +
General: sitting in chair, enjoying the view, eating breakfast.
HEENT: NCAT, anicteric sclera, MMM, symemtric palate elevation.
Tongue is protrudicng mildly from mouth.
CV: RRR; normal S1 and S2; III/VI systolic murmur appreciated,
best heard in the mitral position
Pulm: CTAB
Abd: soft, tender to palpation to epigastrum, +BS, no rebound or
guarding
Ext: warm, well-perfused
Neuro: CN II-XII intact
Pertinent Results:
ADMISSION LABS
___ 01:48AM BLOOD WBC-7.5 RBC-3.65* Hgb-12.8* Hct-36.7*
MCV-101* MCH-35.0* MCHC-34.8 RDW-13.8 Plt ___
___ 01:48AM BLOOD Neuts-78.2* Lymphs-15.4* Monos-4.2
Eos-1.9 Baso-0.2
___ 01:48AM BLOOD ___ PTT-32.7 ___
___ 01:48AM BLOOD Glucose-163* UreaN-13 Creat-0.7 Na-140
K-4.3 Cl-106 HCO3-25 AnGap-13
___ 01:48AM BLOOD ALT-28 AST-43* AlkPhos-33* TotBili-0.9
___ 04:21AM BLOOD Calcium-8.2* Phos-3.6 Mg-1.7
___ 01:48AM BLOOD Albumin-3.3*
___ 04:15PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE IgM HAV-NEGATIVE
___ 04:15PM BLOOD AFP-3.8
___ 01:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:15PM BLOOD HCV Ab-POSITIVE*
___ 03:19AM BLOOD Type-ART Temp-36.5 Tidal V-450 PEEP-5
FiO2-100 pO2-497* pCO2-43 pH-7.37 calTCO2-26 Base XS-0 AADO2-183
REQ O2-39 Intubat-INTUBATED
___ 02:02AM BLOOD Lactate-1.3
DISCHARGE LABS
___ 05:10AM BLOOD WBC-6.7 RBC-2.83* Hgb-9.7* Hct-29.0*
MCV-102* MCH-34.4* MCHC-33.6 RDW-15.2 Plt ___
___ 05:10AM BLOOD ___ PTT-36.4 ___
___ 05:10AM BLOOD Glucose-110* UreaN-17 Creat-0.7 Na-138
K-3.5 Cl-102 HCO3-29 AnGap-11
___ 05:10AM BLOOD ALT-28 AST-41* AlkPhos-31* TotBili-0.6
MICRO
___ IMMUNOLOGY HCV VIRAL LOAD- 653,000 IU/mL.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
IMAGING
___ LUE ultrasound
No evidence of deep vein thrombosis in the left upper extremity.
The left cephalic vein could not be well visualized.
___ CXR
1. Endotracheal tube in appropriate position.
2. Chronic right rib deformity from multiple healed rib
fractures.
3. Bibasilar atelectasis.
___ EGD
Upon entry of the oropharynx the ET tube was in place. Upon
entering the esophagus there was evidence of old blood noted
though out. 3 ___ of grade II - III varices were seen
extending from 34 cm to 40cm at the GEJ. One varix had a
adherent blood clot. Two small ___ tears were noted in
the lower third of the esophagus which had contact bleeding. 4
bands were sucessfully paced between 40 - 35cm. A band was
sucessfully placed on the varix with an adherent clot. There was
a small amount of bleeding s/p banding. Excellent hemostasis was
acheived.
There was a large amount of old blood seen in the body of the
stomach with no active bleeding or gastric varix seen. Due to
excessive clot ___ the cardia could not be visualized thus
direct visaliztion for gastric varix could not be completed. The
antrum had evidence of old blood. There was diffuse erythema and
congestion consistent with portal hypertensive gastropathy.
Old blood seen in the duodenal bulb. D2 was normal.
Otherwise normal EGD to third part of the duodenum
PERTINENT LABS:
___ 05:52AM BLOOD %HbA1c-6.3* eAG-134*
___ 04:15PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE IgM HAV-NEGATIVE
___ 04:15PM BLOOD AFP-3.8
___ 12:52PM BLOOD HIV Ab-NEGATIVE
___ 04:15PM BLOOD HCV Ab-POSITIVE*
___ 4:11 pm IMMUNOLOGY Source: Venipuncture.
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
653,000 IU/mL.
Brief Hospital Course:
___ with chronic alcohol abuse, HCV, and cirrhosis presents with
upper GI bleed for 2 days and found to have variceal bleed.
#Variceal bleed: Underwent EGD with banding of esophageal
varices x 4 on ___. He was initially admitted to the ICU for
intubation for airway protection. He received 2u of pRBCs for
resuscitation. After banding, he was extubated without any
complications. He was kept on protonix and octreotide gtt for 72
hours, then transitioned to BID protonix. He also received CTX
for SBP ppx x 7 days, carafate 1g QID. He was started on nadolol
on ___. Plan to repeat EGD in 4 weeks.
#alcoholic and HCV cirrhosis: MELD of 4. No evidence of
synthetic dysfunction. Per daughter, no hx of jaundice,
encephalopathy, but does have a history of ascites. RUQ u/s was
negative for hepatoma and PVT. He was started on lactulose q2h
and rifaximin for hepatic encephalopathy post intubation. His
PCPs office confirmed their ability to set him up with a
hepatologist after discharge.
# HCV: Viral load 653,000. AFP 3.8. No evidence of hcc on
ultrasound. ___ need genotyping as an outpatient, to be
facilitated by ___ office.
# substance abuse: Unclear on extent of drinking history, but
patient admitted to MDs at ___ that he was an everyday drinker
of vodka. Last drink was the night prior to his presentation.
Per daughter, also abuses prescription drugs and cocaine.
Received loading dose of phenobarb, but rest of the doses
discontinued due to somnolence. SW and addiction were consulted.
He was given 3 days of high dose thiamine, folic acid, and MVI
and continued on daily dosing for nutritional support. He was
told if he does not stay sober, he risks death.
TRANSITIONAL ISSUES
- needs to be set up with hepatologist - to be facilitated by
___ office
- repeat EGD in 4 weeks
- needs genotyping of hepatitis C
- resources provided by social work for assistance staying sober
were largely deferred
- he was instructed to take all his medications as prescribed or
risk death
# Communication: daughter ___ (___)
# Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 5 mg PO QID:PRN pain
2. Adderall (dextroamphetamine-amphetamine) 15 mg oral BID
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins & Minerals] 1 tablet(s)
by mouth daily Disp #*30 Tablet Refills:*0
3. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*90 Tablet Refills:*0
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Lactulose 30 mL PO TID
RX *lactulose 10 gram/15 mL 15 mL by mouth three times a day
Refills:*0
7. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
1. cirrhosis
2. esophageal variceal bleed
3. hepatitis C infection
4. alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted with bleeding from
esophageal varices - varices are enlarged blood vessels in your
esophagus that form because of cirrhosis of your liver.
Cirrhosis is end-stage liver disease. It is absolutely
imperative that you stop drinking immediately. You also need to
stop doing any drugs. You need to stay sober. If you do not do
these things, you can die. Also, if you do not take your
medication, you risk bleeding again and becoming confused.
Lactulose helps prevent confusion. Nadolol helps prevent
bleeding.
You also have hepatitis C. This likely contributed to your
cirrhosis.
You need to take all your medications to help protect your
health. It is also imperative to follow-up with a liver doctor
to discuss further treatment of your hepatitis C. Your primary
care doctor ___ set you up with a liver doctor to see.
We wish you all the best,
Your ___ team
Followup Instructions:
___
|
19748295-DS-8
| 19,748,295 | 24,349,104 |
DS
| 8 |
2173-09-14 00:00:00
|
2173-09-14 18:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Eu Critical ___ AKA ___ is a ___ yo M with
no significant past medical history. Patient is an ___
and was at work today when he fell from the second step of a
ladder backwards striking his headache. Approximate fall was 8
feet. Per report he immediately lost consciousness and was
incontinent of urine. He was brought to ___
around 11:25. Head CT was done at 11:53 which reveals a L SDH
and
?L EDH with minimal mass effect or midline shift. He was
transferred here for neurosurgical evaluation. Upon arrival
patient is confused and does not remember events of fall. GCS
15.
He reports minor headache but denies visual changes, weakness,
numbness, tingling.
Past Medical History:
Per wife no significant past medical history.
Social History:
___, married
Physical Exam:
O: BP: 146/90 HR:74 R 12 O2Sats 100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm EOMs intact
Neck: Supple.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. Confused
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
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.
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.
--------------------
EXAM ON DISCHARGE:
AAO x 3, PERRL, EOMs intact
No pronator drift
Moves all extremities with full strength. Sensation intact
throughout.
Pertinent Results:
CT: L SDH, ?L EDH minimal mass effect or midline shift
Labs: INR @ OSH 0.9
___ CT head without contrast:
1. No significant interval change of left frontoparietal
subdural hematoma, right temporoparietal nondisplaced fracture
with associated 6 mm right middle cranial fossa epidural
hematoma.
2. Newly apparent left sylvian fissure subarachnoid blood with
hemorrhage
layering within the interpeduncular cistern.
3. Possible left inferior frontal contusion.
___ CT C-spine without contrast:
No cervical spine fracture or malalignment.
___ Non-contrast head CT:
6 mm epidural hematoma in the right middle cranial fossa, deep
to the right parietal/temporal bone fracture, is stable.
Thin subdural hematoma overlying the left convexity is stable.
Left inferior frontal lobe hemorrhagic contusion with mild
surrounding edema are stable in extent, though the edema is more
conspicuous with decreased density, as expected over time.
Previously noted subarachnoid blood in the left sylvian fissure
is less
apparent on the current study. No new hemorrhage or edema are
detected. Ventricles and sulci are stable in size. Basal
cisterns are not effaced. Cerebellar tonsils are normally
positioned.
There is mild mucosal thickening in the ethmoid air cells.
Other included paranasal sinuses are clear. Middle ear
cavities, left mastoid air cells, and partially included right
mastoid air cells are clear.
IMPRESSION:
1. Right middle cranial fossa epidural hematoma deep to the
right
parietal/temporal bone fracture, thin left convexity subdural
hematoma, and hemorrhagic contusion within the inferior left
frontal lobe are stable.
2. Previously noted left sylvian fissure subarachnoid blood is
less apparent.
___ CT orbits, sella, IAC (prelim read)
1. There is a nondisplaced fracture through the squamous portion
of the right temporal bone without involvement of the middle ear
canal.
2. Degenerative changes are seen on the left temporal mandibular
joint with erosion of the mandibular condyle.
___ 05:45AM BLOOD WBC-9.8 RBC-4.96 Hgb-15.0 Hct-42.7 MCV-86
MCH-30.2 MCHC-35.1 RDW-11.7 RDWSD-36.4 Plt ___
___ 03:11AM BLOOD WBC-11.3* RBC-4.80 Hgb-14.5 Hct-41.1
MCV-86 MCH-30.2 MCHC-35.3 RDW-11.7 RDWSD-36.2 Plt ___
___ 01:38PM BLOOD WBC-15.2* RBC-5.13 Hgb-15.6 Hct-43.7
MCV-85 MCH-30.4 MCHC-35.7 RDW-11.5 RDWSD-35.3 Plt ___
___ 05:45AM BLOOD ___ PTT-25.9 ___
___ 03:11AM BLOOD ___ PTT-26.6 ___
___ 01:38PM BLOOD ___ PTT-24.3* ___
___ 05:45AM BLOOD Glucose-115* UreaN-19 Creat-0.8 Na-139
K-3.7 Cl-99 HCO3-27 AnGap-17
___ 03:11AM BLOOD Glucose-139* UreaN-21* Creat-0.8 Na-135
K-3.7 Cl-101 HCO3-22 AnGap-16
___ 10:33PM BLOOD Glucose-145* UreaN-22* Creat-0.8 Na-136
K-3.9 Cl-102 HCO3-21* AnGap-17
___ 05:45AM BLOOD Calcium-9.2 Phos-2.5* Mg-2.1
___ 03:11AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0
___ 10:33PM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9
___ 01:38PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Mr. ___ was admitted on ___ with acute left SDH and
tSAH. He was admitted to the ___ for further monitoring. On
the morning of ___, a repeat head CT was obtained and showed a
stable hemorrhage. He remained neurologically and
hemodynamically intact and was written for transfer to the
floor. The patient was evaluated by ___ and OT. ___ thought the
patient needed one to two more visits while the patient was
inpatient. OT felt that the patient needed cognitive neurology
follow-up as an outpatient.
On ___, Mr. ___ was complaining of right ear fullness
and decreased hearing. Upon further review of the head CT on
___, the patient was found to have a right parietal/temporal
bone fracture. ENT was consulted and a CT of the sella, orbits
and IAC was obtained. Although there was a non-displaced
fracture of the temporal bone, it was not involving the inner
ear. This was discussed with Dr. ___ ENT. Their
recommendation was that the patient continue Ciprodex ear drops
to the right ear for five days and follow up with Dr.
___ in four weeks as an outpatient. Final ___ and OT
recommendations were that the patient could be safely discharge
home with no services. Per discharge instructions, the patient
should also follow up with Dr. ___ cognitive neurology
regarding his traumatic brain injury.
Mr. ___ was discharged home the evening of ___ in the
care of his wife. He was afebrile, hemodynamically and
neurologically stable.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Ciprofloxacin 0.3% Ophth Soln 2 DROP RIGHT EAR BID
RX *ciprofloxacin-dexamethasone [Ciprodex] 0.3 %-0.1 % 2 drops R
ear twice a day Refills:*0
3. Docusate Sodium 100 mg PO BID
4. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left subdural hematoma
Left frontal lobe contusion
Right epidural hematoma
Traumatic subarachnoid hemorrhage
Right temporal bone fracture (not involving the middle ear
canal)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
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 until instructed to stop at your follow up
appointment. It is important that you take this medication
consistently and on time.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
Followup Instructions:
___
|
19748558-DS-17
| 19,748,558 | 22,995,674 |
DS
| 17 |
2164-06-20 00:00:00
|
2164-06-20 15:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
cough/left rib pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo male with h/o depression, tbi, seizure disorder, heronin
abuse(on suboxone currently) presenting with 2 days of left
sided chest pain dyspnea and fevers. Patient had a seizure on
___ and fell to the ground and went to ___ to have a cut on
his ear sutured. He was discharged home, but then developed
left rib pain with deep breathing. Also felt feverish at home
and checked temp of 102. Tried taking motrin for the pain with
minimal improvement. He denied any hemoptysis or recent weight
loss. He thinks that he had a ppd about ___ year ago that was
negative. No recent travel outside the ___
ago). No n/v/diarrhea
Pertinent ROS noted above rest of ros wnl
Past Medical History:
PSYCHIATRIC HISTORY
From ___ note, confirmed with patient:
Dx/Sxs: Depression, ADHD and PTSD, question of bipolar d/o.
Hospitalizations: Most recently at ___ in ___, also
multiple dual diagnosis programs including ___, ___,
___, CSU, ___ and ___, also psych hospitalization at
___
in ___.
SA/SIB: Endorses past suicide attempts, including 5 overdoses on
heroin, most recently leading to a coma for 10 days.
Medication Trials: Ritalin, Adderal, Wellbutrin, Depakote
Psychiatrist: Dr. ___ (___), reportedly last
seen 2
months ago
Therapist: ___ at ___
PAST MEDICAL HISTORY:
Confirmed with patient:
TBI following MVC in ___. Seizure disorder--patient reports
grand mal seizures in the context of alcohol withdrawal, though
he states that he has since had seizures outside of withdrawal.
Neurologist - Dr. ___ (___)
Hep C
Social History:
SUBSTANCE ABUSE HISTORY: Per OMR, confirmed with Pt
Patient has been through multiple detoxes. His longest period of
sobriety was for 17 months starting in ___.
EtOH: Reports 2 months of sobriety, then 1 pint vodka daily for
~4 days, last drink today. Has experienced withdrawal
seizures and a history of DTs.
Opiates: Suboxone since ___, now reportedly at ___.
___ with Dr. ___.
Tobacco: smokes 1 ppd.
Benzodiazepines: Reports an unknown numbers of benzos the last
couple of days "totem poles", possibly valium. None prior to
that.
SOCIAL HISTORY: ___
Family History:
Family history
colon ca(mother)
heart disease(father)
FAMILY PSYCHIATRIC HISTORY:
-FHX Suicides: denies
-FHX Substance Abuse: denies
-FHX Mental Illness: denies
Physical Exam:
Admission Exam
Vitals
Temp: 98.2 BP 138/75 HR 79 ___ 100RA
VSS
GEN: Patient lying comfortably in bed nad a+ox3
HEENT: MMM oropharynx clear. sutures noted in left ear with
bruising around left eye
NECK: supple no thyromegaly
CV: rrr no m/r/g
RESP: ctab no w/r/r pain with deep inspiration
ABD: soft nt nd bs+
EXTR: no ___ edema good pedal pulses bilaterally
DERM: no rashes, ulcers or petechiae
neuro: cn ___ grossly intact non-focal
PSYCH: normal affect and mood
Pertinent Results:
___ 10:20AM BLOOD WBC-10.7 RBC-4.98 Hgb-14.0 Hct-43.6
MCV-88# MCH-28.0 MCHC-32.0# RDW-12.4 Plt ___
___ 10:20AM BLOOD Glucose-108* UreaN-11 Creat-0.9 Na-140
K-4.7 Cl-102 HCO3-30 AnGap-13
___ 10:20AM BLOOD Calcium-9.5 Phos-2.5* Mg-1.8
___ 10:39AM BLOOD Lactate-1.2
CT thorax:
Wet Read: ___ WED ___ 3:06 ___
1. Solitary cavitary lesion in the superior aspect of the left
lower lobe with
small amount of surrouding ground glass opacification.
Differential is broad
and includes infection such as bacterial, fungal or TB. Cannot
exclude
malignancy. Less likely vasculitis such as Wegener's. 2. No
pulmonary
embolism.
CT head:
Wet Read: ___ WED ___ 10:12 AM
No acute intracranial process.
Brief Hospital Course:
___ yo male with h/o seizures, TBI, heroin abuse presenting with
left sided chest pain, dyspnea and fevers found to have a
cavitary pulmonary lesion. The imaging findings were consistent
with pulmonary abscess as there was an air fluid level. He did
not have other systemic signs of vasculitis, thus a rheum workup
was not performed.
#Pulmonary abscess with bacterial pneumonia:
He was ruled out for TB with three negative induced sputum,
though mycobacterial cultures are currently pending. Blood
cultures remained negative and sputa was contaminated by
respiratory flora, thus a bacterial pathogen was not isolated.
He has been emperically treated with Clindamycin, Ceftriaxone
and Vancomycin (which was added because of continued fevers).
He then defervesced, though it is unclear if his fevers resolved
from just the natural history of treatment with gram negative
and anaerobic coverage or from coverage the additional treatment
for MRSA (given his IVDU history). HIV ab negative. ID
followed the patient during the admission and vancomycin dosing
was adjusted based on trough (last trough 23 on ___ AM after 4
doses of 1250mg q8h), so dose was reduced to 1250mg q12h.
Pleuritic chest pain treated with combination of oral dilaudid
and NSAIDs. HIV serology negative.
A repeat chest CT was performed on ___ as he had higher WBC and
a larger pulmonary lesion on CXR seen on ___ compared with CXR
on ___ and mostly as the patient was very insistent on seeing
repeat CT to feel less woried despite tellign him risks for
excess radiation exposure from imaging. The repeat chest CT
showed a slightly larger abcess cavity with more fluid and less
air. ID and myself agreed that since he was afebrile for over
48hrs with clinical improvement then he can be discharged with
the current antibiotic regimen.
--monitor CBC, chem7, LFTs weekly
--continue total course of Clindamycin, ceftriaxone, Vancomycin
for 3 weeks following last fever) to end on ___
--repeat chest xray after he completes course of antibiotics
#Substance abuse: Takes suboxone prior to admission. States he
uses benzodiazpines bought on the street (klonopin 2mg TID).
Klonopin 1mg BID started to minimize anxiety. No evidence of
active benzo/ETOH withdrawal. He is now on dilaudid PO q3h PRN
for pleuritic chest pain related to lung abscess. He frequently
asked for higher doses though he looked very comfortable.
Explained that dose will not be increased. He was advised to
resume suboxone 8mg TID when pain is improved and he should be
taken off of dilaudid as soon as possible
#Seizure disorder: chronic, no evidence of seizure activity
during this admission
--Remained on neurontin He had fevers until ___.
#Depression: chronic,
-he remained on wellbutrin 100 bid and seroquel 50mg qhs for
sleep
#chronic hep c: patient interested in treatment, deferred to
outpatient setting
Medications on Admission:
suboxone 8mg tid
wellbutrin 100mg bid
seroquel 50mg qhs
neurontin 800mg qid
Discharge Medications:
1. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
2. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. quetiapine 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath/weasing.
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain/fever.
7. clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 3 weeks.
8. CeftriaXONE 2 gm IV Q24H
9. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
twice a day for 3 weeks.
10. clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
12. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for pain: please discontinue medication and
resume suboxone when his pain improves.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
16. Wellbutrin 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pulmonary Abcess
Bacterial Pneumonia
HCV (chronic)
Substance abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with cough. You were found to have a large
cavitary lesion consistent with a pulmonary abscess and
pneumonia. You were started on antibiotics. You were seen by the
infectious disease and pulmonary consult services. At this
point you will need approximately 3 weeks of antibiotics.
Medication Changes:
NEW:
clindamycin
ceftriaxone
vancomycin
dilaudid
Labs pending at discharge:
final sputum mycobacterial culture
You will need at least weekly blood work to monitor your blood
counts, chem7 and lfts. you should also have another vanco
trough ordered.
You are advised to have a repeat chest xray after you complete
your antibiotics
Currently you are on dilaudid PO for pain, but this should be
transitioned back to suboxone when your pain control is better.
Followup Instructions:
___
|
19748773-DS-9
| 19,748,773 | 24,172,059 |
DS
| 9 |
2121-03-01 00:00:00
|
2121-03-03 17:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ M with PMHx notable for amyloidosis with
cardiac involvement diagnosed ___ by ___ findings and
abdominal fat pad biopsy, atrial flutter on Coumadin, HFrEF
(___), and non-insulin dependent T2DM who presents as a
transfer from ___ with dizziness.
Per ___ report, Mr. ___ presented to ___ with several
short episodes of dizziness. No associated chest pain,
palpitations, syncope, headache, visual changes, nausea, recent
illness. EMS providers who responded noted a wide-complex
tachycardia with stable hemodynamics. The tachycardia resolved
spontaneously before arrival to ___. While at ___, the
patient reported feeling the same dizziness sensation that
prompted presentation and was noted to be in pronounced
tachycardia to 180 bpm with same wide complexes that preceded
and
followed the run of tachycardia, lasting ___ seconds and broke
spontaneously.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes: yes
- Hypertension: yes
- Dyslipidemia: yes
2. CARDIAC HISTORY
- Cardiac amyloidosis with isoleucine-122 amyloid mutation ___
- HFrEF with LVEF ___ on TTE ___
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None, no history of
coronary angio
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- Atrial flutter
- Atrial fib
- LBBB
- Prostate cancer
- Monoclonal gammopathy
- Glaucoma suspect of both eyes
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Exam:
======================
VS: 97.7 135 / 65 85 18 97 ra Weight 162.5lbs
GENERAL: Well developed, well nourished elderly male in NAD.
Oriented x3. Mood, affect appropriate.
HEENT: PERRL. EOMI. Conjunctiva were pink. No pallor or cyanosis
of the oral mucosa.
NECK: Supple, no JVD though engorged EJ.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. regular rate and rhythm. No murmurs.
LUNGS: Mildly decreased BS left base, otherwise CTAB.
Respiration is unlabored with no accessory muscle use.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused, trace ___.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Discharge Exam:
======================
VS:97.9 PO BP 113 / 75HR80 RR16 Sat98 RA
GENERAL: Well developed, well nourished elderly male in NAD.
Oriented x3. Mood, affect appropriate.
NECK: Supple, JVP ~8cm
CARDIAC: regular rate and rhythm. No murmurs.
LUNGS: Mildly decreased BS left base, otherwise CTAB.
Respiration is unlabored with no accessory muscle use.
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused, trace ___.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
Admision Labs:
================
___ 06:25AM BLOOD WBC-4.1 RBC-3.77* Hgb-11.6* Hct-36.3*
MCV-96 MCH-30.8 MCHC-32.0 RDW-15.0 RDWSD-53.3* Plt ___
___ 06:25AM BLOOD ___ PTT-31.8 ___
___ 07:30PM BLOOD Glucose-109* UreaN-22* Creat-1.2 Na-143
K-4.8 Cl-101 HCO3-29 AnGap-13
___ 07:30PM BLOOD ALT-21 AST-31 AlkPhos-74 TotBili-0.4
___ 07:30PM BLOOD CK-MB-4 ___
___ 07:30PM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.9 Mg-1.7
Pertinent Studies:
=====================
___ TTE:
The left atrial volume index is severely increased. The right
atrium is moderately dilated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. There is severe symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. There is severe
global left ventricular hypokinesis (LVEF = ___ %). The
estimated cardiac index is depressed (<2.0L/min/m2). No masses
or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with moderate global free
wall hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace aortic regurgitation is
seen. Mild (1+) mitral regurgitation is seen. There is mild to
moderate pulmonary artery systolic hypertension. There is a very
small pericardial effusion. There are no echocardiographic signs
of tamponade.
IMPRESSION: A left pleural effusion is present. Very small
pericardial effusion without echo evidence of tamponade. Severe
symmetric left ventricular hypertrophy with severe global
hypokinesis c/w reported history of amyloid cardiomyopathy (EF
___ in ___ echo Atrius records). Moderate global right
ventricular hypokinesis. Increased PCWP.
___ Shoulder x-ray
Right shoulder osteoarthritis. No acute fracture or dislocation
detected.
___ CXR:
There is persistent elevation of the left hemidiaphragm. The
heart remains moderately enlarged. There is unfolding of the
thoracic aorta. Hilar contours are preserved. There is a small
left-sided pleural effusion. Otherwise there is no focal
consolidation. There is no interstitial edema. There is no
pneumothorax.
Discharge labs:
===================
___ 06:20AM BLOOD WBC-3.9* RBC-3.89* Hgb-12.3* Hct-37.9*
MCV-97 MCH-31.6 MCHC-32.5 RDW-15.1 RDWSD-53.9* Plt ___
___ 06:20AM BLOOD ___
___ 06:20AM BLOOD Glucose-150* UreaN-24* Creat-1.2 Na-143
K-4.5 Cl-102 HCO3-29 AnGap-12
___ 06:20AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.1
Brief Hospital Course:
Patient summary:
====================
___ with PMHx notable for HTN, DMII, cardiac amyloidosis
diagnosed ___ c/w HFrEF (___), LBBB, PAF/PA flutter status
post CV ___ on warfarin who presented for intermittent episodes
of
dizziness likely ___ SVT. Increased metoprolol succinate to 50mg
for SVT and consulted EP. ___ for placement of biventricular
pacemaker given cardiomyopathy, Class ___ chronic systolic CHF,
and LBBB. ___ for outpatient placement of CRT by Dr. ___.
# Dizziness
# SVT
Presented with multiple brief episdoes of dizziness, lasting
seconds. Patient has experienced this for months, however
patient notes episodes are more frequent over the last month.
Negative orthostatic vitals. He has had loop recording ___
notable for brief episodes of aflutter with 2:1 conduction at
130 BPM, afib episodes and PVCs. Episode of dizziness at OSH
with tele recording of SVT reviewed by EP at ___. Rhythm
consistent with likely atrial tachycardia given same QRS
morphology as sinus and history of Afib/flutter. Other potential
possibility is bundle branch reentry, but thought to be less
likely. ___ for CRT pacemaker implantation as below to allow
for further increase in metoprolol dosing to help with symptoms
of dizziness with SVT as well. Metoprolol succinate increased to
50mg daily without recurrent dizziness during hospitalization.
# HFrEF ___ amyloid cardiomyopathy (EF ___
# LBBB
At risk for development of heart block given amyloid heart
disease. Dr. ___ previously suggested biventricular CRT
given cardiomyopathy, LBB and low EF. Patient previously
hesitant but agreeable to impantation now. Evaluated by EP
inpatient with ___ for placement of CRT given cardiomyopathy,
Class ___ chronic systolic CHF, and LBBB. ICD placement was
deferred given little benefit in cardiac amyloidosis. ___ for
outpatient placement of BiV pacemaker by Dr. ___ week
with his office contacting patient with final appointment. Given
hx of cardiac amyloide, he is at higher risk of stroke so ___
to perform implant on uninterrupted coumadin. Additionally
diuresed with one dose of IV Lasix 40mg but appeared close to
euvolemic and restarted on home dose of PO Lasix 40mg BID on
discharge.
Discharge weight:72.6kg (160lb)
Discharge Cr: 1.2
Discharge diuretic: Lasix 40mg BID
# Troponin elevation
TNT 0.06 at ___ prior to transfer, here 0.13 but MB wnl. EKG
without acute changes. No anginal symptoms. Suspect the
troponin leak is likely due to demand ischemia and heart failure
and cardiac amyloid and less likely due to true epicardial
coronary artery disease. Given other comorbidities and negative
nuclear stress test in ___ did not pursue further workup.
#Right shoulder pain
Prior history of osteoarthritis of right shoulder with ongoing
pain. Acute worsening during transfer to ___. X-ray imaging
with evidence of osteoarthritis and without acute fracture.
# Atrial flutter/Afib
SVT as above at OSH but without episodes of Afib/flutter while
at ___. Continued on warfarin at home dose with INR 1.7 on
___. Instructed to take 3mg on ___ and continue on 2mg as
scheduled previously. Goal INR ___. Metoprolol succinate
increased to 50mg daily from 25mg given mild first degree AV
block and recent episode of SVT.
# Type 2 DM - on sliding scale insulin. Discharge on home
medications.
# Leukopenia
# Anemia
Chronic per prior labs. Leukopenia appears at baseline of 3.0 to
3.5 and anemia at baseline of ___ per ourpatient records.
Patient without infectious symptoms or evidence of bleeding per
exam and history.
Transitional Issues:
===========================
[] Outpatient follow up will be planned by Dr. ___
for placement of BiV pacemaker
[] Metoprolol succinate increased to 50mg daily for dizziness
found to be ___ SVT. Consider uptitrating for symptom management
following pacemaker placement
[] Please recheck lytes, Cr in 1 week given increased Lasix dose
of 40mg BID, may consider decreasing to 20mg in ___ as previously
[] Does not require to discontinue Coumadin prior to pacemaker
placement per Dr. ___
[] Previously on PO Lasix 40mg daily, increased to BID on ___.
Consider decreasing dose on follow up.
#CODE STATUS: Full presumed
#CONTACT: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 5 mg PO DAILY
2. Furosemide 40 mg PO BID
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Simvastatin 20 mg PO QPM
5. Warfarin 2 mg PO DAILY16
6. glimepiride 1 mg oral DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
2. Enalapril Maleate 5 mg PO DAILY
3. Furosemide 40 mg PO BID
4. glimepiride 1 mg oral DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Simvastatin 20 mg PO QPM
7. Warfarin 2 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
supraventricular tachycardia
Mild acute exacerbation of heart failure with reduced ejection
fraction
Secondary diagnosis:
Atrial flutter/atrial fibrillation
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
___ were admitted to the hospital because ___ were feeling
dizzy. Please see below for more information on your
hospitalization. It was a pleasure participating in your care!
We wish ___ the best!
- Your ___ Healthcare Team
What happened while ___ were in the hospital?
- ___ were admitted to the hospital for evaluation of the
dizziness spells ___ have been having at home
- We found out that these episodes are related to really fast
heart beats that make ___ feel dizzy
- ___ were seen by Dr. ___ continued to recommend
placement of a pacemaker to help ___ with your heart failure and
allow us to better treat the fast heart rates as well
- ___ will have the pacemaker placed when ___ leave the hospital
by Dr. ___
- ___ got intravenous medications to take fluid off of ___ as
well
What should ___ do after leaving the hospital?
- Please take 3mg of warfarin tonight (___) and return to
normal 2mg dosing tomorrow
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
- Dr. ___ will contact ___ about a time for placement
of the pacemaker.
- Continue to take your Lasix 40mg twice daily until ___ see
your cardiologist
- Your weight at discharge is 160lb. Please weigh yourself today
at home and use this as your new baseline
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
- If ___ have a repeat episode of dizziness, please make sure
that ___ are sitting down to avoid passing out. We have
increased your metoprolol back to 50mg daily that should help
with the fast heart rates as well.
Followup Instructions:
___
|
19749427-DS-12
| 19,749,427 | 20,706,697 |
DS
| 12 |
2191-11-29 00:00:00
|
2191-11-29 18:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
fruit / pollen extracts
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This patient is a ___ G3P1 @ 6w3d by ultrasound at OSH who
complains of Abd pain, N/V, and is 6 weeks Pregnant. She has had
4 days of vomiting 10x/day, upper abd pain. She has not had a BM
in 1 week, but has flatus. No urinary symptoms.
The patient was seen on ___ for the same reason, and
was discharged home with Zantac and Reglan. The patient reports
taking 4 tablets of the Reglan with no relief of her nausea. She
also reports that she has not been able to tolerate any food
since ___, and that she has severe upper abdominal pain only
relieved with morphine. She describes the pain as epigastric/RUQ
and it radiates to her chest, which then causes shortness of
breathe and dyspnea.
In the ED, VS: Temp: 98.2 HR: 102 BP: 139/95 Resp: 24 O(2)Sat:
100 Normal
The ED reviewed the ob consult note from yesterday - seen for
ruq
pain,n/v, sub-chorionic hematoma on imaging, and per radiology
her US consistent with a molar pregnancy and IUP present, which
is ___ rare. Presumptive diagnosis with hyperemesis of
pregnancy,
pain due to frequent vomiting, and given Zofran and IV fluids.
She has been unable to eat for a week and was initially
hyponatremic and hypokalemic.
She was seen by Ob, who does not want to admit her but feels she
should be admitted to medicine give her electrolyte
abnormalities
for repletion and for further workup of this abdominal pain,
which they did not believe is due to hyperemesis. Patient is
requesting therapeutic termination, and we have explained to her
that will not happen here as an inpatient but she is feeling so
unwell she wants to be admitted
Per ob reccomendations:"Patient presenting with anorexia and RUQ
pain, inconsistent with hyperemesisof pregnancy. The pt does
have an early intrauterine pregnancy with possible partial molar
pregnancy or subchorionic bleed, but reasonable to repeat US in
1
week for ___. Patient interested in family planning apt for
possible termination which can be performed as an outpatient."
She denies emesis. Denies hematemesis, diarrhea, constipation,
fevers, chills, palpitations, dizziness, chest pain, vaginal
bleeding, change in vaginal discharge
On arrival to the floor, pt vital signs were stable, she was
mildly anxious requesting morphine and Zofran.
Past Medical History:
PAST MEDICAL HISTORY:
G3P1, recent d+c, ITP, migraines, asthma, chlamydia
G1 ___ FT SVD x 1, uncomplicated
G2 ___ 6wk SAB c/b continued bleeding and persistently positive
requiring D&C ___, benign path, did not get follow up hcg per
patient
G3 current - U/S on ___ shows an IUP with cystic structures
adjacent to it, possible hematoma versus partial molar pregnancy
PGynHx: History of chlamydia ___, and ___,
treated. Has never had Pap smear as last ob/gyn visit was at age
Social History:
___
Family History:
Unknown
Physical Exam:
=======================
Admission Physical Exam
.
General: NAD
VITAL SIGNS: 97.5 130/88 60 20 100RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: GRAVID, SIGNIFICANT RUQ AND RLQ PAIN ON PALPATION,
GUARDING
ON RUQ/RLQ, NO REBOUND TENDERNESS, MILD EPIGASTRIC TENDERNESS,
NORMOACTIVE BOWEL SOUNDS
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: 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;
reflexes are 2+ of the biceps, triceps, patellar, and Achilles
tendons, toes are down bilaterally; gait is normal, Romberg is
non pathologic, coordination is intact.
.
=======================
Discharge Physical Exam
.
VS: T 98.3 BP 122/63 HR 67 RR 16 pOx 100% on RA
Gen: young woman who appears comfortable sitting up in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, 2+ distal pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, no distention, no abdominal tenderness to light or
firm palpation, no guarding, BS+ in all quadrants
no rebound tenderness, BS are present in all quadrants
MSK: grossly normal aROM and normal strength throughout
Skin: No visible rash. No jaundice.
Neuro: AAOx3. Normal mentation
Psych: calm, cooperative
Pertinent Results:
=======================
Admission labs:
.
___ 11:30AM BLOOD WBC-5.2 RBC-4.44 Hgb-11.7 Hct-36.2 MCV-82
MCH-26.4 MCHC-32.3 RDW-17.3* RDWSD-50.8* Plt ___
___ 11:30AM BLOOD Neuts-48.4 ___ Monos-14.2*
Eos-0.0* Baso-0.8 Im ___ AbsNeut-2.53 AbsLymp-1.90
AbsMono-0.74 AbsEos-0.00* AbsBaso-0.04
___ 11:30AM BLOOD Glucose-81 UreaN-11 Creat-0.8 Na-128*
K-8.1* Cl-97 HCO3-20* AnGap-19
___ 11:30AM BLOOD ALT-22 AST-82* AlkPhos-42 TotBili-1.4
___ 11:30AM BLOOD Lipase-32
___ 11:30AM BLOOD Albumin-4.9
___ 11:30AM BLOOD TSH-0.46
___ 11:30AM BLOOD ___
___ 12:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
=======================
Other notable labs:
.
Urine cannabinoids - positive
Urine opioids - positive
Influenza swab - negative
=======================
Labs prior to discharge:
.
___ 07:09AM BLOOD WBC-5.4 RBC-3.91 Hgb-10.5* Hct-32.8*
MCV-84 MCH-26.9 MCHC-32.0 RDW-18.0* RDWSD-54.9* Plt ___
___ 07:09AM BLOOD Glucose-71 UreaN-9 Creat-0.7 Na-133 K-3.8
Cl-98 HCO3-20* AnGap-19
___ 07:09AM BLOOD ALT-24 AST-17 AlkPhos-52 TotBili-1.3
___ 07:09AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.8
___ 07:09AM BLOOD Lipase-157*
___ 07:09AM BLOOD ___
=======================
Imaging:
.
RUQ US - some sludge, otherwise WNL
GYN US - pregnancy, see full report for ? of molar preg
Abd US - appendix not visualized
Chest CTA - no PE or pneumonia
___ OB/GYN U/S -
"FINDINGS: An intrauterine gestational sac is seen and a single
living embryo is identified with a crown rump length of 11.6 mm
representing a gestational age of 7 weeks 3 days. This
corresponds satisfactorily to the menstrual dates of
7 weeks 1 day. The heartbeat is 144 beats per minute. Again
seen in the endometrium in the lower uterine segment is an
echogenic area with cystic spaces, slightly less prominent on
today's study. The ovaries are normal.
IMPRESSION:
1. Single live intrauterine pregnancy with size = dates.
2. Echogenic cystic area in the endometrium, slightly less
prominent than on the prior study consistent with a involving
subchorionic hematoma"
Brief Hospital Course:
# Generalized abdominal pain with nausea, vomiting, and
constipation
Unclear etiology. DDx was thought to include ___,
(given her marijuana use, hx of migraines, pregnancy), PUD,
gastritis, gastroenteritis and constipation. Appendicitis less
likely given absence of fever, WBC, and focal tenderness.
Pancreatitis, choledocholithiasis with obstruction,
cholecystitis essentially r/o by US and labs (biliary dyskinesia
remains possibility but no focal tenderness). GYN cause seemed
unlikely based on gestational age and GYN US, though could be
contributor. The OB/GYN team evaluated the patient and felt
this was not related to her IUP, and was most likely due to
constipation. Serial abdominal exams were benign throughout her
hospital course. She reported no bowel movements in over a
week, and with no other specific features or findings on exam,
labs, or imaging, constipation-induced abdominal pain became the
leading diagnosis. The GI team evaluated the patient and
recommended she take miralax, given her report of
nausea/vomiting with some of the other pro-motility agents (i.e.
senna). She gradually improved with symptomatic therapy
including Zofran, promethazine, and lorazepam PRN
nausea/vomiting, Tylenol PO PRN mild/moderate pain, and
Oxycodone ___ mg PO PRN severe pain. She had no clear
improvement with sucralfate which was stopped. She was initially
treated with IV famotidine for acid reduction, and this was
transitioned to PO once she was tolerating PO. We treated her
constipation aggressively with PO and PR regimen, with no
success in achieving a patient-reported bowel movement, but with
eventual improvement in her abdominal pain.
.
# Electrolyte disturbances (hypokalemia, hypophosphatemia,
hypomagnesemia) from poor PO intake and N/V resolved with IV and
PO repletion.
.
# Report of SOB initially with history of asthma: She did note
prior to admission some dyspnea and intermittent cough, but none
since admit. Flu swab was negative.
CTA was negative. No hypoxia during her hospital course. She
did not require nebulizer treatment or exhibit any
SOB/dyspnea/respiratory distress while hospitalized.
.
# Pregnancy, with initial question of early molar preg: She is
now ~7wks by US. She
desires termination. Per OB/GYN note from ___, patient should
have repeat u/s on
___: which showed a normal IUP and possible evolving
subchorionic hematoma. We provided her the contact information
to arrange outpatient f/u with ___ family planning for
options for termination. The patient reported that she was
planning to seek pregnancy termination over the weekend, so as
to avoid missing additional work. The ___ clinic is not open
on weekends, but we provided her with the contact information in
case she was unable to find a clinic open on this holiday
weekend.
.
# Day of discharge: On the day of discharge, she was feeling
better with no significant abdominal pain, mild nausea, and no
vomiting with intake of a regular diet without requiring oral
pain medications. She told me that she planned to pursue
termination of her pregnancy in the next ___ days (over the
weekend, if possible, so as to avoid missing additional time at
work). I provided her with the contact information for the
___ (___) in case she wanted
to follow-up with them re: options for terminating her
pregnancy. She is being discharged on Miralax BID until having
normal BMs. 40 minutes spent in patient care, counseling, and
discharge-related activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheeze
Discharge Medications:
1. Polyethylene Glycol 17 g PO BID
Ok to stop once you are having regular bowel movements.
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth twice
a day Disp #*60 Packet Refills:*3
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheeze
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Nausea and vomiting
Pregnancy - unwanted
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
VS: 98.3 122/63 67 16 100% on RA
Gen: young woman who appears comfortable sitting up in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
Cardiovasc: RRR, no MRG, 2+ distal pulses, no edema
Resp: normal effort, no accessory muscle use, lungs CTA ___.
GI: soft, no distention, no abdominal tenderness to light or
firm palpation, no guarding, BS+ in all quadrants
no rebound tenderness, BS are present in all quadrants
MSK: grossly normal aROM and normal strength throughout
Skin: No visible rash. No jaundice.
Neuro: AAOx3. Normal mentation
Psych: calm, cooperative
Discharge Instructions:
Dear ___,
You were admitted to ___ with abdominal pain, nausea and
vomiting. No major abnormalities to explain your symptoms were
found on laboratory testing or imaging studies of your abdomen.
You were evaluated by the OB/GYN and GI physicians. Although it
is possible that several factors contributed to your symptoms,
it was thought that constipation was playing a key role. We
recommend you continue taking Miralax twice daily until you are
having regular bowel movements, at which point you can stop that
medication or use it on an as-needed basis.
Regarding your pregnancy, you have told us that you intend to
terminate the pregnancy and are planning to do this within the
next 2 days. If you would like to have this done through your
primary gynecologist, please
Followup Instructions:
___
|
19751020-DS-4
| 19,751,020 | 21,558,046 |
DS
| 4 |
2126-04-01 00:00:00
|
2126-04-01 15:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending: ___
Chief Complaint:
neck pain and HA
Major Surgical or Invasive Procedure:
___ arthrocentesis
History of Present Illness:
___ pmhx factor V leiden on coumadin, Mollaret's meningitis on
valacyclovir, temporal lobe epilepsy presenting with worsening
neck pain back pain and headache consistent with another episode
of meningitis.
Patient was seen at ___ 4 days ago, admitted,
did not get a lumbar puncture because he is anticoagulated on
Coumadin, got IV valacyclovir but felt that his pain was not
being adequately managed so he left AMA. He returns today with
worsening headache neck and back pain. No fevers or chills, no
focal neurologic symptoms. He has been taking p.o. valacyclovir
at home.
- In the ED, initial vitals were:
98.5, 100, 122/71, 18, 98% RA
- Exam was notable for:
Neck and back pain
- Labs were notable for:
Lack of leukocytosis
INR 1.6
Lactate 1.1
- The patient was given:
IV acyclovir
1L IVF
On arrival to the floor, he gives the above history.
He affirms that the symptoms are identical to his prior
meningitis episodes.
The only new symptom has actually developed just on day of
presentation, his L knee and calf have become swollen and
erythematous.
Past Medical History:
Nonischemic cardiomyopathy
Hypertension, essential
Aortic valve, bicuspid
Chronic diastolic congestive heart failure
Thoracic aortic aneurysm without rupture s/p repair
Temporal lobe epilepsy
Recurrent HSV-2 meningitis (Mollaret's meningitis; most recent
___ L thalamic stroke ___ 1 week after motorcycle accident)
Hypercoagulable state (Factor V Leiden and protein C deficiency)
on Coumadin
History of DVT
Depression
Anxiety
Neuropathy
Radiculopathy
Social History:
___
Family History:
Maternal aunt breast ca
___ uncle ?? ca
Physical ___:
ADMISSION EXAM:
VITALS: ___ 2124 Temp: 98,6 PO BP: 124/75 L Lying HR: 73
RR: 18 O2 sat: 95% O2 delivery: RA
GEN: relatively well appearing and not in distress
HEENT: marked nuchal rigidity, +kernig
CV: RRR nl s1s2 nomrg
PULM: CTA anteriorly
GI: S/ND/NT
EXT: L knee and calf swollen and warm, unable to flex past 150
deg, marked effusion on exam.
DISCHARGE EXAM:
VITALS: 24 HR Data (last updated ___ @ 311)
Temp: 97.5 (Tm 97.8), BP: 133/80 (115-140/65-86), HR: 54
(54-66), RR: 18 (___), O2 sat: 93% (93-97), O2 delivery: Ra
GEN: sitting up in bed, wearing cervical collar
HEENT: marked nuchal rigidity
CV: RRR nl s1s2 no m/r/g
PULM: CTA anteriorly
GI: S/ND/NT
EXT: L knee no longer warm to touch, swelling and effusion
resolved, full ROM without any pain
Pertinent Results:
ADMISSION LABS:
___ 06:10PM ___ PTT-26.4 ___
___ 06:10PM PLT COUNT-238
___ 06:10PM NEUTS-70.4 LYMPHS-14.1* MONOS-14.6* EOS-0.2*
BASOS-0.2 IM ___ AbsNeut-6.92* AbsLymp-1.38 AbsMono-1.43*
AbsEos-0.02* AbsBaso-0.02
___ 06:10PM WBC-9.8 RBC-4.13* HGB-12.3* HCT-36.8* MCV-89
MCH-29.8 MCHC-33.4 RDW-13.7 RDWSD-44.5
___ 06:10PM Lyme Ab-NEG
___ 06:10PM CRP-229.6*
___ 06:10PM GLUCOSE-100 UREA N-13 CREAT-0.7 SODIUM-135
POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-26 ANION GAP-16
___ 06:26PM LACTATE-1.1
DISCHARGE LABS:
___ 05:22AM BLOOD CRP-111.2*
___ 05:22AM BLOOD WBC-4.9 RBC-4.07* Hgb-11.9* Hct-36.9*
MCV-91 MCH-29.2 MCHC-32.2 RDW-14.0 RDWSD-46.5* Plt ___
___ 05:22AM BLOOD Plt ___
___ 05:22AM BLOOD ___ PTT-33.7 ___
___ 05:22AM BLOOD Glucose-98 UreaN-10 Creat-0.6 Na-143
K-4.2 Cl-104 HCO3-28 AnGap-11
___ 05:22AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.1
MICRO:
___ 2:42 am JOINT FLUID Source: Knee.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
IMAGING:
___ L Doppler U/S
IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity veins.
___ L Knee plain film
IMPRESSION:
There are interference screws and staples consistent with prior
ACL and likely MCL repair. No definite hardware related
complications are seen. There is a small suprapatellar knee
joint effusion. There are trace degenerative changes of the
patellofemoral compartment. No acute fractures are seen.
Mineralization is relatively preserved.
Brief Hospital Course:
BRIEF HOSPITAL SUMMARY:
=======================
___ with PMH of factor V leiden on coumadin, Mollaret's
meningitis on prophylactic valacyclovir, and temporal lobe
epilepsy presented with worsening neck pain, back pain and
headache consistent with recurrent meningitis.
TRANSITIONAL ISSUES:
====================
[] Patient was treated with IV acyclovir transitioned to PO
valacyclovir for 10d course per recommendation of ID team and
patient's ID provider ___. Discharged on PO valacyclovir
1000mg three times a day until ___. Then should resume
prophylaxis with PO valacyclovir 1000mg daily.
[] Patient's warfarin was held while determining utility of
lumbar puncture. Bridging with lovenox at time of discharge. INR
on day of discharge was 1.5. Patient should continue lovenox
90mg twice daily and warfarin 2.5mg daily (reduced from 5mg
daily due to supratherapeutic INR on presentation to outside
hospital). Patient will follow up at his ___ clinic
on ___ for INR check. If INR ___, can discontinue lovenox and
continue warfarin alone until PCP follow up next week. If INR
<2, patient should continue daily warfarin and lovenox twice
daily until repeat INR check on ___.
ACUTE/ACTIVE ISSUES:
====================
# Mollaret's meningitis
Patient has a history of recurrent benign lymphocytic
meningitis, possibly linked to HSV so on valacyclovir
suppression as outpatient. Presented with symptoms consistent
with recurrence. Neurology and infectious disease teams were
consulted. LP was not performed as per consultants, procedure
would not change management. Patient was started on IV acyclovir
(___) then switched to PO valacyclovir 1000 TID for 10 day
course (end date ___. He will follow up with his ID provider
___. His home oxycodone was increased while inpatient
due to acute worsening pain. Given afebrile without
leukocytosis, bacterial meningitis was not likely and he was not
treated with antibiotics.
#L knee reactive arthritis
Patient presented with swollen, erythematous and warm left knee
with decreased ROM. U/S negative for DVT. Patient underwent
arthrocentesis on ___ with joint fluid with ___ TNC, no
crystals and negative gram stain and cultures. Unlikely septic
arthritis given these findings. Rheumatology was consulted and
diagnosed likely reactive arthritis given joint fluid analysis
consistent with non-crystal inflammatory arthritis. Lyme
serology was negative. ESR was normal. CRP improved from 230 to
111, although hard to say if this parameter was more related to
meningitis treatment. Knee effusion had resolved at time of
discharge.
# Factor V ___
Patient's home coumadin was held while deciding on LP. His last
DVT was ___ year ago. Once LP was not indicated, he was started
on lovenox 1mg/kg BID (90mg) as well as warfarin. INR on day of
discharge was 1.5. Home dose warfarin was initially 5mg, but
given that patient was supratherapeutic on admission to ___
___, decreased dose to 2.5mg qd on discharge. Patient
will continue bridging with lovenox and will follow up with
___ clinic for INR check on ___.
CHRONIC ISSUES:
===============
# HTN: continued home amlodipine, losartan and metoprolol
# Epilepsy: continued home Keppra
# chronic Pain: continued home cyclobenzaprine, oxycodone
# Depression: continued home sertraline
# BPH: continued home Tamsulosin
# Health Maintenance: continued home furosemide
# CODE: Full
# CONTACT:
Name of health care proxy: ___
Relationship: step-mom
Phone number: ___
Cell phone: ___
Proxy form in chart: No
Comments: ___ Mother ___
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.
Greater than 30 minutes spent providing discharge services for
this patient
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Furosemide 20 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
6. Warfarin 5 mg PO DAILY16
7. Cyclobenzaprine ___ mg PO TID:PRN back pain
8. Keppra XR (levETIRAcetam) 3000 mg oral DAILY
9. Sertraline 150 mg PO DAILY
10. ValACYclovir 500 mg PO Q24H
11. Tamsulosin 0.4 mg PO QHS
12. Topiramate (Topamax) 25 mg PO DAILY
13. Losartan Potassium 12.5 mg PO DAILY
14. Lidocaine 5% Patch 1 PTCH TD QAM
15. Enoxaparin Sodium 90 mg SC Q12H AS DIRECTED BRIDGE
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. ValACYclovir 1000 mg PO TID Duration: 5 Days
End date= ___. Then take 1000mg daily.
2. Warfarin 2.5 mg PO DAILY16
3. amLODIPine 5 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Cyclobenzaprine ___ mg PO TID:PRN back pain
6. Enoxaparin Sodium 90 mg SC Q12H AS DIRECTED BRIDGE
7. Furosemide 20 mg PO DAILY
8. Keppra XR (levETIRAcetam) 3000 mg oral DAILY
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Losartan Potassium 12.5 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
13. Sertraline 150 mg PO DAILY
14. Tamsulosin 0.4 mg PO QHS
15. Topiramate (Topamax) 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
#Mollaret's meningitis
#Reactive arthritis of the left knee
#Factor V Leiden on coumadin
#HTN
#epilepsy
#depression
#BPH
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 WAS I IN THE HOSPITAL?
- You came to the hospital because you were having a headache
and neck pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were started on IV acyclovir to treat recurrent
meningitis. You were transitioned to oral valacyclovir.
- You had fluid removed from your left knee that was consistent
with inflammation. The swelling in your knee improved.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below,
please call your primary care doctor or go to the emergency
department immediately.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19751438-DS-19
| 19,751,438 | 23,395,859 |
DS
| 19 |
2146-12-28 00:00:00
|
2147-01-11 12:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
cat
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ year old gentleman with abdominal pain for 30
hours that started first around the umbilical area and has now
migrated to the right lower quadrant. He also reports fatigue
that developed 2 days ago, associated with weakness and
headache.
When he ate yesterday, he had nausea but no emesis. He did have
fever to 101 at home. He last had a normal colonoscopy ___
and has no history of inflammatory bowel disease. He otherwise
reports anxiety, some associated shortness of breath,
constipation, (last BM today after contrast).
Past Medical History:
PAST MEDICAL HISTORY:
anxiety, urinary incontinence
PAST SURGICAL HISTORY:
nose surgery
Social History:
___
Family History:
Aunt with IBD
Physical Exam:
PHYSICAL EXAM:
VS: T 97.3, HR 87, BP 156/81, RR 18, SaO2 100% RA
GEN: anxious appearing, not in distress
HEENT: NCAT, EOMI, MMM
CV: Regular rate and rhythm
PULM: Clear to auscultation
ABD: Softly distended, tender to palpation RLQ with some
guarding. +Rovsing sign
MSK: Warm, well perfused
NEURO: slight disconjugate gaze, otherwise CII-XII intact
PSYCH: Anxious, otherwise appropriate
Discharge Physical Exam:
VS: 97.5, 64, 120/69, 18, 96%ra
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
incisionally, non-distended. Incisions: clean, dry and intact,
dressed and closed with steristrips.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
================================================
Pertinent Results:
___ 05:00AM BLOOD WBC-13.6* RBC-4.57* Hgb-13.8 Hct-40.0
MCV-88 MCH-30.2 MCHC-34.5 RDW-13.3 RDWSD-41.7 Plt ___
___ 07:18PM BLOOD WBC-14.8* RBC-5.18 Hgb-15.4 Hct-45.0
MCV-87 MCH-29.7 MCHC-34.2 RDW-13.3 RDWSD-41.9 Plt ___
___ 07:18PM BLOOD Neuts-81.1* Lymphs-10.4* Monos-7.3
Eos-0.5* Baso-0.2 Im ___ AbsNeut-12.00* AbsLymp-1.54
AbsMono-1.08* AbsEos-0.07 AbsBaso-0.03
___ 05:00AM BLOOD Glucose-102* UreaN-12 Creat-0.9 Na-141
K-4.1 Cl-103 HCO3-28 AnGap-14
___ 07:18PM BLOOD Glucose-117* UreaN-15 Creat-0.9 Na-136
K-3.7 Cl-97 HCO3-26 AnGap-17
___ 05:00AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.1
IMAGING:
CT A/P: Abnormally dilated appendix with wall hyperenhancement
and adjacent fat stranding, consistent with acute appendicitis.
No perforation or abscess. Secondary adjacent cecal wall
inflammation.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed appendicitis. WBC was
elevated at 14.8. The patient underwent laparoscopic
appendectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating sips, on IV fluids, and IV analgesia for pain
control. The patient was hemodynamically stable.
.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
MEDICATIONS AT HOME:
Trifuloperazine 1 mg prn
Gabapentin 300 mg BID
Sertraline 150 mg QD
Clonazapam 0.5 mg ___ times daily prn anxiety
ASA 325 mg occasionally
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. ClonazePAM 0.5 mg PO QID:PRN anxiety
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
4. Gabapentin 300 mg PO BID
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
7. Sertraline 100 mg PO DAILY
8. Trifluoperazine HCl 1 mg PO Q12H:PRN anxiety
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 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 to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 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.
o You may start some light exercise when you feel comfortable.
o 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:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o 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:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. 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).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o 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.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. 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.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o 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.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o 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.
Followup Instructions:
___
|
19751450-DS-10
| 19,751,450 | 20,679,622 |
DS
| 10 |
2163-07-24 00:00:00
|
2163-07-25 19:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male who presented to ___
___ as a trauma activation after a
dirt bike accident. He had been traveling at 30mph and
attempting a trick when he lost control and flipped on his bike.
He was wearing a helmet. No LOC, possible handlebars to chest.
He was found to have a right clavicle fracture, left rib
fractures and a small left pneumothorax, He was admitted to ___
for the above injures and for further monitoring.
Past Medical History:
No past medical or surgical history
Social History:
___
Family History:
Non-contributory
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Vitals: Temp 98.1 HR 68 BP 123/69 RR 18 SpO2 94% RA
General: awake, alert, no acute distress
HEENT: trachea midline, no facial abrasions
CV: regular rate and rhythm
Pulm: normal respiratory effort
GI: abdomen soft, non-distended, non-tender
Musculoskeletal: edema and ecchymoses of right clavicle,
tenderness to palpation of left chest wall, tenderness to
palpation of thoracic and lumbar spine without step offs
Wounds: abrasions right posterior shoulder and right knee
Pertinent Results:
ADMISSION LABS:
___ 08:46PM BLOOD WBC-14.4* RBC-4.53* Hgb-14.4 Hct-40.5
MCV-89 MCH-31.8 MCHC-35.6 RDW-11.9 RDWSD-38.2 Plt ___
___ 08:46PM BLOOD ___ PTT-24.3* ___
___ 09:01PM BLOOD Glucose-115* Lactate-1.8 Na-140 K-4.1
Cl-104
IMAGING:
___ Chest xray:
IMPRESSION:
No acute cardiopulmonary process.
Displaced fracture of the distal third of the right clavicle, as
above.
Chronic appearing irregularity of the distal aspect of the right
clavicle.
___ Chest xray:
IMPRESSION:
In comparison with the study ___, the comminuted fracture
of the distal portion of the right clavicle is again seen though
no definite pneumothorax is appreciated. Continued low lung
volumes with the cardiac silhouette within normal limits and no
vascular congestion or pleural effusion. Atelectatic changes are
seen at the left base in the retrocardiac region.
___ Clavicle xray
IMPRESSION:
1. Comminuted fracture of mid third right clavicle.
2. Widening of AC joint associated with spurring at the distal
clavicle and ossification at the insertion of the coracoid
clavicular ligament likely reflecting a remote AC joint
separation.
___ Right thumb xray
IMPRESSION:
No acute osseous injury the right thumb.
Brief Hospital Course:
Mr. ___ is a ___ year old male otherwise healthy male who
presented to ___ on ___ as
a trauma activation after a dirt biking accident. He was found
to have a right clavicle fracture, left sided rib fractures and
a small left pneumothorax. Orthopedic surgery was consulted and
recommended a sling for his right clavicle fracture. He was
admitted to the Acute Care Surgery service for pain control and
further management.
.
The patient underwent a repeat chest xray the next morning which
demonstrated resolution of his left pneumothorax. At this point,
the patient was tolerating a regular diet, ambulating
independently, voiding spontaneously without issue, and his pain
was well controlled on oral pain medication alone. He was deemed
ready for discharge to home. He was instructed to use a sling
for the collarbone for comfort and that he can bear weight and
do range of motion as tolerated. He was scheduled to follow up
with orthopedic surgery in outpatient clinic with repeat imaging
in a few weeks.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*15 Tablet Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN
BREAKTHROUGH PAIN
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth once a day Disp #*14 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
[] Comminuted fracture of the distal portion of the right
clavicle
[] Right 1st rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after a dirt bike accident. You were
found to have a fractured collar bone and rib fractures. These
injuries are non-operative. You can use a sling for the
collarbone for comfort and can bear weight and do range of
motion as tolerated. The Orthopedic team was consulted and they
will see you in outpatient clinic for follow-up and repeat
imaging in a few weeks. You pain is well controlled and you are
medically stable for discharge home to continue your recovery.
Please note the following:
* Your injury caused a clavicle and rib fractures which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
19751455-DS-13
| 19,751,455 | 25,008,396 |
DS
| 13 |
2111-07-08 00:00:00
|
2111-07-10 02:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Bronchoscopy ___
History of Present Illness:
___ with history of COPD, PE on lovenox, LUL wedge resection for
aspergilloma and NSCLC undergoing photodynamic therapy c/b
recurrent airway obstruction by necrotic mucosal debris.
He reports that he was in his usual state of health until 7:30pm
today when he began to feeling unwell. he noticed increased WOB
and placed himself on his home O2, which he usually does not
wear during the day. He used his inhaler and then placed himself
on his home oximeter which showed a measurement of 74% on 2L. He
coughed several times and felt relief of his breathing but did
not bring anything up. An ambulance was called. By the time the
EMTs arrived he was satting 90% on 4L and was feeling better. On
arrival to the ED he was satting 99% on 3L Nasal Cannula and 92
on RA. His baseline O2 on RA is 96%
He denies fevers, chills, any a change in his breathing and
health prior to this acute episoe. He is currently breathing
well.
Of note, he has a recent admission for photodynamic therapy that
was complicated by SVT and respiratory failure requiring MICU
stay. In regards to his malignancy he was was noted to have FDG
avid LLL nodule concerning for neoplasm. ___ guided biopsy of the
nodule showed preliminary results concerning for ___. He
subseuqently had a bronchoscopy showing CIS in the RMS, RUL, LUL
biopsy proven. The plan was for patient to undergo PDT of the
CIS followed by SBRT for the malignant nodule (to be done at a
later date at ___.
Past Medical History:
___ as above
COPD
GERD
PE on lovenox
s/p LUL wedge for Aspergilloma (c/b PTX requring rib resection,
pectoral flap and pleurodesis -per patient)
AAA s/p repair ___ ___
s/p tonsillectomy childhood
Social History:
___
Family History:
Brother, deceased, "cancer in the eye"
Sister, deceased, colon ca
Mother, deceased, SLE
Physical Exam:
On admission:
Vitals- T: 98.2 BP: 106/66 P: 82 R: 17 18 O2: 97 on 3L.
GENERAL: Sedated s/p bronch, comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Diffuse wheeze bilaterally
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, no rebound tenderness or
guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
On discharge:
HR 98 RR 16 O2 100 % on 2 L T 36.8
GENERAL: AAOX3, comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Diffuse wheeze bilaterally
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, no rebound tenderness or
guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS
___ 10:10PM GLUCOSE-106* UREA N-10 CREAT-0.5 SODIUM-135
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-23 ANION GAP-15
___ 10:10PM estGFR-Using this
___ 10:10PM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-2.0
___ 10:10PM ___ O2-21 PO2-56* PCO2-37 PH-7.45 TOTAL
CO2-27 BASE XS-1 INTUBATED-NOT INTUBA
___ 10:10PM WBC-5.9 RBC-4.40* HGB-13.8* HCT-40.1 MCV-91
MCH-31.3 MCHC-34.3 RDW-14.7
___ 10:10PM NEUTS-76.7* LYMPHS-15.4* MONOS-6.1 EOS-1.3
BASOS-0.6
___ 10:10PM PLT COUNT-393
___ 10:10PM ___ PTT-28.8 ___
DISCHARGE LABS
___ 05:00AM BLOOD WBC-4.1 RBC-4.32* Hgb-13.2* Hct-39.9*
MCV-92 MCH-30.5 MCHC-33.1 RDW-14.6 Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.2
Brief Hospital Course:
Mr ___ is a ___ with history of COPD, PE on lovenox, LUL
wedge resection for aspergilloma and NSCLC undergoing
photodynamic therapy c/b recurrent airway obstruction by
necrotic mucosal debris. He presented to the hospital with
dyspnea and was admitted to the ICU for bronchoscopy and
monitoring. He had a bronch w/ removal of debris and watched in
the ICU overnight. There were no complications, no increase in
O2 requirements, and he was subsequently was discharged home
from the ICU. He is scheduled for a repeat bronchoscopy on ___
with Dr ___. He should continue taking bactrim for 7 days
(___)
**transitional issues**
-repeat bronch on ___ with Dr ___ bactrim for 7 days (stop ___
-prescription given for trazodone
-F/U BAL cultures
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ClonazePAM 0.25 mg PO HS
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Guaifenesin ER 600 mg PO Q12H
4. Omeprazole 40 mg PO BID
5. Sertraline 50 mg PO DAILY
6. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
7. Voriconazole 200 mg PO Q12H
8. Albuterol Inhaler 2 PUFF IH Q6H
9. Ranitidine 150 mg PO BID
10. Tiotropium Bromide 1 CAP IH DAILY
11. Sulfameth/Trimethoprim DS 1 TAB PO BID
12. Enoxaparin Sodium 70 mg SC Q12H
13. Diltiazem Extended-Release 180 mg PO DAILY
14. ValACYclovir 1000 mg PO Q12H
15. Cefpodoxime Proxetil 200 mg PO Q12H
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H
2. ClonazePAM 0.25 mg PO HS
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Guaifenesin ER 600 mg PO Q12H
7. Omeprazole 40 mg PO BID
8. Sertraline 50 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. ValACYclovir 1000 mg PO Q12H
11. Voriconazole 200 mg PO Q12H
12. Ranitidine 150 mg PO BID
13. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
14. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
15. TraZODone 25 mg PO HS:PRN insomnia Duration: 1 Dose
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Non-small cell lung cancer
Dyspnea
Pneumonia
Secondary Diagnosis:
COPD
PE on lovenox
LUL aspergilloma
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 came into the
hospital with shortness of breath. You had a bronchoscopy
(procedure that looks at your lungs) that removed debris from
your lungs. You tolerated the procedure well and were monitored
in the ICU overnight. You should follow up with Interventional
Pulmonary as an outpatient. You completed your cefpodoxime. You
should continue bactrim for a 7 day course (stop ___.
Followup Instructions:
___
|
19751571-DS-10
| 19,751,571 | 24,540,241 |
DS
| 10 |
2163-10-12 00:00:00
|
2163-10-14 08:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin
Attending: ___.
Chief Complaint:
Candidemia
Major Surgical or Invasive Procedure:
transesophageal echo
tracheostomy decannulation (___)
History of Present Illness:
___ with recent prolonged hospital course beginning in ___ for
bacterial and candidal endocarditis with flail mitral valve s/p
CABG/MRV with multiple complications incl. cardiac arrest,
respiratory failure s/p trach/peg admitted with positive
candical culture from his rehab today. The patient denies
fevers or chills. He complains of ongoing nausea, diarrhea, and
poor appetite since his discharge. He is very disheartened by
his lack of mobility and progress.
In the ED, initial VS: 98.2 104 136/84 16 96% RA. The patient
was seen by ___, who pulled his hemodialysis catheter. Catheter
tip was sent for culture. ID was also consulted by phone, and
he was recommended to start micafungin 100 mg IV daily. Cardiac
surgery recommended admission to medicine. VS prior to
transfer: 103 145/84 16 97%.
Currently, the patient reports feeling horribly depressed by
what he has been through. Review of systems negative as below.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
chest pain, abdominal pain, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
s/p CABG with MVR
Recent admission for endocarditis complicated by multiorgan
failure
atrial fibrillation during previous hospitalization
CKD, on HD following circulatory compromise during previous
admission
Ischemic colitis
Asthma
seizure disorder
chronic hyponatremia since ___
BPH
depression
history of syncope
s/p bilateral knee replacement
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Admission Physical Exam:
General: Pleasant man in NAD; trach collar in place
HEENT: EOMI, PERRL, MMM, oropharynx clear
Neck: NO lymphadenopathy or thyromegaly; trach in place, capped
CV: Normal S1, S2, ___ holosystolic murmur
Lungs: Bibasilar crackles
Abdomen: Soft, mildly distended, non-tender, normoactive bowel
sounds
GU: foley in place draining clear yellow urine
Ext: trace ankle edema
Neuro: Grossly intact, diminished strength in upper and lower
extremities bilaterally; paucity of arm and leg movement during
exam
Skin: Median sternotomy covered in dry gauze; incision CDI,
Surrounding skin with mild blistering and erythema; abdominal
incision CDI
Discharge physical exam:
98.3 152/76 (148-153 / 76-92) 100 (98-100)
GEN: Resting in bed, NAD
HEENT: Moist MMM, dressing overlying tracheostomy site in place
COR: RRR, +S1S2, no m/r/g
PULM: CTAB
___: + G-tube in place. +BS. Soft, non-tender, non-distended
EXT: WWP, no c/c/e.
INCISIONS: sternotomy site c/d/i, midabdominal incision c/d/I
with staples taken out
NEURO: Alert, appropriate. Generalized weakness but moving all
extremities.
Pertinent Results:
Admission Labs:
___ 05:40PM BLOOD WBC-14.9*# RBC-3.38* Hgb-10.6* Hct-32.6*
MCV-96 MCH-31.4 MCHC-32.6 RDW-15.5 Plt ___
___ 05:40PM BLOOD Neuts-59.3 ___ Monos-4.9 Eos-1.2
Baso-0.5
___ 05:40PM BLOOD ___ PTT-26.4 ___
___ 05:40PM BLOOD Glucose-105* UreaN-55* Creat-2.0* Na-139
K-3.9 Cl-101 HCO3-27 AnGap-15
___ 08:20AM BLOOD ALT-59* AST-58* LD(LDH)-260* AlkPhos-129
TotBili-0.4
___ 08:20AM BLOOD Phenyto-3.8*
___ 05:45PM BLOOD Lactate-1.2
Relevant Labs:
___ 08:10AM BLOOD WBC-17.9* RBC-3.23* Hgb-10.4* Hct-31.2*
MCV-96 MCH-32.1* MCHC-33.3 RDW-15.3 Plt ___
___ 08:00AM BLOOD WBC-17.8* RBC-3.01* Hgb-9.5* Hct-29.4*
MCV-98 MCH-31.6 MCHC-32.3 RDW-15.0 Plt ___
___ 07:50AM BLOOD WBC-13.3* RBC-2.76* Hgb-9.1* Hct-26.8*
MCV-97 MCH-32.9* MCHC-34.0 RDW-15.3 Plt ___
___ 09:10AM BLOOD WBC-12.6* RBC-3.17* Hgb-10.1* Hct-30.6*
MCV-97 MCH-31.9 MCHC-33.1 RDW-14.7 Plt ___
___ 09:03AM BLOOD WBC-14.6* RBC-3.00* Hgb-9.7* Hct-29.2*
MCV-97 MCH-32.2* MCHC-33.1 RDW-15.1 Plt ___
___ 08:00AM Creat-1.3*
___ 07:50AM Creat-1.1
___ 09:03AM Creat-0.9
Discharge Labs:
___ 07:12AM BLOOD WBC-13.9* RBC-3.03* Hgb-9.6* Hct-29.5*
MCV-97 MCH-31.7 MCHC-32.6 RDW-14.8 Plt ___
___ 07:12AM BLOOD Glucose-114* UreaN-27* Creat-1.2 Na-139
K-3.9 Cl-105 HCO3-22 AnGap-16
___ 07:12AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9
Pertinent Micro/Path:
___ 5:40 pm BLOOD CULTURE STAPHYLOCOCCUS EPIDERMIDIS.
Isolated from only one set in the previous five days.
SENSIS REQUESTED BY ___ ON ___ @
10:40AM.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 4 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE
COCCI IN CLUSTERS.
___ 7:35 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
___. >100,000 ORGANISMS/ML..
SERRATIA MARCESCENS. >100,000 ORGANISMS/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.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
___
| SERRATIA MARCESCENS
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 128 R 256 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ 5:55 pm BLOOD CULTURE: NO GROWTH.
___ 7:05 pm CATHETER TIP-IV WOUND CULTURE (Final ___:
No significant growth.
___ 8:20 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 8:20 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:20 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:21 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
URINE CULTURE (Final ___:
___. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
GRAM NEGATIVE ROD #2. ~5000/ML. SECOND MORPHOLOGY.
___ 12:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 8:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 7:50 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Pertinent Imaging and Studies:
Liver/GB U/S ___. Sludge and stones within the gallbladder. No signs of
cholecystitis. No ductal dilatation
2. Right pleural effusion.
EEG ___
IMPRESSION: This is an abnormal routine EEG in the awake and
drowsy states
due to the presence of left temporal sharp waves, as well as
bilateral
temporal slowing, left more than right. These findings suggest
the presence
of a potential focus of epileptogenesis in the left temporal
region, as wellas subcortical dysfunction in both temporal
regions. No electrographic
seizures are seen. Note is made of a regular tachycardia.
CXR ___
Tracheostomy is in adequate position in this patient with prior
sternotomy.
Right basal pleural effusion is minimal. Left lower lobe is
chronically
atelectatic with adjacent moderate pleural effusion. There is
no new lung
consolidation.
ECHO ___
IMPRESSION: No vegetations seen. Normally functioning mitral
valve bioprosthesis.
Brief Hospital Course:
___ with recent prolonged hospital course beginning in ___ for
bacterial and candidal endocarditis with flail mitral valve s/p
CABG/MRV with multiple complications including cardiac arrest,
respiratory failure s/p trach/peg admitted with recurrent
candidemia and diarrhea.
Active Diagnoses
# Candidemia: Found on surveillance cultures from rehab. The
patient's HD catheter was pulled in the ED as a likely source
(he had not required HD since discharge in early ___. CXR did
not show evidence of pneumonia. TEE was negative for
bioprosthetic valve vegetation. Ophtho was consulted and were
not concerned for endophthalmitis. The patient was treated with
iv Micafungin ___. He was switched to po fluconazole ___,
once weaned off Dilantin for his seizures. Per ID
recommendations, he will have a 7 day course of fluconazole
which should continue through ___ (to end on ___.
Blood cultures were negative for fungemia while in house. He
will need repeat fungal cultures one week after discontinuation
of fluconazole (to be drawn on ___.
# Possible Coag Negative Staph bacteremia: Grew out on ___ BCx
on ___. While it was possibly a contaminant, the patient was
started on iv vanc for a 7day course given his complicated
recent course of infections per recommendations of ID. Repeated
blood cultures did not grow out any bacteria.
# Seizures: Patient had EEG significant for epileptiform
activity with bitemporal activity. Neurology was consulted, and
they recommended weaning of phenytoin in favor of Keppra. He was
started on Keppra while weaning off of phenytoin without any
seizure-like activity during the bridging process. Last dose of
phenytoin was ___. The patient will be continued on Keppra 500mg
po bid.
#C. difficile colitis: This was thought to be likely secondary
to C. diff. Although it was not documented, the patient was
started on vancomycin PO at the rehab on ___, and is planned to
have a course to complete ___ after iv antibiotics complete
(this course should be continued through ___. Symptoms
mildly improved since initiating antibiotics though he continued
to have intermittent loose stool during the hospitalization.
# S/P hypoxic Respiratory failure: Patient was trach'ed during
prior hospitalization. Lasix held starting day 2 of admission
out of concern for impending hypovolemia. Per interventional
pulmonary consult, the cuff was removed and the trach was capped
on ___. After tolerating this for 48 hours with O2sat>96, the
trach was decannulated. The site was dressed with care. Healing
and improvement of the patient's voice is expected over the next
several weeks.
# ___: Last admission complicated by ___ secondary to
hypotension requiring HD, which he has not required since prior
hospitalization. He was noted to have residual impairment of
renal function on admission. Creatinine has improved throughout
hospitalization.
# Malnutrition: Patient with poor nutrition since his prior
complicated hospitalization course. During the hospitalization,
he has been on G-tube feeds at night. Speech and swallow cleared
the patient for regular diet, although he was fearful of
aspiration. Nutrition followed the patient throughout
hospitalization. As the patient continues to bolster his PO
intake, he tube feed requirements will need to be readdressed.
He should be evaluated by nutrition while in rehab.
# S/P cardiac surgery: Patient had recent complicated and
prolonged hospitalization course. After admission for bacterial
and candidial endocarditis c/b mitral flail, he had a CABG/MVR
complicated by respiratory failure and cardiac arrest. Staples
were removed from abdominal incision. Patient will need to
follow-up with Dr. ___. He was continued on his daily statin
and aspirin therapy.
CHRONIC DIAGNOSES
# Depression: Patient has been previously diagnosed wth
depression, and he noted difficulty coping with his complex
medical situation. In latter stages of hospitalization, the
patient's mood improved, as he expressed hope to regain mobility
and to be near his wife. He was continued on quetiapine.
#Atrial fibrillation: Patient had history of atrial
fibrillation. He was kept on amiodarone. He was monitored on
telemetry until ___, and he was in sinus rhythm without notable
events. Given prior GIB, the patient is not being started on
anticoagulation beyond aspirin.
#Asthma: Patient has been on steroids long-term for asthma. This
was continued at 10mg ___ and 5mg ___. There
was no asthmatic exacerbations during hospitalization. It is
recommended that the patient eventually undergo a long steroid
taper in the future.
#History of chronic hyponatremia: The patient had chemistries
trended with normal serum sodium throughout hospitalization.
TRANSITIONAL ISSUES:
# LABWORK: One week after finishing fluconazole o, the patient
should have repeat blood cultures to ensure clearance of
candidemia. These cultures should be drawn on ___.
# PENDING TESTS: Several blood cultures are pending on
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg NG DAILY
4. Atorvastatin 20 mg PO DAILY
5. Bisacodyl ___AILY:PRN constipation
6. Docusate Sodium 100 mg PO BID
7. Heparin Dwell (1000 Units/mL) ___ UNIT DWELL PRN
dialysis
Dwell to CATH Volume
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
9. Ipratropium Bromide MDI 6 PUFF IH Q6H
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Lidocaine Viscous 2% 10 mL PO QID:PRN mouth sores
12. MethylPHENIDATE (Ritalin) 2.5 mg PO BID
13. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
14. Nephrocaps 1 CAP PO DAILY
15. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
16. Phenytoin (Suspension) 100 mg PO QAM
17. Phenytoin (Suspension) 100 mg PO QPM
18. Phenytoin (Suspension) 100 mg PO QHS
19. PredniSONE 10 mg PO 3X/WEEK (___)
20. QUEtiapine Fumarate 50 mg PO QHS
21. Vitamin D ___ UNIT PO DAILY
22. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
23. Florastor *NF* (saccharomyces boulardii) 250 mg Oral daily
24. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting
25. Magnesium Oxide 400 mg PO TID
26. Furosemide 100 mg PO BID
27. caspofungin *NF* 250 ml Injection daily
28. PredniSONE 5 mg PO 4X/WEEK (___)
29. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Medications:
1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
3. Amiodarone 200 mg PO DAILY
4. Aspirin 81 mg NG DAILY
5. Atorvastatin 20 mg PO DAILY
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD DAILY
8. Lidocaine Viscous 2% 10 mL PO QID:PRN mouth sores
9. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
10. PredniSONE 10 mg PO 3X/WEEK (___)
11. PredniSONE 5 mg PO 4X/WEEK (___)
12. Vancomycin Oral Liquid ___ mg PO Q6H
Please take through ___
13. Vitamin D ___ UNIT PO DAILY
14. Fluconazole 200 mg PO Q24H Duration: 3 Days
Continue through ___
15. LeVETiracetam 500 mg PO BID
16. Bisacodyl ___AILY:PRN constipation
17. caspofungin *NF* 250 ml Injection daily
18. Docusate Sodium 100 mg PO BID
19. Florastor *NF* (saccharomyces boulardii) 250 mg Oral daily
20. Ipratropium Bromide MDI 6 PUFF IH Q6H
21. Magnesium Oxide 400 mg PO TID
22. MethylPHENIDATE (Ritalin) 2.5 mg PO BID
23. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
24. QUEtiapine Fumarate 25 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Candidemia
Secondary diagnoses: Clostridium dificile colitis, urinary tract
infection, gram-positive cocci bacteremia, seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at the ___
___. You were admitted because there was
fungus in your blood, which can be a very dangerous situation.
You were started on anti-fungal medications, and we monitored
you for fevers and other signs of infection. You will need to
continue this medication for roughly one more week.
During your hospitalization, you were also noted to have a
possible urinary tract infection, which you were treated for.
You had also had diarrhea prior to coming to the hospital which
was caused by a bacteria known as "C. Diff". You will continue
to receive antibiotics for this process.
You also were switched to a different seizure medication, as our
testing showed you may have some activity related to seizures
during your hospitalization.
You had received a tracheostomy during your prior
hospitalization. The lung specialists put a cap on the
tracheostomy, and you were able to breathe well without it.
After watching you for 2 days, you were safe to have the tube
taken out. We now have it covered with a dressing, and the vast
majority of patients have natural closing within a few weeks.
Followup Instructions:
___
|
19751571-DS-11
| 19,751,571 | 25,077,788 |
DS
| 11 |
2163-12-26 00:00:00
|
2163-12-29 14:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin
Attending: ___.
Chief Complaint:
high fevers
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
Mr. ___ is a ___ y/o male with a complex medical history
including CABG with MVR c/b endocarditis and multiorgan failure,
atrial fibrillation, CKD on HD, ischemic colitis, asthma,
seizure disorder, chronic hyponatremia, BPH and depression who
presents from ___ Rehab with fevers to 104.4, rigors,
diaphoresis, and emesis. The patient reports that he has been
feeling unwell for the past 4 days. He endorses a cough
productive of small amount of clear sputum and loose stools x 3
days. Last BM yesterday. Additionally, the patient reports that
he has been feeling weak over this time period noting that he
has had a harder time getting out of bed and walking with his
walker. He had one episode of emesis today. Denies dysuria or
urinary frequency. A CXR was obtained at ___ on ___
with report that states partial consolidation which may
represent atelectasis or pna.
In the ED, initial vital signs were T 98.8, HR 109, BP 109/55,
RR 32, 92% on RA. Tmax in ED to 101.0. Exam was notable for soft
but tender abdomen and he was noted to be diaphoretic. The
patient was seen by cardiac surgery who felt the surgical site
was well-healed and without erythema. A CXR showed pleural
effusions and atelectasis and could not rule out infection. A CT
abd/pelvis showed moderate fecal loading of the right colon,
thickened bladder wall, small right pleural effusion, and
moderate left pleural effusion. He was given 2L NS IVFs,
vancomycin, ciprofloxacin, and flagyl. Vital signs on transfer T
98.2, HR 77, BP 109/56, RR 26, 96% RA.
On arrival to the MICU, the patient reports that he is feeling
ok. He denies SOB, CP, abdominal pain, N/V currently. Dose
endorse cough.
Of note, the patient had a prolonged hospital course in ___ for bacterial and candidal endocarditis with mitrial valve
flail. The patient underwent CABG and MVR at that time with
multiple complications including cardiac arrest, respiratory
failure s/p trach/PEG. He was then again admitted ___ from
rehab with candidemia.
Past Medical History:
s/p CABG with MVR
Recent admission for endocarditis complicated by multiorgan
failure
atrial fibrillation during previous hospitalization
CKD, on HD following circulatory compromise during previous
admission
Ischemic colitis
Asthma
seizure disorder
chronic hyponatremia since ___
BPH
depression
history of syncope
s/p bilateral knee replacement
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION:
Vitals: T: 98.3 BP: 113/51 P: 77 R: 17 O2: 95% on RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, dry mucous membranes
Neck- supple, JVP not elevated, no LAD, previous trach scar
present
Chest- midline sternostomy scar c/d/i
Lungs- decreased breath sounds at bases bilaterally, bronchial
breath sounds and egophony at left base, dullness to percution
at left base, no wheezes, rales, ronchi
CV- distant heart sounds, 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
GU- no foley
Ext- warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema, thickened toenails bilaterally, dry skin present
DISCHARGE:
Vitals: T: 98.2 HR 72 BP 145/65
General- NAD, A+Ox3
Neck- supple, no JVP
Lungs-CTA bilaterally
CV- RRR, nl s1&s2, no murmurs
Abdomen- soft, non-tender, non-distended
GU: no foley
EXT: no edema, cyanosis or clubbing, no ___ lesions, no
Oslers nodes, thick toenails bilaterally, +1 DP pulses
Pertinent Results:
===================================
ADMISSION LABS
===================================
___ 01:50PM BLOOD WBC-15.0* RBC-3.68* Hgb-11.4* Hct-34.2*
MCV-93 MCH-31.0 MCHC-33.4 RDW-16.0* Plt ___
___ 02:18AM BLOOD WBC-24.0*# RBC-2.97* Hgb-9.2* Hct-27.6*
MCV-93 MCH-31.1 MCHC-33.4 RDW-15.4 Plt ___
___ 06:55AM BLOOD WBC-16.6* RBC-3.30* Hgb-10.2* Hct-30.7*
MCV-93 MCH-30.8 MCHC-33.0 RDW-15.3 Plt ___
___ 01:50PM BLOOD Glucose-98 UreaN-48* Creat-1.5* Na-139
K-4.5 Cl-104 HCO3-19* AnGap-21*
___ 02:18AM BLOOD Glucose-85 UreaN-45* Creat-1.3* Na-138
K-4.5 Cl-108 HCO3-19* AnGap-16
___ 06:55AM BLOOD UreaN-43* Creat-1.2 Na-142 K-4.2 Cl-109*
HCO3-21* AnGap-16
==================================
IMAGING
==================================
CT ABD & PELVIS WITH CONTRAST ___
IMPRESSION:
1. No evidence of toxic megacolon, moderate fecal loading in
the right colon.
2. Wall of the urinary bladder appears thickened, although this
could relate to under distension, clinical correlation,
urinarlysis recommended.
3. Small right pleural effusion and moderate left-sided pleural
effusion with associated compressive atelectasis.
TRANSTHORACIC ___
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is an inferobasal left ventricular aneurysm. LV
systolic function appears depressed (ejection fraction = 40
percent) secondary to akinesis of the inferior and posterior
walls. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
A bioprosthetic mitral valve prosthesis is present. The mitral
prosthesis appears well seated, with normal leaflet/disc motion
and transvalvular gradients. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. No definite vegetations
seen (best excluded by TEE)
TRANSESOPHAGEAL ECHO ___:
IMPRESSION: Bioprosthetic mitral valve endocarditis with a small
vegetation on the posterior mitral leaflet with a normal
functioning valve. Mildly depressed left ventricular systolic
function. Complex atheroma in the aortic arch. Ill-defined
echogenic structure in the descending aorta is likely artifact,
but cannot completely rule out thrombus - consider CT for
further characterization.
Compared with the prior study (images reviewed) of ___,
the small vegetation on the posterior mitral leaflet is new. The
other 2 masses on the posterior/anterior annulus were present
and are unchanged, and thus likely a part of the bioprosthesis.
The ill-defined echogenic structure in the descending aorta was
not previously seen.
=========================================
MICROBIOLOGY
=========================================
___ 9:10 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 2:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
SERRATIA MARCESCENS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
==========================================
HOSPITAL COURSE LABS
==========================================
___ 07:40AM BLOOD WBC-13.1* RBC-3.39* Hgb-10.4* Hct-31.4*
MCV-93 MCH-30.8 MCHC-33.3 RDW-15.0 Plt ___
************refusing labs at time of discharge
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a complex medical history
including CABG with MVR c/b endocarditis and multiorgan failure,
atrial fibrillation, CKD on HD, ischemic colitis, asthma,
seizure disorder, chronic hyponatremia, BPH and depression who
presents from ___ Rehab with fevers to 104.4, rigors,
diaphoresis, and emesis. The patient reports that he has been
feeling unwell for the past 4 days. He endorses a cough
productive of small amount of clear sputum and loose stools x 3
days. Last BM yesterday. Additionally, the patient reports that
he has been feeling weak over this time period noting that he
has had a harder time getting out of bed and walking with his
walker. He had one episode of emesis today. Denies dysuria or
urinary frequency. A CXR was obtained at ___ on ___
with report that states partial consolidation which may
represent atelectasis or pna.
In the ED, initial vital signs were T 98.8, HR 109, BP 109/55,
RR 32, 92% on RA. Tmax in ED to 101.0. Exam was notable for soft
but tender abdomen and he was noted to be diaphoretic. The
patient was seen by cardiac surgery who felt the surgical site
was well-healed and without erythema. A CXR showed pleural
effusions and atelectasis and could not rule out infection. A CT
abd/pelvis showed moderate fecal loading of the right colon,
thickened bladder wall, small right pleural effusion, and
moderate left pleural effusion. He was given 2L NS IVFs,
vancomycin, ciprofloxacin, and flagyl. Vital signs on transfer T
98.2, HR 77, BP 109/56, RR 26, 96% RA.
On arrival to the MICU, the patient reports that he is feeling
ok. He denies SOB, CP, abdominal pain, N/V currently. Dose
endorse cough.
Of note, the patient had a prolonged hospital course in ___ for bacterial and candidal endocarditis with mitrial valve
flail. The patient underwent CABG and MVR at that time with
multiple complications including cardiac arrest, respiratory
failure s/p trach/PEG. He was then again admitted ___ from
rehab with canidemia.
In the MICU, the patient did not have any concerning symptoms,
and was continued on vanc and meropenem to cover GNR's which
grew out of his blood Cx's (speciation/sensis pending). He did
not need any pressors or respiratory assistance, and improved
clinically overnight.
Upon MICU callout, the pt denies feeling ill and says he feels
quite well. He denies SOB, cough, CP, abdominal pain, N/V
currently. He has also had c-dif for which he was on a PO vanc
taper.
# serratia sepsis / endocarditis: The patients blood cultures
were positive for serratia. This is likely ___ urine source as
there was bladder wall thickening on CT, his UA shows 49 WBC
(which always has WBC's) and few bacteria, and he has had
Morganella grow from his urine in ___. Given the patient's
extensive history of infections including canidemia, UTI
(___, serratia marcescens), and bacteremia with
staph epi, the patient was begun on broad spectrum antibiotics
until culture data became available. When culture data became
available, he was continued on ciprofloxaxin. Surveillance
cultures became negative on the ___. TEE showed
(+) post leaflet vegetation of his bioprosthetic mitral valve.
After the pt discussed his treatment options with ID, the pt
decided that the best option was to continue PO ciprofloxacin
500mg, twice daily for four weeks after his first negative blood
culture. His first negative blood culture was ___. 4 weeks
after this is ___. He will also follow up with infectious
disease at this time as well.
# Recurrent C. Diff: Infectious disease recommended continuing
PO vancomycin for 10 days after he completes his antibiotic
course for endocarditis. He had a negative C. diff PCR on
___. He will continue his oral vancomycin until ___.
# ___: Cr of 1.3 on ___, up from 1.1 at rehab on ___. Likely
___ pre-renal etiology in setting of acute infection and likely
poor PO intake over while not feeling well. Additionally
patients Hct was above baseline likely indicating
hemoconcentration. His creatinine trended down to his baseline
range.
# Anion Gap Metabolic Acidosis: Admission HCO3 was 16 and anion
gap 16, lactate was 2.1. Likely was secondary to acute renal
injury and lactic acidosis. As the patients infection was
treated, his lactitic acidosis and metabolic acidosis resolved.
# Anemia: normocytic; Hct has chronically been in high 20's, is
likely ___ CKD. His CBC was trended (until the pt refused labs)
and his hct remained stable.
=====================================
CHRONIC ISSUES:
======================================
# A-Fib: The pt was continued on amiodarone. No additional
anticoagulation given history of GIB.
# Seizure Disorder: The pt was continued on his home medication
of keppra.
# Depression: Mirtazapine was continued.
# Asthma: continued on home meds.
===========================================
TRANSITIONAL ISSUES
===========================================
# bacterial endocarditis - After discovery of vegetations on the
pts bioprosthetic valve on ___, it was decided to treat with
oral ciprofloxacin 500mg, two times daily until ___. He
will follow up with Dr. ___ infectious disease doctor,
in four weeks.
# recurrent c. diff - The pt should be continued on PO vanc
while on his antibiotics for bacterial endocarditis. The PO vanc
should be continued for ten days after he completes his
antibiotics for bacterial endocarditis. He should continue his
oral vancomycin until ___.
# nutrition - the pt has been on tube feeds for FTT since his
prolonged hospitalization in ___. They caused him a lot of
distress in addition to nausea and GI discomfort. Tube feedings
were adjusted and changed to Jevity and PO intake was
encouraged. He can tolerate a regular diet though needs TF
suppplements for history of low caloric intake.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 25 mg PO HS
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Atorvastatin 20 mg PO DAILY
7. Mirtazapine 15 mg PO HS
8. MethylPHENIDATE (Ritalin) 5 mg PO BID
9. LeVETiracetam 500 mg PO BID
10. Magnesium Oxide 400 mg PO TID
11. Acetaminophen 650 mg PO HS
12. Vancomycin Oral Liquid ___ mg PO Q6H
13. Azithromycin 250 mg PO Q24H
14. PredniSONE 5 mg PO 4X/WEEK (___)
15. PredniSONE 10 mg PO 3X/WEEK (___)
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. MethylPHENIDATE (Ritalin) 5 mg PO BID
5. Mirtazapine 15 mg PO HS
6. PredniSONE 5 mg PO 4X/WEEK (___)
7. PredniSONE 10 mg PO 3X/WEEK (___)
8. TraZODone 25 mg PO HS
9. Vitamin D ___ UNIT PO DAILY
10. Atorvastatin 20 mg PO DAILY
11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Weeks
take until ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*46 Tablet Refills:*0
12. LeVETiracetam Oral Solution 500 mg PO BID
13. Vancomycin Oral Liquid ___ mg PO Q6H
take until ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Gram negative bacteremia
Secondary:
___
C.difficile
CHF
Atrial fibrillation
Asthma
Seizure disorder
H/O depression
Discharge Condition:
Mental status: clear and coherent A+Ox3
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a privilege to take care of you at the ___
___. You were brought into the hospital
because of high fevers. Work up was done including chest xray,
CT scan of your belly, cultures of your blood and urine. You had
bacteria growing in your blood and are currently being treated
with antibiotics.
A heart study (echocardiogram) showed a new infection of your
prosthetic mitral valve. You decided with Dr. ___ to take
oral antibiotics for four weeks. You will see Dr. ___
follow up.
You were continued on liquid vancomycin for your recurrent C.
diff diarrhea. You had a negative stool test during your stay
here. But you should continue vancomycin while you are taking
the ciprofloxacin.
Thank you for coming to ___ for your care,
Your Medicine Team
Followup Instructions:
___
|
19751685-DS-6
| 19,751,685 | 23,673,797 |
DS
| 6 |
2119-07-06 00:00:00
|
2119-07-07 17:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Antihistamines - Alkylamine
Attending: ___
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
Paracentesis ___
History of Present Illness:
___ w/ PMHx with ?HCV cirrhosis, ETOH use disorder and seizure
disorder who presents with hematemesis, diarrhea and abd pain
from ___.
Patient reports that she has been having worsening RUQ abdominal
pain since ___. On ___ she began to have vomiting
that she describes as watered down V8. Her vomiting transitioned
to coffee ground appearance at which point she decided to
present
to the hospital for further evaluation. She has also been having
diarrhea for the last week with some component of black stools
but without hematochezia.
She reports drinking a 6 pack + 5 nips of vodka per day for the
last ___ years with an extended drinking history since ___. Her
longest period of sobriety was in ___ for ___ years. Last drink
was ___ AM and she does have a history of ETOH withdrawal
seizures. She has been diagnosed with Hepatitis C in the past
and
reportedly has undergone treatment at ___.
In the ED, initial vitals:
- Exam notable for: T 98.5 HR 110 BP 111/74 RR 24 O2 Sat 98% RA
Gen: Lethargic
HEENT: Dry MM
CV: tachy reg rhythm
Abd: soft, not tense, RUQ tenderness, hepatomegaly
GU: no foley
Ext: 1+ pitting edema b/l to knee
Neuro: A&OX3, DOWB WNL, +asterixis
- OSH labs notable for:
110/70, 103 ETOH 148
ALK 215
AST 223
ALT 56
Tbili 4.4
H/H ___
WBC 11
- Pt given:
IV pantoprazole 40mg
Octreotide gtt
IV morphine 4mg
IV Zofran 4mg
IV lorazepam .5mg
75g 25% albumin
- Vitals prior to transfer: T 98.4 HR 112 BP 107/71 RR 18 O2
Sat98% RA
Upon arrival to the floor, the patient reports her abdominal
pain
has improved and she has had no further hematemesis.
Past Medical History:
- HAV
- HCV cirrhosis, not treated
- Pancreatitis
- ETOH use disorder
- Spine surgery
Social History:
___
Family History:
- Mother: DM, RA, alive
- Father: alive and healthy
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ 0018 Temp: 98.1 PO BP: 106/70 L Lying HR: 111
RR: 17 O2 sat: 97% O2 delivery: 3L
General: Alert, oriented, no acute distress
HEENT: Sclerae icteric, MMM, oropharynx clear, EOMI, PERRL, neck
supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, moderately tender in RUQ, moderately distended,
no rebound or guarding
GU: No foley
Ext: Warm, well perfused, trace pedal edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, alert, oriented to ___, ___,
no asterixes
DISCHARGE PHYSICAL EXAM:
========================
Vitals: Temp: 98.2 PO BP: 100/64 HR: 96 RR: 18 O2 sat: 98% RA
GENERAL: Chronically ill appearing woman in no acute distress.
Jaundiced.
HEENT: +Scleral icterus. NCAT. MMM.
CARDIAC: Regular rate & rhythm w/ normal S1/S2. No murmurs,
rubs, or gallops.
PULMONARY: Normal respiratory effort. CTAB without wheezes,
rales or rhonchi.
ABDOMEN: Soft, mild distension but soft, nontender. No rebound
or guarding.
EXTREMITIES: Warm, well perfused. No ___ edema or erythema.
SKIN: Warm, dry. No significant rashes.
NEURO: AOx3, NAD, answering questions appropriately. No
asterixis. Moves all extremities.
Pertinent Results:
ADMISSION LABS:
================
___ 11:59AM BLOOD WBC-12.1* RBC-2.45* Hgb-8.7* Hct-26.3*
MCV-107* MCH-35.5* MCHC-33.1 RDW-17.2* RDWSD-66.8* Plt ___
___ 11:59AM BLOOD Neuts-87* Bands-1 Lymphs-10* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-10.65*
AbsLymp-1.21 AbsMono-0.24 AbsEos-0.00* AbsBaso-0.00*
___ 11:59AM BLOOD ___ PTT-27.5 ___
___ 11:59AM BLOOD Glucose-97 UreaN-8 Creat-1.8* Na-137
K-3.6 Cl-97 HCO3-20* AnGap-20*
___ 11:59AM BLOOD ALT-38 AST-164* AlkPhos-156* TotBili-3.4*
___ 11:59AM BLOOD Albumin-2.3* Calcium-7.8* Phos-4.0
Mg-1.5*
MICRO/PERTINENT LABS:
======================
___ 11:59AM BLOOD Lipase-17
___ 04:45AM BLOOD cTropnT-<0.01
___ 03:26AM BLOOD Hapto-<10*
___ 08:45AM BLOOD calTIBC-81* VitB12-1681* Hapto-12*
Ferritn-1779* TRF-62*
___ 02:05AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG IgM HAV-NEG
___ 06:05PM BLOOD HAV Ab-POS*
___ 11:59AM BLOOD ASA-NEG Ethanol-91* Acetmnp-NEG
Tricycl-NEG
___ 04:56PM BLOOD HCV Ab-POS*
___ 04:56PM BLOOD HCV VL-NOT DETECT
___ 06:05PM BLOOD HCV VL-NOT DETECT
___ 12:28PM ASCITES TNC-281* RBC-109* Polys-1* Lymphs-32*
Monos-0 NRBC-1* Plasma-1* Mesothe-5* Macroph-60* Other-0
___ 09:48PM ASCITES TNC-63* RBC-36* Polys-3* Lymphs-51*
___ Mesothe-1* Macroph-45*
___ 10:11AM ASCITES TNC-91* RBC-113* Polys-0 Lymphs-13*
___ Mesothe-5* Macroph-82*
___ 08:55AM ASCITES TNC-54* RBC-580* Polys-1* Lymphs-10*
Monos-2* Mesothe-1* Macroph-86*
___ 03:51PM ASCITES TNC-27* RBC-181* Polys-1* Lymphs-7*
Monos-4* Mesothe-18* Macroph-70*
___ 12:28PM ASCITES TotPro-0.5 Glucose-108 Albumin-0.3
___ 09:48PM ASCITES TotPro-1.2 Glucose-89 LD(LDH)-62
Albumin-0.9
___ 08:55AM ASCITES TotPro-1.1
___ C. diff PCR/toxin: positive
___ BCX: No growth
___ Peritoneal fluid:
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
DISCHARGE LABS:
===============
___ 04:42AM BLOOD WBC-7.0 RBC-2.12* Hgb-7.2* Hct-20.2*
MCV-95 MCH-34.0* MCHC-35.6 RDW-24.0* RDWSD-81.8* Plt Ct-48*
___ 04:42AM BLOOD ___ PTT-29.6 ___
___ 04:42AM BLOOD Glucose-88 UreaN-19 Creat-0.9 Na-133*
K-3.9 Cl-95* HCO3-26 AnGap-12
___ 04:42AM BLOOD ALT-9 AST-58* LD(LDH)-172 AlkPhos-105
TotBili-3.9*
___ 04:42AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0
IMAGING/PROCEDURES:
===================
CT ABD/PEVLIS ___:
1. Interval improvement in colonic wall thickening involving the
descending and sigmoid portions, however wall thickening of the
ascending and transverse colon persists. Findings suggest
partly resolving pancolitis. No megacolon or pneumatosis.
2. Redemonstration of moderate to large volume abdominopelvic
ascites, hepatic steatosis and diffuse subcutaneous edema,
similar to prior.
CT ABD/PELVIS ___:
1. Diffuse pancolitis unchanged since prior. No megacolon. No
pneumatosis.
2. Interval worsening of the ascites and bilateral pleural
effusions.
3. Hepatic steatosis.
CT ABD/PELVIS ___:
1. Newly developed areas of airspace disease within the lungs
concerning for multifocal pneumonia.
2. Small bilateral pleural effusions.
3. Diffuse colonic wall edema which is either related to ascites
or pancolitis in the appropriate clinical scenario. Underlying
etiologies are infectious or inflammatory, less likely ischemic
given the lack of atherosclerotic disease or other known
underlying etiologies.
4. Severe hepatic steatosis and moderate volume ascites.
CXR ___:
The tip of the left PICC line extends up into the left jugular
venous system but beyond the field of view of this radiograph.
Mildly increased degree of pulmonary edema.
KUB ___: normal
ECHO ___:
The left atrial volume index is normal. 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 70%. There is no resting left
ventricular outflow tract gradient. Normal right ventricular
cavity size with depressed 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) 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 tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
CXR ___:
New bilateral airspace opacities likely reflect noncardiogenic
pulmonary edema given non enlargement of the cardiac silhouette.
EGD ___:
- Grade A esophagitis in the distal esophagus
- No gastric or esophageal varices
- Congestion, petechiae and mosaic mucosal pattern in the
stomach fundus and stomach body compatible with portal
hypertensive gastropathy
- Erythema and congestion in the duodenal bulb compatible with
duodenitis
Brief Hospital Course:
Mr. ___ is a ___ woman with history of EtOH/HCV
cirrhosis and seizure disorder who initially presented for upper
GI bleeding secondary to portal gastropathy with hospital course
complicated by severe C. diff colitis and septic shock requiring
MICU transfer, hepatic encephalopathy, volume overload, acute
hypoxic respiratory failure, and acute kidney injury.
#Hematemesis
#Upper GI Bleed
Initially presented with hematemesis that transitioned to a
coffee ground appearance. Hgb downtrending from ~11 to 6.4. She
initially needed 1u pRBC and was started on IV PPI as well as
CTX for ppx. Hepatology was consulted and EGD on ___ showed
portal hypertensive gastropathy, esophagitis, and duodenitis.
She required 2u pRBC throughout the hospitalization but
otherwise remained HD stable without active bleeding. She was
maintained on PPI BID for at least ___ weeks with plan to follow
up with hepatology for further management.
#Septic shock ___ severe C. diff with pan-colitis
During the hospitalization, she developed worsening abdominal
pain and distension, her workup was notable for positive C. diff
with CT evidence of pan-colitis. She was started on po
vancomycin and IV metronidazole. Given her minimal stool output
there was initially concern for toxic megacolon. Colorectal
surgery was consulted who recommended NPO status, vancomycin per
rectum, and serial abdominal exams. Ultimately felt that her
symptoms, while severe, were not actually manifestation of toxic
megacolon and so diet was subseqeuently advanced. Serial CT
abdomen/pelvis consistently demonstrated pan-colitis though no
signs of toxic megacolon. ID was consulted with recommendations
made for PO/PR vancomycin and Flagyl course. Fecal transplant
was not pursued. She completed a 10 day course (___) of
PO/PR vancomycin, IV flagyl while hospitalized with resolution
of her symptoms.
___
Cr rose to 2.0 from baseline ~0.8-1. Diagnosed with ATN during
this admission which resolved without intervention. Attributed
to sepsis and hypovolemia iso GI losses. Further during the
admission, Cr began to rise again. Urine lytes with sodium avid
state. Improved with albumin resusitacion. Cr 0.9, her baseline,
at time of discharge.
#Acute hypoxic respiratory failure
Hospital course initially c/b hypoxia with 6L NC requirement,
felt to be ___ volume overload iso fluid resuscitation and
worsening renal function. She was diuresed with improvement in
her breathing and was back to room air prior to discharge.
#Septic shock
Hypotensive during ICU stay requiring vasopressors. Felt to be
septic shock iso c.diff colitis. She was weaned off vasopressors
on ___ and stayed HD stable for the remainder of the
hospitalization.
#EtOH/HCV Cirrhosis
Childs C, MELD-Na 21 on admission. Underlying causes of EtOH use
and HCV. Unclear if HCV previously treated though currently
without a detectable VL. Has not undergone any transplant
evaluation. Presented with decompensation with ascites, HE and
UGIB as described elsewhere. Imaging without obvious liver
lesions. She will need q6month screening for HCC upon discharge.
#Altered mental status
#Hepatic encephalopathy
Noted to have worsening AMS. Work up was pursued and ultimately
AMS attributed to hepatic encephalopathy ___ decompensated
cirrhosis. She was started on lactulose and rifaxamin with
improvement in her exam.
#Volume overload
CT from ___ with moderate to severe volume ascites.
Paracenteses on ___ and ___ without SBP. She was started on
SBP prophylaxis given low protein in the ascites fluid. However,
this was stopped per hepatology recommendations given high risk
of recurrent c.diff infection. She had serial paracentesis on
___ and ___ for volume control. Ultimately, she was
discharged on Lasix 40 mg and spironolactone 100 mg with stable
exam.
#Nutrition
Given concern for malnutrition iso altered mental status, she
had a dobhoff placed and tube feeds were initiated. She was
later advanced to a regular diet prior to discharge.
#ETOH Use Disorder
On admission, patient reported drinking a 6 pack + 5 nips of
vodka per day for the last ___ years with an extended drinking
history since ___. She was given a phenobarb loading in the
MICU without recurrent withdrawal signs. She was started on
folate, thiamine and MVI.
#Coagulopathy
Progressive thrombocytopenia, rising INR (despite IV vitK) and
PTT, decreasing fibrinogen, early in the admission, concerning
for low grade DIC from liver failure. She was also oozing from
her midline though no other active bleeding. Ultimately
attributed to liver disease and improved with time. INR 1.3, plt
48 at time of discharge.
#Hyponatremia
Newly developed after uptitration of diuretics to lasix
40/spironolactone 100mg late in her admission. Na remained low
130-133 but stable. Hepatology recommended continuing this
regimen and following up as an outpatient.
#Tobacco use disorder: On nicotine patch while hospitalized.
#Seizure disorder: Continued divalproex (DELayed Release) 1000
mg PO QHS
DISCHARGE VALUES:
==================
- Na: 133
- Cr: 0.9
- Hgb: 7.2
- Diuretics: Lasix 40 mg/spironolactone 100 mg
- Weight: 136.9 lbs
TRANSITIONAL ISSUES
====================
[]Follow up with PCP and hepatology. ___ closed on
day of discharge. Appointment made at the ___. Patient
willing to come to the ___ number also provided
for the patient to switch if she desires.
[]Repeat BMP/CBC at follow up appointment
[]Volume exam at follow up appointment. Titrate diuretics as
necessary
[]Continue PPI BID until at least hepatology follow up
[]Needs q6month HCC screening
[]Discharged on lactulose and rifaxamin for hepatic
encephalopathy
[]Continue with ETOH/tobacco use counseling
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (DELayed Release) 1000 mg PO QHS
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Lactulose 30 mL PO TID
RX *lactulose 10 gram/15 mL (15 mL) 30 ml by mouth three times a
day Disp #*90 Packet Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Spironolactone 100 mg PO DAILY
RX *spironolactone [Aldactone] 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
9. Divalproex (DELayed Release) 1000 mg PO QHS
RX *divalproex ___ mg 2 tablet(s) by mouth nightly Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Primary
EtOH/HCV cirrhosis complicated by:
Hepatic encephalopathy
Ascites/volume overload
Upper GI bleed
#Secondary
Severe c. diff colitis
Septic shock
Acute hypoxic respiratory failure
Acute kidney injury
ETOH use disorder
Coagulopathy
Hyponatremia
Tobacco use disorder
Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after you had vomiting with blood.
While here, you underwent procedures to stabilize this. You also
were found to have an infection called C. difficle in your colon
which we treated with antibiotics. You became confused and we
treated you with medications for this and you improved. You had
multiple paracentesis done while admitted to remove extra fluid
in your belly. It is now safe for you to go. Please continue
taking your medications as prescribed and follow up at the
appointments below. If you wish to be seen at ___
rather than ___, please call ___ to schedule
an appointment.
Wishing you the best,
Your ___ Team
Followup Instructions:
___
|
19751764-DS-8
| 19,751,764 | 20,630,348 |
DS
| 8 |
2192-07-19 00:00:00
|
2192-07-19 08:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"infected right ___ toe"
Major Surgical or Invasive Procedure:
Right ___ toe Incision & Drainage ___ the ED) ___
Right ___ toe open amputation ___
Right ___ met head resection with closure of amputation ___
History of Present Illness:
Briefly, this is a ___ with a history of neuropathy and multiple
previous right foot surgeries who presented to the emergency
room on ___ with a purulent draining right ___ digit. He
stated that over the past few days he noticed increased redness
to his toe, and was ___ antibiotics after speaking over
the phone with a resident. However, he felt like the redness
was worsening despite being on antibiotics. On ___, he
squeezed his toe and noticed pus come from the toe. He presented
to the ED for evaluation and admission.
Past Medical History:
___ neuropathy, Depression, H/o R foot surgery including
free skin flap ___ ago, Right ___ bunionectomy ___ for right
plantar ulceration.
Social History:
___
Family History:
non-contributory
Physical Exam:
PE:
Gen: Pleasant, NAD, A&Ox3
Vitals: VSS
CV: RRR, no murmurs, no gallops
Pulm: CTAB, no wheezes, no rhonchi
Abd: Soft, NT, ND, +BS
RLE: Bandage c/d/i to right foot. No strikethrough. CFT <3
secs to digits ___ right. Sensation grossly diminished to ankle
via light touch, right foot. Passive ROM intact to RLE.
Pertinent Results:
___ 06:25PM WBC-13.6*# RBC-4.36* HGB-13.4* HCT-38.7*
MCV-89 MCH-30.7 MCHC-34.6 RDW-12.2
___ 06:25PM NEUTS-84.2* LYMPHS-10.8* MONOS-3.7 EOS-1.0
BASOS-0.3
___ 06:25PM CALCIUM-9.4 PHOSPHATE-3.8 MAGNESIUM-2.2
___ 06:25PM GLUCOSE-111* UREA N-20 CREAT-0.9 SODIUM-140
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
___ 07:07PM ___ PTT-28.3 ___
___ 08:23PM %HbA1c-5.4 eAG-108
___ 06:25PM BLOOD ESR-48*
___ 06:25PM BLOOD CRP-142.5*
.
Time Taken Not Noted ___ Date/Time: ___ 6:47 pm
SWAB RIGHT TOE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Brief Hospital Course:
Mr. ___ was seen ___ the ED on ___ after calling a couple
of times throughout the holiday weekend. ___ the ED, he had
notable erythema & edema to his Right lateral forefoot with a
___ toe that was dusky ___ appearance. ___ the ED, an I&D was
performed releasing about 5ccs of purulent drainage. Please
refer to admission note for full details. He was then admitted
to the hospital to start IV antibiotics. He was made NPO, and
taken to the OR the following morning.
.
On ___, Mr. ___ was taken to the OR for open amputation of
his Right ___ toe, which was disarticulated at the MPJ. Please
refer to OR op-note for full details. His wound cultures from
the ED grew pan-sensative MSSA. He was maintained on vanco,
cipro, flagyl, however, since his WBC continued to decline.
.
On ___, his wound was assessed, and with a downward trending
WBC and continuously maintaining afebrile, he was added on to
the OR for ___ met head resection and closure ___. Please
refer to OP-note for full details. He remained on IV
antibiotics, and his electolytes were replenished PRN.
.
___: after assessment POD#1, MR. ___ remained afebrile,
normal WBC, and skin edges well coapted. He was thus d/c on oral
Bactrim (prescribed over-the-phone this past weekend). He will
f/u with Dr. ___ week.
Medications on Admission:
Vicodin PRN
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*2*
2. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
Disp:*28 Tablet(s)* Refills:*2*
3. Vicodin ___ mg Tablet Sig: ___ Tablets PO every ___ hours
as needed for pain: Do NOT drink or drive when taking this
medication.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Right foot infection, osteomyelitis Right ___ toe
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You are to remain Weight-Bearing to your Right Heel ___ a post-op
shoe until your follow-up appointment with Dr. ___. You
are to keep your dressings clean, dry and intact until your
follow-up appointment.
.
You are to continue taking all of your previous home medications
___ addition to any new medications that were prescribed to you.
.
If you notice any, or increased redness, swelling, drainage to
your Right foot or leg, or if you develop a fever or fever-like
symptoms such as nausea, vomiting, chills, you are to come to
the emergency department for evaluation.
Followup Instructions:
___
|
19751789-DS-8
| 19,751,789 | 25,031,167 |
DS
| 8 |
2131-03-18 00:00:00
|
2131-03-18 18:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right lower quadrant pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
___ p/w RLQ dull pain x3 days, anorexia x 7 days, and a sense of
abdominal fullness for the past 4 days. He was in good state of
health until a week ago he noted decreased appetite. This was
followed by a sense of abdominal fullness, which he thought was
due to constipation. He then describes LUQ pain 4 days ago
beneath his ribs which then migrated to his RLQ for the past
days. He denies nausea, emesis, bloody bowel movements. He is
passing flatus, last bowel movement was yesterday. he denies
frequency, urgency or dysuria or flank pain.
Past Medical History:
None
Social History:
___
Family History:
No family history of IBD. Type1 DM in sibling and
uncle.
Physical Exam:
General: Appears comfortable in bed. AxOx3. Answers questions
appropriately
HEENT: No scleral icterus. Oral mucosa appears moist. EOMI.
PEERLA.
Lungs: CTAB. No dullness to percussion
Cardiac: RRR. No murmurs/rubs/gallops
Abdomen: Soft, nondistended. Appropriately tender with incisions
CDI and no erythema, no bleeding.
Extremities: No edema, no rashes.
Pertinent Results:
DISCHARGE LABS:
___ 07:24AM BLOOD WBC-6.2 RBC-4.85 Hgb-15.1 Hct-44.3 MCV-91
MCH-31.1 MCHC-34.1 RDW-12.4 RDWSD-41.2 Plt ___
___ 07:24AM BLOOD Glucose-93 UreaN-11 Creat-0.9 Na-143
K-4.5 Cl-103 HCO3-27 AnGap-13
___ 07:24AM BLOOD Calcium-10.1 Phos-4.5 Mg-2.1
ADMISSION LABS:
___ 09:41PM BLOOD WBC-8.5 RBC-4.95 Hgb-14.9 Hct-44.2 MCV-89
MCH-30.1 MCHC-33.7 RDW-12.4 RDWSD-40.5 Plt ___
___ 09:41PM BLOOD Neuts-56.0 ___ Monos-9.0 Eos-1.9
Baso-0.6 Im ___ AbsNeut-4.77 AbsLymp-2.72 AbsMono-0.77
AbsEos-0.16 AbsBaso-0.05
___ 09:41PM BLOOD Glucose-87 UreaN-8 Creat-0.9 Na-140 K-4.2
Cl-100 HCO3-26 AnGap-14
___ 09:41PM BLOOD Calcium-9.8 Phos-3.2 Mg-2.2
RADIOLOGY:
CTAP ___:
IMPRESSION:
Enlarged appendix measuring up to 1.2 cm with mucosal hyperemia
and multiple
appendicoliths, compatible with acute appendicitis. Minimal
haziness of the
periappendiceal fat. No drainable fluid collection or
extraluminal gas.
Brief Hospital Course:
The patient was seen in our emergency department the night of
___ with RLQ pain. Exam revealed tenderness in the RLQ, with
rebound and positive Rovsing. CT scan confirmed the diagnosis of
acute appendicitis. He was admitted to the surgery service and
was made NPO. The patient was added on to the OR and had an
uncomplicated appendectomy the morning of ___. In the
afternoon he was feeling much better, had voided, and was
tolerating a full regular diet. His pain was well controlled on
PO pain meds. He was given instruction to return if his pain
worses, he is unable to pass BMs, or has a fever. The patient
voiced understanding of these instructions and was discharged in
stable condition.
Medications on Admission:
None
Discharge Medications:
Oxycodone 5mg 3 pills
Discharge Disposition:
Home
Discharge Diagnosis:
Acute apendicitis
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 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 to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 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.
o You may start some light exercise when you feel comfortable.
o 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:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o 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:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. 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).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o 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.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. 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.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o 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.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o 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.
Followup Instructions:
___
|
19752416-DS-8
| 19,752,416 | 27,852,286 |
DS
| 8 |
2183-12-17 00:00:00
|
2183-12-17 16:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / dicloxacillin
Attending: ___
Chief Complaint:
Difficulty speaking
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old right-handed man who presents
after an episode of transient aphasia this afternoon. Last week
he had an upper respiratory tract infection and for the past
couple days has had right ear pain, diagnosed with acute otitis
media and started on antibiotics yesterday. This afternoon, he
went to take a nap around 2 ___. When he awoke around 3 ___ he
felt that his vision was blurry, "cock-eyed" and described this
as not being able to focus well. He could not make sense of
what
he was seeing very well. He sat up in his whole body "felt
heavy". He did not notice lateralizing weakness. He had a cell
phone on him and try to call his partner but could not think
through the steps to coordinate making a phone call. So, he
used
Siri to call his partner and while on the phone the he was
having
trouble getting words out. He was using the correct words but
could not speak more than ___ words at a time. He was afraid
and
heard people outside of his apartment in the hallway so tried to
go seek help from them but was unable to walk, so he crawled
across his apartment into the hallway. Throughout this time he
was on the phone with his partner while awaiting for his friend
to arrive.
When his friend arrived around 30 minutes later he found him
very
off from his baseline. He was having difficulty talking and
difficulty explaining what it happened. They came to the
emergency department. He has had a gradual improvement in his
symptoms and now feels better though is not back at baseline.
He
still feels "slow", somewhat similar to as if he had been
drinking alcohol.
He denies a history of seizures. He denies tongue bite, other
injuries, and incontinence during his nap this afternoon.
Past Medical History:
ARTHRITIS
SEASONAL ALLERGIES
ADHD
BENIGN PROSTATIC HYPERTROPHY
HYPERLIPIDEMIA
CHRONIC ABDOMINAL PAIN
H/O HEADACHES
H/O LTBI
H/O SINUSITIS
H/O GASTROESOPHAGEAL REFLUX
H/O GIARDIA
H/O MENISCAL TEAR
H/O SHINGLES
Social History:
___
Family History:
Mother Living DIABETES TYPE II
BREAST CANCER
Father Unknown
___ GASTRIC CANCER
Comments: Family h/o HTN, hyperlipidemia, hypothyroidism,
migraine, OA
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT
Pulmonary: breathing comfortably on RA
Cardiac: RRR on bedside monitor
Abdomen: soft, nondistended
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Alert, oriented. Able to relate history without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects on the
stroke card. Described the cookie jar picture with detail. Able
to read without difficulty. Speech was not dysarthric. Able to
follow cross body in multistep commands. Attentive, able to
name
___ backward without difficulty. There was no evidence of
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm bilaterally.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop with symmetric upper and lower facial
musculature bilaterally
VIII: Hearing intact to finger-rub on the left but not the
right.
IX, X: Palate elevates symmetrically.
XI: Shoulder shrug is symmetric.
XII: Tongue protrudes in midline with full ROM right and left
-Motor: Normal bulk throughout. No pronator drift bilaterally.
No
tremor noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 2 2
R 1 1 1 2 2
- Toes were mute bilaterally
- no clonus at the ankles
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense throughout.
-Coordination: No dysmetria on FNF bilaterally. Rapid
alternating
movements with normal and symmetric cadence and speed.
-Gait: Good initiation. Narrow-based, normal stride. Able to
walk in tandem without difficulty. Romberg absent.
DISCHARGE PHYSICAL EXAM:
Non-focal
Pertinent Results:
___ 05:35AM BLOOD WBC-7.7 RBC-4.56* Hgb-14.1 Hct-41.5
MCV-91 MCH-30.9 MCHC-34.0 RDW-11.8 RDWSD-39.3 Plt ___
___ 03:20PM BLOOD WBC-10.3*# RBC-5.01 Hgb-15.7 Hct-45.7
MCV-91 MCH-31.3 MCHC-34.4 RDW-11.9 RDWSD-39.4 Plt ___
___ 07:30AM BLOOD ___ PTT-33.1 ___
___ 03:20PM BLOOD ___ PTT-34.9 ___
___ 05:35AM BLOOD Glucose-92 UreaN-16 Creat-0.9 Na-140
K-4.4 Cl-101 HCO3-26 AnGap-17
___ 03:20PM BLOOD Glucose-87 UreaN-10 Creat-0.8 Na-139
K-4.2 Cl-100 HCO3-26 AnGap-17
___ 04:32PM BLOOD ALT-13 AST-16 AlkPhos-104 TotBili-0.3
___ 07:30AM BLOOD cTropnT-<0.01
___ 07:30AM BLOOD Calcium-9.3 Phos-3.0 Mg-2.3 Cholest-206*
___ 04:32PM BLOOD Albumin-4.3 Calcium-9.6 Phos-2.7 Mg-2.4
___ 07:30AM BLOOD %HbA1c-5.3 eAG-105
___ 07:30AM BLOOD Triglyc-115 HDL-46 CHOL/HD-4.5
LDLcalc-137* LDLmeas-145*
___ 07:30AM BLOOD TSH-3.3
___ 04:32PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___
1. No acute intracranial process.
2. Sinus disease.
___ H&N
. No evidence of infarction, hemorrhage, or edema.
2. Paranasal sinus disease with suggestion of acute bilateral
maxillary
sinusitis.
3. Unremarkable CTA head.
4. Unremarkable CTA neck.
___
Abnormal portable EEG due to the occasional bursts of focal
slowing in the left temporal region and the much more frequent
bursts of
generalized rhythmic delta slowing with frontal emphasis. The
first
abnormality indicates a focal subcortical dysfunction in the
left hemisphere.
The tracing cannot specify its etiology, but vascular disease is
a common
cause. The bursts of generalized slowing imply a dysfunction in
midline
structures but are not specific with regard to etiology. There
were no
epileptiform features or electrographic seizures.
___ Head w/o
1. No evidence of acute infarct.
2. Paranasal sinus disease.
3. Nonspecific opacification of the right mastoid air cells.
___
The left atrium and right atrium are normal in cavity size. With
maneuvers, there is early appearance of agitated
saline/microbubbles in the left atrium/left ventricle most
consistent with a patent foramen ovale. Normal left ventricular
wall thickness, cavity size, and global systolic function (3D
LVEF = 76 %). Transmitral and tissue Doppler imaging suggests
normal diastolic function, and a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: PFO seen using saline contrast with Valsalva
maneuver only.
Brief Hospital Course:
Mr. ___ was hospitalized at ___ due to transient episode
of blurry vision, lethargy with generalized weakness, and
expressive aphasia that resolved at time patient was evaluated
in BI ED. He underwent NCHCT which was unremarkable and was
admitted to Stroke Service. He was monitored on telemetry and
underwent laboratory workup which only showed mildly elevated
cholesterol level. He underwent MRI Brain which showed no acute
stroke. Due to concern that his event may have been postical
symptoms following a seizure, he was evaluated with extended
routine EEG with resultant slowing (possibly related to pt's
preexisting infection) and no clear epileptiform activity. Due
to appearing clinically stable, he was discharged home with no
need for further rehab.
Medications on Admission:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 9 Days
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 9 Days
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Otitis Media
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized at ___ due to symptoms of generalized
weakness and transient difficulty speaking concerning for an
acute stroke. You were evaluated by the Stroke Service and
underwent CT and MRI which showed no intracranial pathology. You
additionally underwent EEG to rule out propensity for seizures
with no concerning epileptiform activity. Due to appearing
clinically stable, you will be discharged home.
Please continue your home medications as prescribed. While your
LDL cholesterol is not elevated enough to require pharmacologic
treatment, we recommend improving your diet and instituting an
effective exercise regimen to address a mild elevation.
Please follow up with your primary care doctor in the next few
weeks for a post-hospitalization evaluation.
It was a pleasure taking care of you!
Sincerely,
___ Neurology Team
Followup Instructions:
___
|
19752428-DS-9
| 19,752,428 | 29,172,046 |
DS
| 9 |
2121-07-09 00:00:00
|
2121-07-09 13:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Transvenous biopsy of IVC Mass
History of Present Illness:
Ms. ___ is a ___ year old female with minimal past medical
history who presents for abdominal pain. Patient noticed sudden
onset of right sided flank/abdominal pain 10 days PTA. Denies
any association with food. Initially thought she was
constipated however has had normal bowel movements after using
laxatives with no improvement in pain. pain described as
crampy, no radiation, no positional variation. No dyspnea on
exertion. Denies any recent immobilzation. Has no history of
pain similar to this.
While patient was down in the ED, she had a CT abd/pelvis which
showed large mass arising from IVC near porta hepatis-> IVC
clot vs. mesenchymal tumor. Vascular surgery saw the patient
and recommended admission to medicine as well as an MRV to
further clarify the etiology of the mass. A read on the MRV is
still pending.
Patients labs in the ED were unremarkable, including a normal
lactate, UA. Pelvic exam was wnl.
On the floor, vs were: 97.7 128/72 57 18 100RA. Patient's pain
was controlled with Morphine sulfate IV and patient was made NPO
for possible procedure while MRV was pending.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Ten point review of
systems is otherwise negative.
Past Medical History:
morbid obesity
migraine headaches occasionally
tendinitis in her ankles
Social History:
___
Family History:
no known history of blood clots or cancers
Physical Exam:
ADMISSION:
Vitals: 97.7 128/72 57 18 100RA
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 to palpation, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: dry, no erythema or rashes
DISCHARGE:
Vitals: 98.1 110/57 62 18 100ra
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 to palpation, non-distended, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: dry, no erythema or rashes
Pertinent Results:
ADMISSION:
___ 05:05PM BLOOD WBC-7.6 RBC-4.93 Hgb-13.1 Hct-40.7 MCV-83
MCH-26.6* MCHC-32.1 RDW-13.1 Plt ___
___ 05:20AM BLOOD ___ PTT-66.9* ___
___ 05:05PM BLOOD Glucose-94 UreaN-10 Creat-1.0 Na-140
K-4.8 Cl-102 HCO3-27 AnGap-16
___ 05:05PM BLOOD ALT-23 AST-28 AlkPhos-92 TotBili-0.5
___ 05:05PM BLOOD Lipase-17
___ 05:05PM BLOOD Albumin-4.3
___ 05:14PM BLOOD Lactate-1.0
DISCHARGE:
___ 07:35AM BLOOD WBC-5.7 RBC-4.58 Hgb-12.6 Hct-37.9 MCV-83
MCH-27.6 MCHC-33.3 RDW-13.2 Plt ___
___ 07:35AM BLOOD ___ PTT-32.7 ___
___ 07:35AM BLOOD Glucose-171* UreaN-12 Creat-0.9 Na-138
K-4.2 Cl-99 HCO3-28 AnGap-15
REPORTS:
TRANSVAGINAL US:
IMPRESSION:
1. Technically limited by body habitus. IUD appears in
appropriate position.
2. No fibroids, ovarian mass or cyst.
CT ABDOMEN:
IMPRESSION: Hypodense soft tissue mass at the porta hepatis of
unclear
origin, possibly arising from the caudate lobe of liver or IVC.
Differential
diagnosis includes mesenchymal tumors of the inferior vena cava
such as
leiomyosarcoma. Although unusual, a large clot within the IVC
cannot be
completely excluded with this appearance. Further assessment
with MR is
recommended for a more complete characterization.
MRV:
IMPRESSION:
1. 4.5 cm mass centered on the anterior wall of the
infrahepatic suprarenal
inferior vena cava. The anterior component of the lesion
enhances and is
suspicious for an intrinsic tumor of the wall of the inferior
vena cava such as a leiomyosarcoma. The more posterior
component of the lesion occupying the lumen of the inferior vena
cava does not enhance and is consistent with bland
thrombus and likley hemorrhage within the lesion as a portion is
extraluminal.
The inferior vena cava remains patent.
2. Bilateral simple renal cysts.
BIOPSY OF IVC MASS:
IMPRESSION:
Preliminary Report
Successful biopsy of an inferior vena cava mass, with multiple
fragments obtained and sent to pathology.
Brief Hospital Course:
___ without sig PMH presents with abdominal pain, found to have
irregular mass of the IVC concerning for leiomyosarcoma.
# Abdominal pain/irregular mass/mesenchymal tumor of the IVC: Pt
presented w/ 10 days of R sided abdominal pain. Seen in ED and
CT scan performed with follow up MRV showing mass of IVC with
partial thrombus in IVC. Vascular surgery and transplant
surgery were consulted, as well as oncology. After speaking
with Dr. ___ was made to pursue biopsy of
presumed leiomyosarcoma given that pre-operative radiation would
be beneficial if it were high grade. Biopsy of IVC mass was
performed on ___ without incident and sent to pathology.
Patient has follow up appointments with Dr. ___ Dr.
___ as an outpatient. Pathology specimens were verified via
telephone to be in the pathology department to be logged.
-f/u with Dr. ___ Dr. ___ as an outpatient
-oxycodone PRN for pain
#IVC Thrombus: likely in setting of hypercoaguable state from
malignancy as well as local endothelial dysfunction from mass.
patient initially maintained on heparin drip IV via weight based
protocol. Patient tolerated this well. After biopsy, she was
watched overnight and switched to enoxoparin in the AM (150mg SC
BID). She should continue this until directed by her surgeon to
discontinue prior to surgery.
-Continue lovenox ___ SC BID
TRANSITIONAL ISSUES:
-patient has follow up with oncology and transplant surgery
-Patient's path slides should be examined by sarcoma team
including path and ___
-Patient has f/u with her PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Diclofenac Sodium ___ 75 mg PO BID:PRN pain
2. Multivitamins 1 TAB PO DAILY
3. Mirena *NF* (levonorgestrel) 20 mcg/24 hour ___ years)
Intrauterine ___
Discharge Medications:
1. Enoxaparin Sodium 150 mg SC BID
RX *enoxaparin 150 mg/mL 150 mg sc twice a day Disp #*60 Syringe
Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q6 Disp #*15 Tablet
Refills:*0
4. Diclofenac Sodium ___ 75 mg PO BID:PRN pain
5. Mirena *NF* (levonorgestrel) 20 mcg/24 hour ___ years)
Intrauterine ___
6. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
IVC thrombus
Possible Leiomyosarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ for evaluation of abdominal pain. While
you were here you were found to have a mass of one of the blood
vessels in your body called the IVC (inferior vena cava). There
was also a clot in the same blood vessel. We were concerned
that this may be something called a leiomyosarcoma. This is a
tumor/cancer that arises from the muscular wall of blood
vessels. You were seen by oncology and discussed thoroughly
with Dr. ___ as well as the transplant surgery
team. You had a biopsy performed on ___ to better identify
the mass.
It will take roughly 1 week for the results of your biopsy to
arrive. You have an appointment with Dr. ___ on ___,
however it may be pushed back a few days if the biopsy results
haven't arrived yet. You also have an appointment with Dr.
___ on ___ regarding your surgical options. Please see
them in their clinics to discuss your best options.
You should continue to take Lovenox (enoxoparin) twice daily for
the clot in your IVC. Please discuss this with Dr. ___ in
clinic and ___ when you approach surgery so that they may
tell you when to stop taking it in anticipation for surgery.
Please follow up with your primary care doctor as well.
If you develop severe pain, difficulty breathing, or high
fevers, please return to the hospital.
Followup Instructions:
___
|
19753029-DS-20
| 19,753,029 | 22,888,975 |
DS
| 20 |
2149-04-03 00:00:00
|
2149-04-03 18:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
ERCP with stent placement
Foley catheter placement
History of Present Illness:
Majority of history obtained via incomplete documents from
various hospitals and facilities - pt is also a poor historian.
Mr. ___ is a ___ M with ___ significant for recent CVA
___ w/ residual R hemiparesis and expressive aphasia, afib on
Coumadin, CHF (EF 40% ___, CAD, moderate AS, HTN who p/w
fever, hypotension, and jaundice from ___.
On review of OSH notes, it appears that pt recently was admitted
to ___ after experiencing a stroke (d/c ___. He
was discharged to rehab. While at rehab, he was found to have
?abnormal LFTs and underwent a CT scan which showed
emphysematous cystitis and 7mm gallstone without CBD dilatation,
and ILD - he was started on ?amp/gent/flagyl for which he
recieved his last dose at 10 AM today - unclear course or target
of tx. He developed a fever today at the SNF to 102, lethargy,
hypotension (SBP of ___. Per OSH records: Patient came from
rehab with BP 80/40, temp 102, Sats 82-84%, RR ___. Required
bolus en route to OSH.
At the OSH ED, pt was found to have WBC of 12.4, H/H ___ (lower
then baseline) and elevated bilirubin (TB 2.7, DB 1.2),
transaminitis. Given Imipenem at 1800. RUQ showed borderline GB
wall edema, stones, but normal ducts. Transferred to ___ for
ERCP given hepatobiliary origin of sepsis.
In the ___ ED, initial vitals: 99.9 120 109/71 21 98% 3L.
-Labs notable for WBC 12.8 (N 88%), H/H 8.6/27.5, AST 82, ALT
49, TB 2.7 (Direct 1.5), AP 251, LDH 537, hapto 7, lipase 77,
INR 2.1 on Coumadin. UA was mixed for UTI. Lactate 1.2. BUN 21,
Cr 1. Trop 0.01.
-Pt given 2.5 L of IVF, Meropenem/Vanco.
-Imaging notable for CT A/P which showed ?GB wall thickening,
CHF, and emphysematous cystitis.
-Urology was consulted who recommended broad spectrum abx/foley,
will continue to follow, but nothing urgent that needs to be
done with the emphysematous cystitis.
-Surgery was consulted for ?GB wall edema/cholecystitis and also
recommended broad spectrum abx, ?ERCP.
-ERCP was consulted but have not left any preliminary recs.
On transfer, vitals were: 98.4 112 121/81 23 95% Nasal Cannula
On arrival to the MICU, pt is aphasic, unable to relate a
history of recent events. Denies any symptoms of pain.
Past Medical History:
HTN
Afib
CVA w/ resultant R hemiparesis and expressive aphasia
CAD
CHF
PUD
B/l TKR
Interstitial lung disease/fibrosis
Chronic cholecystitis (MRCP negative in ___
BPH
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 99.1 111 144/92 20 99% 1.5L
GENERAL: Alert, oriented to self only (did not know year or
place), no acute distress, coughing, slightly jaundiced
HEENT: Poor dentition, dry MM, JVD flat, no LAD
LUNGS: Faint velcro like crackles scattered throughout,
rhoncorous breath sounds b/l, very mild low pitch wheezes
CV: Tachycardic, irregular, systolic murmur heard best over AV
area
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly, ecchymoses over
abdomen 2/t Lovenox
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Extensive ecchymoses of upper extremities
NEURO: Very mild L sided weakness when compared to R side,
aphasic speech, CN2-12 grossly intact
DISCHARGE PHYSICAL EXAM:
========================
General: elderly male, no apparent distress, alert, with
expressive aphasia
Vitals: 97.5 140/98 89 20 98% RA
3 BM
Pain: ___
HEENT: poor dentition, MMM
Lungs: bibasilar crackles
Abdomen: soft, no RUQ or epigastric tenderness, no suprapubic
tenderness, no CVA tenderness
Ext: wwp, no edema
Neuro: expressive aphasia, moves all extremities, limited CN
exam and neuro exam due to patient positioning and ability to
cooperate with instructions.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:05PM BLOOD WBC-12.9* RBC-2.58* Hgb-8.6* Hct-27.5*
MCV-106* MCH-33.2* MCHC-31.2 RDW-22.4* Plt ___
___ 09:05PM BLOOD Neuts-88* Bands-0 Lymphs-8* Monos-3 Eos-0
Baso-0 ___ Metas-1* Myelos-0
___ 09:05PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-2+ Microcy-1+ Polychr-NORMAL Ovalocy-1+ Target-1+ Tear
Dr-1+ Acantho-1+ Ellipto-1+
___ 09:35PM BLOOD ___ PTT-41.3* ___
___ 09:35PM BLOOD ___
___ 09:05PM BLOOD Glucose-118* UreaN-21* Creat-1.0 Na-141
K-4.3 Cl-106 HCO3-23 AnGap-16
___ 09:05PM BLOOD ALT-49* AST-82* LD(LDH)-537* AlkPhos-251*
TotBili-2.7* DirBili-1.5* IndBili-1.2
___ 09:05PM BLOOD Lipase-77*
___ 09:05PM BLOOD cTropnT-<0.01
___ 09:05PM BLOOD Albumin-3.5
___ 09:05PM BLOOD Hapto-7*
___ 09:15PM BLOOD Lactate-1.2
___ 11:20PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-8* pH-6.5 Leuks-NEG
___ 11:20PM URINE RBC-21* WBC-14* Bacteri-FEW Yeast-NONE
Epi-0
___ 03:47PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
IMAGING:
========
Bone Scan:
Three foci of tracer uptake in the left lateral skull. Recommend
obtaining a skeletal survey including the skull for better
evaluation if there is clinical concern for multiple myeloma
since bone scan is usually not very sensitive for multiple
myeloma.
Video swallow: Small amount of silent aspiration with thin
liquids and deep penetration with nectar.
CXR: ___: In comparison with the study of ___, there
has been substantial increase in the diffuse bilateral pulmonary
opacifications, consistent with improving pulmonary edema and
decreasing areas of multifocal pneumonia. Continued enlargement
of the cardiac silhouette with left subclavian catheter
extending to the lower SVC.
ERCP ___
Impression: Normal biliary tree. High pressure cholangiogram
was not performed given suspicion for cholangitis. A biliary
stent was emperically placed. (stent placement). Otherwise
normal ercp to third part of the duodenum.
CT Abdomen ___
1. Cholithiasis without cholecystitis. 2. Bilateral renal
cortical hypodensities, most compatible with several simple
renal cysts. 3. Enlarged heart, bilateral pleural effusions,
right greater than left, prominent interstitial markings, and
heterogeneous attenuation of the liver, findings felt most
compatible with right sided heart insufficiency. 4. Significant
sigmoid diverticular disease without evidence of diverticulitis.
5. Foci of air within the bladder wall with subtle enhancement
of the bladder wall. Complete evaluation of the bladder is
difficult in a bladder decompressed with Foley catheter.
Correlation with UA is recommended. 6. Several lucencies within
the bilateral iliac bones which are of soft tissue density.
These raise concern for multiple myeloma or potentially
metastatic disease. Non emergent serum electrophoresis and bone
scan is recommended.
CXR ___
1. Findings suggesting mild vascular congestion. 2. Focal but
vague opacity in the right upper lung, which persists. When
clinically feasible assessment with standard PA and lateral
radiographs may be helpful. This appearance may be a focal form
of edema, scarring but potentially pneumonia.
___ OSH RUQ U/S:
IMPRESSION: Cholelithiasis with borderline gallbladder wall
thickening. Nondilated bile ducts.
___ OSH CXR:
Comparison to exam dated ___. Underlying COPD.
Interstitial fibrosis, worst in the right upper lobe, no
significant change. No definite acute infiltrates or pleural
effusions identified. No evidence of CHF.
___BD/PELV:
IMPRESSION: 1. Emphysematous cystitis. 2. Findings may represent
a chronic interstitial process within the visualized lung bases.
An additional consideration includes mild fluid overload given
the cardiomegaly and small to moderate R pleural effusion 3.
Other incidental findings include an enlarged prostate for which
clinical correlation is recommended including PSA levels, a
nonobstructing gallstone, and diverticulitis.
DISCHARGE LABS:
===============
___ 05:45AM BLOOD WBC-7.6 RBC-2.36* Hgb-8.0* Hct-25.1*
MCV-107* MCH-34.0* MCHC-31.9 RDW-23.9* Plt ___
___ 05:45AM BLOOD Neuts-70.4* ___ Monos-4.4
Eos-4.6* Baso-0.9
___ 05:02AM BLOOD ___
___ 05:02AM BLOOD Na-142 K-3.4 Cl-110*
___ 05:45AM BLOOD ALT-22 AST-43* LD(LDH)-456* AlkPhos-126
TotBili-2.1*
___ 05:45AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.0
___ 06:25AM BLOOD calTIBC-234* VitB12-1334* Ferritn-399
TRF-180*
___ 05:42AM BLOOD FreeKap-29.0* FreeLam-32.7* Fr K/L-0.89
___ 02:59PM BLOOD b2micro-4.0*
___ 02:35AM BLOOD PEP-NO SPECIFI
Micro:
C. difficile DNA amplification assay (Final ___: Positive
for toxigenic C. difficile by the Illumigene DNA amplification.
(Reference Range-Negative).
Blood culture negative.
Urine culture negative.
Brief Hospital Course:
___ with recent CVA with residual deficits, CHF, ILD, COPD
presents with sepsis from infection. Found to have likely PNA,
UTI, C. diff colitis. In addition, he was found to have bone
lesions concerning for multiple myeloma in addition to abnormal
blood smear.
# Sepsis:
# Pneumonia:
# Possible UTI:
# C. difficile colitis:
He presented with sepsis. He was treated with broad spectrum
antibiotics (vancomycin and zosyn) and was fluid resuscitated.
He noted RUQ pain and had LFT abnormalities and underwent ERCP
with temporary plastic CBD stent placement. No evidence of
abnormality on cholangiogram. Of note, he will need repeat ERCP
with removal of plastic stent in ___ weeks (to be arranged by
ERCP team, I would advise against sphincterotomy given
alternative causes of sepsis, age and need for anticoagulation).
He had chest imaging which showed concern for multifocal
pneumonia. He was MRSA negative and thus vancomycin was stopped
after 48 hours of treatment. He received 5 days of azithro in
addition to Zosyn. He had emphysematous cystitis which could
indicate an infection. Urology was consulted and recommended 10
days of Zosyn. He will continue this at discharge for another 3
days. He had diarrea and was found to be c. difficile positive.
He was treated with IV flagyl with improvement. This will need
to be continued for 14 days after completion of Zosyn. It would
be acceptable to change to PO at rehab. Of note, PICC was
placed. This should be removed when IV antibiotics are finished.
# Hemolytic anemia:
# Concern for multiple myeloma or other malignancy:
He presented with anemia and was found to have cold agglutinin
anemia. The cause of this was not clear. However, his hematocrit
was stable and evidence of hemolysis improved (normal
haptoglobin). He did have bone lesions and an atypical smear
which was concerning for heme malignancy. Hematology was
consulted and recommended consideration of bone marrow biopsy.
In addition he would need skeletal survery and possible bone
biopsy. After discussion with the family, keeping in mind his
age, comorbidities and side effects of cancer treatment, we
determined that no further work up of the heme malignancy was
appropriate at this time. They preferred to get him to rehab
with continued therapy. They were given the number to ___ heme
malignancy group (___) for follow up after discharge
from rehab if necessary.
# Transaminitis:
He has chronic low grade transaminitis based upon prior lab
results in ___ system. He continued to have some
transaminitis at the time of discharge which was stable. This
can be followed by his primary care physician and likely does
need agressive work up given chronic nature and
age/comorbidities.
# Afib:
# On chronic anticoagulation:
He is on warfarin. He has very high CHADS2 score. INR was at
goal. Warfarin was continued at discharge. He will need close
monitoring of INR to make sure at goal (especially with
antibiotics being stopped in near future). I would check twice
weekly for now with adjustment in warfarin.
# Chronic systolic CHF:
He was euvolemic during presentation. He did have small effusion
with some pulmonary edema on imaging but appeared dry on exam.
Diuresis was held and resumed upon discharge. He should have
close follow up with consideration of increasing or stopping
lasix. Of note, he is not on ACEi or ___. This can be considered
as an outpatient. He was not started on this medication during
the admission given age and inability to thoroughly discuss
allergy history.
# CVA with residual effects:
He had a recent stroke with residual deficits for which he was
receiving therapy at ___. He was discharge to rehab
with aggressive ___, OT, speech and swallow rehabilitation.
# Dysphagia:
He had a speech and swallow evaluation with video swallow. This
showed silent aspiration with thin liquids. He tolerated a
thickened liquid and pureed solid diet. He did require 1:1
supervision with eating with encouragement.
Transitional issues:
- needs ___, OT, speech therapy, S+S evaluation, nutrition at
rehab
- Zosyn for 3 more days. Flagyl for 17 more days. d/c PICC when
complete finished with antibiotics
- consider heme follow up after discharge for evaluation of
blood dyscrasia, consider weekly CBC at rehab to ensure
stability
- INR monitoring with warfarin adjustment. Suggestive ___ per
week until dose stable.
- monitor for volume status. Adjust lasix as needed.
- repeat ERCP for removal of CBD plastic stent in ___ weeks.
- imaging findings showed enlarged prostate, consider PSA as
outpatient if appropriate with goals of care.
Contact: ___ ___ home, ___ cell)
Code: full code
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Senna 17.2 mg PO HS
2. lutein 5 mg oral daily
3. Multivitamins 1 TAB PO DAILY
___ MD to order daily dose PO DAILY16
5. Ferrous Sulfate 325 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Furosemide 20 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO BID
9. TraZODone 25 mg PO HS
10. Cyclobenzaprine 5 mg PO TID
11. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO DAILY:PRN
stomach upset
12. Bisacodyl ___AILY:PRN constipation
13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
14. melatonin 5 mg oral HS: PRN insomnia
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
2. Metoprolol Tartrate 25 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Warfarin 2 mg PO DAILY16
5. FoLIC Acid 1 mg PO DAILY
6. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
7. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
14 days post completion of Zosyn
8. Piperacillin-Tazobactam 4.5 g IV Q8H Duration: 3 Days
9. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
10. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO DAILY:PRN
stomach upset
11. Bisacodyl ___AILY:PRN constipation
12. Docusate Sodium 100 mg PO BID:PRN constipation
13. Ferrous Sulfate 325 mg PO BID
14. Furosemide 20 mg PO DAILY
15. lutein 5 mg oral daily
16. melatonin 5 mg oral HS: PRN insomnia
17. Senna 17.2 mg PO HS:PRN constipation
18. TraZODone 25 mg PO HS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
C. difficile colitis
Pneumonia
Urinary tract infection
Sepsis
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:
You were admitted for sepsis from your rehab. The exact source
was not identified. However, I suspect it was due to c.
difficile infection. In addition, you had possible urinary tract
infection and pneumonia. Also, you had ERCP with stent placement
in your common bile duct but without evidence of obstruction.
You were started on Zosyn and Flagyl with improvement of your
symptoms. You were afebrile, pain free with stable vital signs
at the time of discharge.
Of note, you had evidence of a blood disorder with possible bone
lesions. After discussion with your family, we decided to hold
off on evaluation/work up as work up would be invasive and
required more time in the hospital and not at rehab. They want
to follow up with a hematologist in the future to see if the
blood disorder is stable, improved, or worsening.
Followup Instructions:
___
|
19753118-DS-15
| 19,753,118 | 23,965,459 |
DS
| 15 |
2135-07-03 00:00:00
|
2135-07-03 16:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath and chest discomfort.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt. is an ___ female with a history of paroxysmal a-fib
on warfarin and propafenone, s/p mitral valve repair, HTN,
hypothyroidism, and CAD s/p 2-vessel CABG in ___ here for
evaluation shortness of breath and palpitations. She states
yesterday she noticed increasing shortness of breath and
subsequently developed palpitations, which she describes as
feeling that her heart was racing. She denies any associated
chest pain, diaphoresis, arm pain, neck pain, nausea, abdominal
pain, lightheadedness, lower extremity swelling or calf pain.
Last long distance travel was from ___ to ___ in
___.
In the ED initial vitals were: 98.4 ___ 22 97%
- Labs were significant for creatinine 1.2 and INR 3.2. UA and
CXR were unremarkable.
- Patient was given 5mg IV x2 and 25mf PO metoprolol tartrate
Vitals prior to transfer were: 128 ___ 98% RA
On the floor, patient states that dyspnea and palpitations have
resolved. Her only complaint is mild fatigue.
Past Medical History:
1. Asthma
2. Hyperlipidemia
3. Hypertension
4. Mitral & Tricuspid Regurgitation - declined valve repair
surgery
5. Pulm HTN
6. GERD
7. Nephrolithiasis - declined cholecystectomy
8. Hypothyroidism
9. Osteoarthritis
10. Urinary incontinence
11. History of GI bleed while on ASA/Fosamax
Social History:
___
Family History:
Sister d. with ovarian ca age ___, daughter d. w/ brain tumor age
___.
Physical Exam:
ADMIT PHYSICAL EXAM:
Vitals - 97.9 131/62 111 18 97%RA
GENERAL: NAD. Well-appearing
HEENT: AT/NC, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: irregularly irregular, tachycardic to 110s. S1/S2, no
murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: no gross motor deficits appreciated.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DICHARGE PHYSICAL EXAM:
Vitals - 97.8 110 128/85 18 96%
GENERAL: NAD. Well-appearing
HEENT: AT/NC, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: irregularly irregular, tachycardic to 110s. S1/S2, no
murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: no gross motor deficits appreciated.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMIT LABS:
___ 02:50PM BLOOD WBC-7.9 RBC-4.14* Hgb-13.3 Hct-41.9
MCV-101* MCH-32.1* MCHC-31.7 RDW-12.9 Plt ___
___ 02:50PM BLOOD ___ PTT-36.1 ___
___ 02:50PM BLOOD Glucose-97 UreaN-18 Creat-1.2* Na-141
K-4.3 Cl-105 HCO3-23 AnGap-17
___ 09:20AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.1
CXR
No evidence of pulmonary edema.
DISCHARGE LABS
___ 09:20AM BLOOD WBC-6.0 RBC-4.06* Hgb-13.1 Hct-40.5
MCV-100* MCH-32.4* MCHC-32.4 RDW-12.9 Plt ___
___ 09:20AM BLOOD ___ PTT-37.6* ___
___ 09:20AM BLOOD UreaN-19 Creat-1.1 Na-142 K-4.3 Cl-104
HCO3-26 AnGap-16
Brief Hospital Course:
Pt. is an ___ female with a history of paroxysmal a-fib
on warfarin and propafenone, s/p mitral valve repair, HTN,
hypothyroidism, and CAD s/p 2-vessel CABG in ___ here for
evaluation shortness of breath and palpitations; found to be in
a-fib w/ RVR to 140s.
#Paroxysmal a-fib: Recent cardioverion on ___. Pt. w/
symptomatic dyspnea/palpitations a-fib w/ RVR; rates in 140s on
presentation. No evidence of infectious trigger. Low suspicion
for PE given lack of risk factors; no chest pain; and prompt
resolution of dyspnea w/ rate control. Rates improved s/p IV
metoprolol x2 and 25mg PO metoprolol. Her HR was controlled
overnight with Metoprolol 50mg PO BID and she was discharged
with a new rx for this medication. Her propafenone was continued
but she did not convert to sinus rhythm. She was on warfarin
(goal 2.5 -3.5 ) for her mechanical valve and history of afib.
She was continued on her home regimen and her INR was at goal.
#Hypertension: continued home lisinopril
#CAD: No evidence of active cardiac ischemia. continued
atorvastatin
#Hypothyroidism: recent TSH within target range. continued home
levothyroxine
#GERD: continued home pantoprazole
#Asthma: continued home symbicort
Transitional:
Will allow outpatient cardiologist to make decisions on
cardioversion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Gabapentin 300 mg PO HS
3. propafenone ___ mg oral BID
4. Fluticasone Propionate NASAL 2 SPRY NU BID
5. Warfarin 5 mg PO DAYS (___)
6. Warfarin 2.5 mg PO DAYS (MO,FR)
7. Atorvastatin 40 mg PO DAILY
8. Furosemide 20 mg PO DAILY:PRN leg swelling
9. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
10. Pantoprazole 40 mg PO Q12H
11. Levothyroxine Sodium 175 mcg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
3. Fluticasone Propionate NASAL 2 SPRY NU BID
4. Gabapentin 300 mg PO HS
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. propafenone ___ mg oral BID
9. Warfarin 5 mg PO DAYS (___)
10. Warfarin 2.5 mg PO DAYS (MO,FR)
11. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice per day
Disp #*60 Tablet Refills:*0
12. Furosemide 20 mg PO DAILY:PRN leg swelling
Discharge Disposition:
Home
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 ___ for management of recurrent atrial
fibrillation with elevated heart rate. Your heart rate was
controlled with a new medication called metoprolol. Your
symptoms resolved with heart rate control. If your symptoms
remain well controlled with this new medication, ___ should
discuss possibly stopping your propafenone with your
cardiologist.
It was a pleasure taking part in your care.
Followup Instructions:
___
|
19753816-DS-16
| 19,753,816 | 25,204,309 |
DS
| 16 |
2192-03-25 00:00:00
|
2192-03-25 12:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
headache, hypernatremia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ from ___ with hypertension and diabetes who is admitted
for management of hypernatremia after undergoing resection of
craniopharyngioma on ___.
Her post-operative course was notable for active management of
her post-op issues by the endocrine consultation team. She was
discharged on ___ on desmopression 0.2 mg PO at night, and
sodium at discharge was 144. On ___ she was noted to be quite
thirsty, drinking large amounts of water, and urinating in large
quantities. On labs she was noted to have a sodium of 152. She
also had a headache that was unremitting despite oxycodone and
Tylenol. Given these symptoms she was brought to the ___.
In the ED, initial vital signs were: 98.6 63 135/90 18 98% RA
- Exam was notable for: ambulatory w/ assistance, mental status
reported at baseline despite ___ concerns that patient was
altered
- Labs were notable for: Na 150, Cl 113, BUN/Cr ___, U/A with
spec ___ 1.013. H/H 9.3/31.1
- Imaging: CXR with no pneumonia
- The patient was given: nothing
- Consults: neurosurgery who said admit to medicine
Vitals prior to transfer were: 98.3 61 146/78 16 97% RA
Upon arrival to the floor, the patient is sleepy, but clearly
states she would like to go to sleep. She is alert, and mentally
sharp despite her fatigue. Her husband, present at the bedside,
says that she has had good days and bad days, but is overall
consistent with her prior mental status at discharge.
Past Medical History:
- Hypertension
- Diabetes (HbA1c 6.6% in ___
- Elbow pain
- craniopharyngioma s/p resection ___
Social History:
___
Family History:
No family history of brain cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.5 147/82 66 16 99% RA
GENERAL: well-appearing, in no apparent distress.
HEENT - craniotomy suture c/d/I, no specific tenderness to
palpation of scalp
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: NT/ND + BS
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: patient is not fully cooperative with visual field
assessment, EOMI without nystagmus, tongue protrudes midline,
smile intact, sensation intact, moving all four extremities
without focal weakness, PERRL
DISCHARGE PHYSICAL EXAM:
VITALS: 98.4 120/74 HR 78 RR 18 99%O2
I/O: Since midnight ___ and 24H ___
GENERAL: Alert appearing woman in no acute distress.
HEENT: Erythema is improved bilaterally in sclera, eyelids no
longer tender to palpation, no photophobia, craniotomy suture,
EOMI, PERRLA
NECK: Supple, no LAD
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without
rubs/rhonci/wheezes.
ABDOMEN: NT, at epigastric region pt abd is distended but pt
reports this is nothing new, no quarding, normal BS
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
SKIN: Without rash.
NEUROLOGIC: Pt AOx3, pt still has difficulty with visual fields
test and vision is impaired. CN ___ appear grossly intact,
sensation and proprioception intact with normal strength in
extremities.
Pertinent Results:
LABS ON ADMISSION
=================
___ 11:20PM WBC-9.4 RBC-3.34* HGB-9.3* HCT-31.1* MCV-93
MCH-27.8 MCHC-29.9* RDW-17.2* RDWSD-54.8*
___ 11:20PM NEUTS-57.7 ___ MONOS-11.6 EOS-1.1
BASOS-0.1 NUC RBCS-0.2* IM ___ AbsNeut-5.42 AbsLymp-2.68
AbsMono-1.09* AbsEos-0.10 AbsBaso-0.01
___ 11:20PM PLT COUNT-237
___ 11:20PM GLUCOSE-120* UREA N-29* CREAT-1.0 SODIUM-150*
POTASSIUM-4.5 CHLORIDE-113* TOTAL CO2-30 ANION GAP-12
___ 11:20PM CALCIUM-9.4 PHOSPHATE-4.5 MAGNESIUM-2.4
___ 11:20PM OSMOLAL-325*
___ 11:27PM LACTATE-1.3 NA+-152*
___ 11:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 11:44PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:44PM URINE OSMOLAL-466
LABS ON DISCHARGE
=================
___ 11:08AM BLOOD WBC-6.7 RBC-2.80* Hgb-7.7* Hct-26.1*
MCV-93 MCH-27.5 MCHC-29.5* RDW-15.9* RDWSD-53.2* Plt ___
___ 11:08AM BLOOD Plt ___
___ 11:08AM BLOOD Glucose-156* UreaN-14 Creat-1.0 Na-145
K-3.4 Cl-108 HCO3-29 AnGap-11
___:08AM BLOOD Calcium-8.7 Phos-2.7 Mg-2.0
___ 11:48AM BLOOD WBC-6.5 RBC-3.11* Hgb-8.5* Hct-28.6*
MCV-92 MCH-27.3 MCHC-29.7* RDW-15.7* RDWSD-52.5* Plt ___
___ 11:48AM BLOOD Plt ___
___ 11:48AM BLOOD Glucose-196* UreaN-13 Creat-1.0 Na-141
K-4.0 Cl-104 HCO3-27 AnGap-14
___ 11:48AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.1
MICROBIOLOGY
============
none
IMAGING
=======
CT head w/o contrast ___
1. Increased size of the right subgaleal hematoma, status post
right
craniotomy approximately 11 days prior. Heterogeneous
attenuation reflects mixing of blood products in different
stages, acute and chronic.
2. Increased hypodensity involving the right temporal lobe,
extending to the suprasellar resection bed, when compared with ___. While this may reflect evolving postsurgical
changes, consider infarction in the appropriate clinical
setting.
3. No shift of normally midline structures. Persistent
hyperdense blood products along the right lateral convexity.
CXR ___:
No focal consolidation concerning for pneumonia. Low lung
volumes.
Brief Hospital Course:
___ with hypertension and diabetes who is admitted after being
discharged on ___ after resection of craniopharyngioma on ___
with central diabetes insipidus and headache.
# Central diabetes insipidus: The patient has central diabetes
insipidus manifesting with hypernatremia, polyuria and
substantial thirst in the post-neurosurgical setting. The
patient had been managed with PO demospressin on discharge.
There was concern that the patient had taken her desmopressin
with food after discharge, which may have interfered with the
drug's absorption and led to her hypernatremia.
The patient was initially given D5W IV with good response in her
sodium level. Endocrinology was consulted. The patient was
initially monitored with q4 hour serum sodium and urine specific
gravity/osmolality checks. A foley was placed and urine output
was monitored hourly. The patient was initially dosed with
desmopressin when she would "break through" with >300cc of urine
output per hour for two consecutive hours. Her desmopressin
dosing was gradually stabilized to 0.2mg QHS, with strict
instructions to not take with food. The patient was strongly
encouraged to drink to thirst. Her labs were spaced out to twice
daily. She still had occasional morning hypernatremia that was
likely a consequence of the patient not drinking fluids
overnight. When the patient was stabilized her foley was removed
to reduce infection risk.
The patient was discharged to rehab on 0.1mg desmopressin BID at
7am and 9pm. She was discharged with a ___ appointment in
place with her endocrinologist.
# Headache: The patient had a headache on admission and
occasionally throughout the admission. There was initially
concern for post-operative hematoma. She had a head CT scan
which was not concerning to her neurosurgeons. Her headache
improved with Tylenol and tramadol. Her neurologic exam was
unchanged.
# Bilateral Eye pain/episcleritis: On ___ the patient
developed bilateral eye pain with her headaches. Her eyes were
tender to the touch. Ophthalmology saw the patient. They
diagnosed her with episcleritis. Her pressure in the eyes were <
12 and <10 in the R and L respectively, which was not concerning
for glaucoma. She was treated with artificial tears and
tobramycin-dexamethasone drops with improvement of her eye pain.
Of note, the patient had poor visual fields and acuity during
this admission, which per ophtho is her baseline. She was
discharged with a ___ appointment with ophthalmology.
- continue tobramycin-dexamethasone 0.3 %-0.1 % 1 drop OPH:
Three times a day from ___
#Acute kidney injury: the patient had a creatinine bump to 1.3
on ___, up fro her baseline of 0.9. This was likely from
increased urine output and relatively poor PO intake. On
discharge creatinine and BUN has decreased.
#Anemia: the patient had hemoglobins in the ___ range during
this admission. She had no obvious source of bleeding. Regular
blood draws may have been contributing.
#Thrombocytopenia: Pt developed a thrombocytopenia on ___ that
has been slowly downtrending. Today pt 107. Its unlikely to be
infectious given afebrile, normal WBC count and no indication of
infectious source. Still can be medication, acetamenophen is a
common cause of thrombocytopenia and in <1% of cases Keppra can
cause bone marrow suppression with thrombocytopenia. Broader
differential is increased destruction or decreased production.
Could be MAHA (DIC, HUS, TTP), since there is also an anemia.
Had blood smear with 1+ rouleaux formation on peripheral smear;
should follow up with PCP for further workup as indicated
# Craniopharyngioma. The patient had her brain tumor resected on
her prior admission. During this admission we continued her
pituitary hormone replacement regimen as per endocrinology. In
addition to her desmopressin as above, we continued
lenothyroxine, prednisone, and keppra prophylaxis.
# Diabetes: chronic. The patient was given an insulin sliding
scale during this admission with good control of her blood
sugars.
# Left toe pain: Pt has about a week of tow pain on left toe,
possibly with joint involvement. Tender to palpation, not
erythematous, hard to tell whether it is warm to palpation due
to warm compress. Could be gout, but unlikely infectious.
- Continue to use warm compress
- Increased dose of acetaminophen
***TRANSITIONAL ISSUES***
- 0.1mg Desmopressin BID at 7am and 9pm on empty stomach
- continue to monitor electrolytes once daily
- encourage PO fluid intake
- levothyroxine 50mcg at 6am on empty stomach
- Appointment with Dr. ___ endocrine ___
- f/u appointment at the ___ clinic on ___
- patient has anemia and thrombocytopenia with 1+ rouleaux
formation on peripheral smear; should follow up with PCP for
further workup as indicated
- please follow up with outpatient iron labs
- started iron supplements
- monitor toe pain, treat pain with Tylenol
- ___ with ophthalmology for episcleritis
- continue tobramycin-dexamethasone 0.3 %-0.1 % 1 drop OPH:
Three times a day from ___
- Patient should not drive until she has had formal visual
acuity and visual field testing performed at ophthalmology
appointment
- Contact: ___ ___
- Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Pantoprazole 40 mg PO Q12H
3. Desmopressin Acetate 0.2 mg PO DAILY
4. Dexamethasone 1 mg PO Q12H
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC BID
7. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
8. LevETIRAcetam 500 mg PO BID
9. Levothyroxine Sodium 50 mcg PO DAILY
10. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
11. PredniSONE 5 mg PO DAILY
12. Senna 17.2 mg PO QHS
13. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Desmopressin Acetate 0.1 mg PO BID
RX *desmopressin 0.1 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. LevETIRAcetam 500 mg PO BID
4. PredniSONE 5 mg PO DAILY
5. Senna 17.2 mg PO QHS
6. Simvastatin 20 mg PO QPM
7. Pantoprazole 40 mg PO Q12H
8. Docusate Sodium 100 mg PO BID
9. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
10. Levothyroxine Sodium 50 mcg PO DAILY
11. TraMADol ___ mg PO Q8H:PRN pain/headache
RX *tramadol 50 mg ___ tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
12. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN red
eyes
RX *artificial tears(hypromellose) 0.4 % ___ drop oph four times
a day Refills:*0
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
14. Heparin 5000 UNIT SC BID
15. Tobramycin-Dexamethasone Ophth Susp 1 DROP BOTH EYES TID
Duration: 1 Week
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Central diabetes insipidus
Craniopharyngioma
Episcleritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were ___ to ___ after going to rehab with a
headache and high sodium levels. We re-scanned your head and our
neurosurgeons were not concerned. Our endocrinologists were
involved and adjusted the dosing of your desmopressin.
You also had some eye pain. Our ophthalmologists evaluated you
and you did not have glaucoma. They recommended eye drops to
decrease inflammation.
Our eye doctors and ___ would like to see you as an
outpatient. We made appointments for you that are listed below.
It is very important to drink when you're thirsty! This will
help keep your sodium levels normal.
It was a pleasure taking care of you.
-Your ___ Care Team
Followup Instructions:
___
|
19753912-DS-16
| 19,753,912 | 26,328,835 |
DS
| 16 |
2174-05-25 00:00:00
|
2174-05-25 12:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Suprax
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic appendectomy
History of Present Illness:
We are seeing Mrs. ___ in consultation for acute
appendicitis. She is a ___ y.o. female otherwise healthy who
presents to the ED w/ abd pain, vomiting. Pain began around 1 AM
this morning, described as diffuse epigastric pain. Multiple
episodes of vomiting stomach contents. Notes that she had a meal
of ___ food prior to onset of symptoms around 8 ___ yesterday
that she is concerned may have caused symptoms. Notes chills, no
objective fevers. Denies change in bowel function. Otherwise
healthy. No daily medications. Denies dysuria. Denies chest
pain,
shortness of breath, change in bowel or bladder function, change
in vision or hearing, bruising, adenopathy, new rash or lesion.
On exam, she is afebrile, VSS. She is tender to palpation to
___.
Work up this far demonstrates leukocytosis to ___ and imaging
demonstrating findings consistent with acute non-perforated
appendicitis.
Past Medical History:
Past Medical History: None
Social History:
___
Family History:
Family History: non-contributory
Physical Exam:
On admission:
Physical Exam:
Vitals:
99.0, 58, 94/54, 17, 100% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended. Tender to palpation to
Ext: No ___ edema, ___ warm and well perfused
At discharge:
Gen: [X] NAD, [] AAOx3
CV: [X] RRR, [] murmur
Resp: [X] breaths unlabored, [] CTAB, [] wheezing, [] rales
Abdomen: [X] soft, [] distended, [] tender, [] rebound/guarding
Wound: [X] incisions clean, dry, intact
Ext: [X] warm, [] tender, [] edema
VITALS:
24 HR Data (last updated ___ @ 002)
Temp: 97.9 (Tm 97.9), BP: 144/71, HR: 67, RR: 18, O2 sat:
100%, O2 delivery: RA
Pertinent Results:
___ 04:53AM BLOOD WBC-12.1* RBC-4.22 Hgb-11.8 Hct-36.3
MCV-86 MCH-28.0 MCHC-32.5 RDW-13.3 RDWSD-41.7 Plt ___
___ 08:00AM BLOOD WBC-16.0* RBC-4.73 Hgb-13.0 Hct-42.7
MCV-90 MCH-27.5 MCHC-30.4* RDW-13.3 RDWSD-44.5 Plt ___
___ 08:00AM BLOOD Neuts-84.1* Lymphs-8.4* Monos-5.7 Eos-1.0
Baso-0.4 Im ___ AbsNeut-13.48* AbsLymp-1.34 AbsMono-0.92*
AbsEos-0.16 AbsBaso-0.06
___ 04:53AM BLOOD Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD Glucose-100 UreaN-9 Creat-0.7 Na-140
K-4.0 Cl-108 HCO3-20* AnGap-12
___ 08:00AM BLOOD ALT-12 AST-18 AlkPhos-52 TotBili-0.2
___ 08:00AM BLOOD Lipase-53
___ 08:00AM BLOOD Albumin-4.4
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed acute appendicitis WBC
was elevated at 16.0 The patient underwent laparoscopic
appendectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating clears, on IV fluids, and Tylenol/Oxycodone for pain
control. The patient was hemodynamically stable.
.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*8 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:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
19754677-DS-19
| 19,754,677 | 27,138,064 |
DS
| 19 |
2143-03-21 00:00:00
|
2143-03-24 16:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
N/V, HTN, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ yo ___ speaking female who is presenting
with nausea/vomiting for three days which had progressively
gotten worse, with subsequent chest pain and shortness of
breath. Translation was provided by daughter at bedside. Patient
had been unable to take her home medications over the past day
(primarily blood pressure medications) because of the
intermittent nausea and vomiting. Daughter noticed patient
having increased work of breathing leading her to call EMS. When
EMS picked up patinet, systolic blood pressure was 220/110, she
did not have any headache, weakness, fevers or chills when they
picked her up.
In the ED, initial vitals were: 3 97.8 100 240/88 16 97% RA
She complained of significant central and right sided chest pain
that seemed to worsen with deep inspiration. She also complained
of wheezing and shortness of breath. On exam she was noted to
have diffuse bialteral wheezes. EKG was concerning for ST
elevation/TWI in leads V2-V4. Her picture was concerning for
hypertensive emergency. Patient was given a full dose aspirin
and nitro. She was given Lasix 20mg IV x1. She was initially
started on a heparin gtt for concern of ACS and positive
troponin to 0.09. For her ongoing hypertension, she was then
started on a nitro drip.
The cards fellow was able to perform a bedside TTE which showed
EF of 60-65% with no focal wall motion abnormalities. There was
a mild pericardial effusion noted without evidence of tamponade,
mild to moderate MR, mild TR, good RV function and mild LVH. A
CXR demonstrated findings consistent with decompensated CHF with
small bilateral pleural effusions.
Of note, patient has been seen in ___ ED for episodes of
hypertension. In ___ patient was admitted with hypertensive
urgency with BP 239/47. Prior to this she had episodes of
hypertensive urgency for ?failure to take blood pressure
medications.
Labs were significant for lactate of 1.4, BNP of 17774, Trop of
0.09.
Vitals prior to transfer were: 0 98.2 81 162/68 26 92% RA
Upon arrival to the floor, patient denies headache, vision
changes. She has intermittent coughing but states her breathing
is significantly improved.
REVIEW OF SYSTEMS: Currently denies chest pain, chest pressure,
shorntess of breath, chest palpitations, nausea, vomiting,
diarrhea. Denies headache, blurry vision or change in vision.
Denies numbness or tingling in any of the extremities.
Past Medical History:
Hypertension
Hyperlididemia
Osteoarthritis
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical:
Vitals: 98.1, 195/64, 80, 18, 96% on RA.
General: Elderly appearing female, sitting up in bed, having
coughing spells during examination, otherwise breathing
non-labored.
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition,
EOMI, PERRL
Neck: supple, JVP at 11 cm.
CV: regular rate and rhythm, ___ systolic murmur at apex.
Lungs: Decreased breath sounds at bases, otherwise, no wheezes.
Abdomen: Soft, non-tender, non-distended, no rebound or
guarding, bowel sounds present.
Ext: Warm, well perfused, 2+ pulses, trace pitting edema, no
chronic venous changes appreicated.
Neuro: CNII-XII intact, ___ strength upper/lower extremities.
Discharge Physical:
Vitals: 98.4 57-56 122-147/41-53 18 98%RA
General: Elderly appearing female, lying in bed, otherwise
breathing non-labored.
HEENT: Sclera anicteric, MMM, EOM grossly intact
Neck: supple, no JVP noted at 90degrees
CV: regular rate and rhythm, no murmurs/rubs/gallops
Lungs: No increased work of breathing, good air movement
throughout, unable to take very deep breaths due to coughing.
Abdomen: Soft, non-tender, non-distended, +BS, not tympanic, no
rebound or guarding.
Extremities: warm and well perfused, no edema
Pertinent Results:
Admission Labs:
___ 10:00PM BLOOD WBC-8.3# RBC-3.55* Hgb-10.8* Hct-32.3*
MCV-91 MCH-30.4 MCHC-33.4 RDW-14.9 RDWSD-49.9* Plt ___
___ 10:00PM BLOOD Neuts-65.1 ___ Monos-7.8 Eos-4.6
Baso-1.0 Im ___ AbsNeut-5.43 AbsLymp-1.78 AbsMono-0.65
AbsEos-0.38 AbsBaso-0.08
___ 10:00PM BLOOD Plt ___
___ 10:00PM BLOOD ___ PTT-26.3 ___
___ 10:00PM BLOOD Glucose-113* UreaN-20 Creat-1.0 Na-137
K-5.6* Cl-103 HCO3-23 AnGap-17
___ 10:00PM BLOOD ALT-32 AST-49* AlkPhos-85 TotBili-0.2
___ 10:00PM BLOOD Lipase-30
___ 10:00PM BLOOD ___
___ 10:00PM BLOOD Albumin-3.5
___ 10:06PM BLOOD Lactate-1.4
Pertinent Hospitalization Labs:
___ 05:40AM BLOOD calTIBC-229* Ferritn-201* TRF-176*
___ 05:35AM BLOOD %HbA1c-5.6 eAG-114
___ 05:40AM BLOOD Triglyc-68 HDL-50 CHOL/HD-3.0 LDLcalc-84
___ 04:35AM BLOOD ANCA-NEGATIVE B
___ 04:35AM BLOOD ___ * Titer-1:40
___ 04:35AM BLOOD RheuFac-9
___ 04:35AM BLOOD PEP-NO SPECIFI
___ 04:35AM BLOOD HIV Ab-Negative
Discharge Labs:
___ 04:35AM BLOOD WBC-5.9 RBC-3.57* Hgb-10.6* Hct-32.6*
MCV-91 MCH-29.7 MCHC-32.5 RDW-14.4 RDWSD-48.3* Plt ___
___ 04:35AM BLOOD Neuts-40.4 ___ Monos-13.5*
Eos-8.8* Baso-1.2* Im ___ AbsNeut-2.39# AbsLymp-2.12
AbsMono-0.80 AbsEos-0.52 AbsBaso-0.07
___ 04:35AM BLOOD Plt ___
___ 04:35AM BLOOD Glucose-94 UreaN-45* Creat-1.3* Na-131*
K-4.4 Cl-92* HCO3-29 AnGap-14
___ 04:35AM BLOOD TotProt-7.2 Calcium-9.1 Phos-4.6* Mg-2.2
Studies:
___ CXR:
IMPRESSION:
Findings consistent with decompensated congestive heart failure,
with small bilateral effusions. Difficult to exclude a
superimposed pneumonia at the lung bases.
___ CXR:
IMPRESSION:
Improved pulmonary edema and pleural effusions
___ ECG: Sinus tachycardia. Left atrial abnormality and A-V
conduction delay. Increase in rate. Right bundle-branch block.
Compared to the previous tracing of ___ the rate has
increased. There is ST segment elevation in leads V2-V6. Rule
out myocardial infarction. Followup and clinical correlation are
suggested.
___ ECG: Sinus rhythm. Significant P-R interval prolongation
with the P-R interval of 360 milliseconds. Right bundle-branch
block. Left posterior fascicular block. ST segment elevation in
leads V2-V5 potentially consistent with myocardial infarction.
Left atrial abnormality. Clinical correlation is suggested.
Compared to the previous tracing of ___ these findings are
similar.
___ ECG: Artifact is present. Sinus rhythm with a markedly
prolonged P-R interval of 400 milliseconds. Right axis
deviation. Right bundle-branch block. Possible right ventricular
hypertrophy. ST-T wave changes concerning for ischemia or
myocardial infarction which may be evolving or acute. Compared
to the previous tracing of ___ the P-R interval is longer
and ventricular ectopy is no longer present.
___ TTE:
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is mildly depressed (LVEF= 50 %). 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. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is mild
anterior leaflet mitral valve prolapse. An eccentric,
posteriorly directed jet of Mild to moderate (___) mitral
regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mildly reduced global left ventricular systolic function. Mild
anterior mitral leaflet prolapse with mild to moderate mitral
regurgitation. Mild aortic regurgitation. Moderate pulmonary
artery systolic hypertension. Left pleural effusion.
___ CT-Abd/Pelvis:
IMPRESSION:
1. Allowing for limitations of a noncontrast study, there is no
CT evidence of pancreatitis, and no secondary signs of bowel
ischemia.
2. Scattered colonic diverticulosis without diverticulitis.
3. Grade 1 anterolisthesis of L4 on L5 with bilateral
spondylolysis.
4. Cardiomegaly with bilateral ground-glass opacities and
peribronchial
cuffing, possibly representing pulmonary edema. Left lower lobe
nodular
opacities. Please refer to dedicated CT chest for complete
report.
___ US Renal Artery Doppler:
IMPRESSION:
Both kidneys demonstrate increased cortical echogenicity with
increased
intrarenal arterial resistive indices, likely secondary to
hypertension/underlying medical renal disease. No sonographic
features of
renal artery stenosis.
Micro:
Schistosoma and strongyloides ab pending at discharge *******
Brief Hospital Course:
Ms. ___ is an ___ yo ___ woman with history of HTN
and HLD, presented with hypertensive emergency with flash
pulmonary edema, tropinemia, EKG changes and echo findings
concerning for possible stress cardiomyopathy.
ACTIVE ISSUES
=============
# Hypertensive Emergency: Patient presented with SBP 240/88 with
associated symptoms of chest pain and shortness of breath.
Troponin noted to be 0.09 in ED, repeat 0.09, 0.07. There was
initially concern for ST segment elevation MI given ST
elevations in V2-V6 on ECG. However, cardiology fellow did
bedside TTE in ED which showed preserved systolic function and
no focal wall motion abnormalities. Repeat formal echo was done
with the same results, low normal EF of 50%. Less likely
ischemia given no wall motion abnormalities. Patient was
started on a nitro drip which was quickly titrated off as she
was transitioned to oral anti-hypertensives. Patient's course
was complicated by abdominal pain and vomiting (see below) that
led to spikes in her sBP to the 200s. A work-up of secondary
causes of hypertension was pursued and included negative US for
renal artery stenosis, UA without proteinuria (r/o renal
disease), no adrenal incidentalomas on CT Abd/Pelvis (r/o
primary aldosteronism, ___ Syndrome, Pheochromocytoma), no
documented potassium wasting or hypernatremia on BMPs throughout
hospital stay (r/o primary aldosteronism), no signs Cushingoid
features, no differential of blood pressures in both arms (r/o
Coarctation of the aorta). Her ECG continued to be abnormal
throughout her hospital stay with diffuse ST segment and T-wave
abnormalities. There is concern for stress-induced
cardiomyopathy. She will have a repeat ECHO done as an
outpatient to reassess myopathy once her blood pressure has been
controlled x 1week. She was discharged, stable, on the
following oral anti-hypertensive regimen: Losartan 100mg QHS,
Amlodipine 5mg, Spironolactone 12.5mg, Metoprolol 50mg XL.
# Acute on Chronic diastolic heart failure and flash pulmonary
edema: No known history of heart failure, pt appeared volume
overloaded at presentation likely ___ hypertensive emergency as
stated above with flash pulmonary edema. EF low normal on
formal ECHO with some concern for stress induced cardiomyopathy.
BNP 17,774. She was diuresed with IV Furosemide and her
breathing improved. Her ECHO also showed evidence of moderate
Pulmonary Hypertension. Initial work-up of pulmonary
hypertension was pursued. Given patient's country of origin and
mild eosinophilia on diff, there is concern for possible
Schistosoma and Strongyloides infections. Serum Schistosoma and
Strongyloides antibodies pending at the time of discharge. HIV,
RF, ANCA, SPEP, UPEP negative. ___ positive at 1:40, however,
could be false positive (30% of the normal population has ___
titer of 1:40). As an outpatient, patient will have repeat ECHO
to assess PH and cardiomyopathy as stated above. If warranted,
the following work-up for pulmonary hypertension could be
pursued: PFTs, polysomnography, V/Q scan, exercise testing.
# Vomiting and Abdominal Pain: Seems that this preceded her
hypertensive emergency and was inciting reason for patient
missing medications leading to worsening hypertension. Never
febrile. No sick contacts. She was without abdominal pain for
the first few days of her hospitalization, however, had two days
of intermittent abdominal pain and subsequent vomiting. CT
abd/pelvis with no signs of ischemia or blockage. Normal
lactate and lipase. Differential includes H. Pylori, Gastritis,
and constipation. Her abdominal pain was resolved at the time
of discharge. She was discharged on a trial of high dose PPI
for gastritis. As an outpatient, she should have H. Pylori
testing done.
CHRONIC ISSUES:
===============
#HLD: Not on a statin on admission. Lipids at goal without
statin, however, ASCVD risk 39.4% over ___ years (hard to
interpret as she is out of the ___ year window ASCVD was tested
in). Started on moderate dose statin (Atorvastatin 20mg).
#Normocytic Anemia: Iron studies look like anemia of chronic
inflammation. Unsure as to when patient had last colonoscopy,
however, patient is ___ and it would be reasonable to
avoid colonoscopy. She will need outpatient follow up.
#Elevated Blood Glucose Levels: Patient with several elevated
blood glucose levels on routine BMPs. Hgb A1c sent - 5.6%.
Transitional Issues:
===================
- Patient will need repeat TTE as an outpatient to see if signs
of stress cardiomyopathy have resolved with BP control.
- Consider continued work-up of pulmonary hypertension depending
on results of repeat ECHO. Serologies sent (including HIV, ___,
RF, ANCA, SPEP, UPEP). As per UTD guidelines, further work-up
would include polysomnography, V/Q scan, Exercise testing.
Cardiac MR could also be considered to assess for congenital
heart defects and infiltrative cardiac disease.
- Please see discharge medication sheet for medication changes.
- Patient will need basic metabolic panel to assess her Cr and
electrolytes given new BP regimen at PCP ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Loratadine 10 mg PO DAILY
6. Losartan Potassium 100 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Loratadine 10 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Losartan Potassium 100 mg PO DAILY
Take this medication in the evening.
7. Amlodipine 5 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
9. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Active Issues:
#Hypertensive Emergency
#Acute on Chronic Diastolic Heart Failure
Chronic Issues:
#Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___! You were
hospitalized for high blood pressures that put stress on your
heart, leading to some fluid in your lungs that made it hard to
breathe. We lowered your blood pressure and took some of that
fluid off of your lungs. We also gave you nebulizer treatments
to help with breathing. We did find that your pressures in your
lungs are high. We sent some labs to look at this and we will
send the results to your doctor, ___, and to Dr. ___,
___ new heart doctor. You will see Dr. ___ to continue to
talk about your heart.
Please keep your appointments listed below.
Sincerely,
Your ___ cardiology team
Followup Instructions:
___
|
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.