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19754677-DS-20
| 19,754,677 | 28,796,324 |
DS
| 20 |
2145-10-16 00:00:00
|
2145-10-16 15:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left temporal-parietal stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old F w/ PMH HTN, diastolic HF, MVP w/ mild-mod MR, mild
AI
History provided by family, patient unable to give history.
Patient's family interpreted which was their preference.
She was in her usual state of health until symptoms started
maybe
3 weeks ago, family are not sure of the exact timeline, as she
was with other family in ___ at the time. Relatives said
mother looks sick and that she reported headache. The family
does
not have more information on what really knew what happened, and
the relatives there did not give any more specific information.
The headache is resolved now. She came back to US 1 week ago, on
___. They thought that she looks tired, they thought it
might
have been due to travel initially. They noticed that she has
been
confused intermittently, sometimes doesn't recognize her
children. She will not recognize her son-in-law and then 5
minutes later will be able to recognize him and then at another
point again does not recognize him. They have not noticed any
visual changes. Before this month she did not have any other
symptoms. No previous strokes as far as family knows. She also
has not been eating as well. She needs help standing up because
she is weak, family reports whole body weakness denies
unilateral
symptoms. States that she does not have energy
and is not taking a lot PO due to reduced appetite. No speech
problems. she presented here today for further evaluation as
her
confusion has not been improving CT scan showed subacute to
chronic stroke.
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:
HTN
diastolic HF
MVP w/ mild-mod MR
mild AI
Social History:
Lives in ___ with daughter. ___ alcohol, recreational
drug use or smoking. Originally from ___, moved to the
___ in ___.
- Modified Rankin Scale:
[] 0: No symptoms
[x] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
daughter helps with medications, cooking
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
Vitals: T97.9 HR 59 BP 161/68 RR 18 Spo2 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx. many replaced teeth and missing teeth
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: speech not dysarthric per family, fluent in
native language per family. follows simple commands, but
sometimes requires multiple prompts to follow. not able to state
age, month, or location. Oriented to self only. inattentive,
unable to ___ backwards. naming to high frequency objects
intact.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. blinks to threat bilaterally.
difficult to test confrontationally, but appears intact as well
V: Facial sensation intact to light touch.
VII: L NLFF but activates symmetrically
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
unable to test confrontationally, as she does no tfollow
commands
specifically
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
DISCHARGE PHYSICAL EXAM
=========================
Vitals: ___ 1137 Temp: 98.4 PO BP: 179/65 HR: 58 RR: 16 O2
sat: 98% O2 delivery: RA FSBG: 102
General: Awake, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted
in
oropharynx. many replaced teeth and missing teeth
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: speech not dysarthric per family, fluent in
native language per family. follows simple commands, but
sometimes requires multiple prompts to follow. not able to state
age, month, or location. Oriented to self only. inattentive,
unable to ___ backwards. naming to high frequency objects
intact.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. blinks to threat bilaterally.
difficult to test confrontationally, but appears intact as well
V: Facial sensation intact to light touch.
VII: L NLFF but activates symmetrically
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
unable to test confrontationally, as she does not follow
commands
specifically
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, throughout. No extinction to DSS.
-DTRs:
___
-___: Deferred
-Gait: Deferred
Pertinent Results:
ADMISSION LABS
==============
___ 06:30PM BLOOD WBC-6.1 RBC-4.27 Hgb-12.4 Hct-37.9 MCV-89
MCH-29.0 MCHC-32.7 RDW-14.7 RDWSD-47.6* Plt ___
___ 06:30PM BLOOD Neuts-29.5* ___ Monos-12.0
Eos-11.6* Baso-1.3* Im ___ AbsNeut-1.80 AbsLymp-2.77
AbsMono-0.73 AbsEos-0.71* AbsBaso-0.08
___ 08:30PM BLOOD ___ PTT-26.5 ___
___ 06:30PM BLOOD Glucose-93 UreaN-51* Creat-1.9* Na-136
K-5.4 Cl-90* HCO3-32 AnGap-14
___ 06:30PM BLOOD ALT-13 AST-48* CK(CPK)-65 AlkPhos-56
TotBili-0.3
___ 06:30PM BLOOD CK-MB-<1 cTropnT-0.03*
___ 09:30AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.5* Cholest-175
___ 06:30PM BLOOD Albumin-3.1*
___ 09:30AM BLOOD %HbA1c-5.5 eAG-111
___ 09:30AM BLOOD Triglyc-122 HDL-30* CHOL/HD-5.8
LDLcalc-121
___ 09:30AM BLOOD TSH-2.9
___ 06:36PM BLOOD Lactate-1.5
___ 10:10PM URINE Color-Straw Appear-Clear Sp ___
___ 10:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD*
___ 10:10PM URINE RBC-<1 WBC-9* Bacteri-FEW* Yeast-NONE
Epi-<1
___ 10:10PM URINE CastHy-18*
PERTINENT INTERVAL LABS
=======================
___ 09:30AM BLOOD CK-MB-1 cTropnT-0.03*
___ 05:14AM BLOOD cTropnT-0.03*
___ 01:00PM BLOOD cTropnT-0.02*
___ 05:14AM BLOOD Neuts-39.1 ___ Monos-11.7
Eos-14.0* Baso-0.9 Im ___ AbsNeut-1.81 AbsLymp-1.58
AbsMono-0.54 AbsEos-0.65* AbsBaso-0.04
DISCHARGE LABS
==============
___ 05:30AM BLOOD WBC-5.0 RBC-3.48* Hgb-10.2* Hct-31.0*
MCV-89 MCH-29.3 MCHC-32.9 RDW-15.0 RDWSD-48.9* Plt ___
___ 05:30AM BLOOD Glucose-83 UreaN-31* Creat-1.1 Na-142
K-3.8 Cl-104 HCO3-27 AnGap-11
___ 05:30AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.0
IMAGING
========
___ CXR
IMPRESSION:
No acute cardiopulmonary process. Cardiac silhouette size
appears improved,
cardiac silhouette size appears mildly to moderately enlarged.
___ CT WO CONTRAST
IMPRESSION:
1. Hypodensity and loss of gray-white differentiation in the
left temporal and
parietal lobe is suggestive of subacute to chronic infarct.
Dense material
tracking along several of the primarily parietal sulci is
indeterminate, but
could possibly reflect laminar necrosis. An MRI could be
performed to
establish acuity of this pathology.
2. Chronic, extensive paranasal sinus disease as described
above.
___ TTE
Conclusions
The left atrium is normal in size. No left atrial mass/thrombus
seen (best excluded by transesophageal echocardiography). No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>65%). Regional left ventricular wall
motion is normal. No masses or thrombi are seen in the left
ventricle. Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic arch is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. No masses or vegetations are seen on the aortic valve.
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Moderate aortic regurgitation. Mild left
ventricular hypertrophy with normal biventricular cavity size
and systolic function. No intracardiac thrombus seen.
___ MRI WO CONTRAST
FINDINGS:
There is large zone of chronic infarct involving left temporal
lobe, extending
into the lateral left occipital lobe. Foci of mildly restricted
diffusion
along the posterior periphery of the infarct, with normalized to
mildly
decreased ADC values, consistent with late subacute component of
the infarct.
There are areas of cortical laminar necrosis and cortical
mineralization seen
on T1 and gradient weighted images. No parenchymal hemorrhage.
Suggestion of small focus of mildly restricted diffusion
posterior left
thalamus, suggestive of late subacute infarct.
There is large chronic right PCA distribution infarct involving
posteromedial
right temporal, right occipital lobes.
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift.
Findings consistent with severe chronic small vessel ischemic
changes. Small
left, tiny right chronic cerebellar infarcts. Intracranial
vascular flow
voids are preserved. There is extensive opacification of the
paranasal
sinuses, with periostitis and air-fluid levels, consistent with
acute on
chronic paranasal sinusitis. Mastoids are clear.
IMPRESSION:
1. Late subacute on chronic infarct centered on left temporal
lobe, with areas
of cortical laminar necrosis and mineralization. No parenchymal
hematoma.
2. Suggestion of late subacute infarct posterior left thalamus.
3. Chronic infarcts right PCA distribution, bilateral
cerebellum.
4. Severe chronic small vessel ischemic changes.
5. Extensive paranasal sinus opacification, consistent with
acute on chronic
sinusitis
___ CAROTID US SERIES
IMPRESSION:
No plaque or stenosis right. Mild left ICA ___ stenosis
Brief Hospital Course:
Ms. ___ is a ___ year old ___ speaking woman with HTN,
diastolic HF, MVP w/ mild-mod MR, mild AI who presented with
confusion, found to have a left temporal ischemic stroke.
#Left temporal-parietal ischemic stroke
Patient presented with 3 week history of altered mental status,
mainly confusion and memory loss per family, while travelling
abroad to ___. She was brought in for further evaluation
after her sx persisted 1 week after her return. On admission,
she was found to be inattentive, disoriented, with memory loss
and fluent aphasia. ___ showed left temporal parietal subacute
stroke. MRI was unable to be obtained due to patient's inability
to sit still. CTA unable to be obtained, so carotid dopplers
done. This did not reveal and significant stenosis. Etiology of
stroke is likely cardioembolic given appearance and otherwise
negative work-up. TTE with normal LA size, EF 65% and no
evidence of thrombus. Patient was started on aspirin and
atorvastatin 40 mg QHS given LDL 121. SBPs were maintained <180
with home HCTZ with PRN hydralazine for breakthrough. Home
diuretics were held during this admission. Patient will be
discharged with ___ of hearts monitor to eval for afib.
#Acute on chronic sinusitis
Patient had recent CT scan showing extensive paranasal sinus
opacification, consistent with acute on chronic sinusitis. This
was treated with Augementin 500 mg BID x 10 days (___),
Flonase 1 spray b/l nares qd, and Affrin 1 spray B/L nares TID x
3 days.
#UTI
Patient also with UA c/w with UTI on admission. Treated with
Augmentin 500 mg BID x 10 days as above.
___
On admission pt had prerenal ___ (Cr 1.9) in setting of poor PO
intake per family. This was treated w IVF with return to
baseline creatinine. Home Torsemide was held on discharge with
plan to repeat Cr with PCP as outpatient next week.
#Chronic eosinophilia
Patient with eosinophilia on admission, Per OMR, she has been
worked up in a ___
admission for her eosinophila with negative serum schistosoma
and Strongyloides antibodies and negative HIV, RF, ANCA, SPEP,
UPEP at that time. Her eosinophilia is also consistent with a
recent CT scan showing extensive paranasal sinus opacification,
consistent with acute on chronic sinusitis.
Transitional Issues
=====================
[] ___ Nasal Spray half bottle per nares BID
[] Continue Augmentin 500 mg BID course (___)
[] F/u with PCP ___: diuretics, eosinophilia and ___ of hearts
(PCP updated verbally over phone ___
[] F/u with neurology
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day
2? (x) Yes - () No
4. LDL documented? (x) Yes (LDL = 121) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
35 minutes were spent on the discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H Duration: 7
Days
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*16 Tablet Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
RX *fluticasone [24 Hour Allergy Relief] 50 mcg/actuation 1
spray in each nostril daily Disp #*1 Spray Refills:*0
4. Neilmed Sinus Rinse Complete (sod chlor-bicarb-squeez
bottle) half bottle in each nostril BID
RX *sod chlor-bicarb-squeez bottle [Nasal Relief Sinus
Wash-bottle] half bottle in each nostril twice a day Disp #*1
Bottle Refills:*0
5. Aspirin 81 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. HELD- Torsemide 20 mg PO DAILY This medication was held. Do
not restart Torsemide until cleared by your PCP
10.Rolling Walker
Dx: Left occipital subacute stroke (ICD 10 CODE: ___)
Px: good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left temporal-parietal stroke
Acute kidney injury
Sinusitis
Urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of slurred speech
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:
- High cholesterol
- High blood pressure
We are changing your medications as follows:
- start Augmentin 500 mg twice a day (___) for sinus
infection
- Flonase 1 spray b/l nares daily
- Atorvastatin 40mg nightly
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19754927-DS-11
| 19,754,927 | 29,920,081 |
DS
| 11 |
2143-06-21 00:00:00
|
2143-06-22 08:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of dementia, DM, HTN, paroxysmal Afib, porstate
cancer, and thalassemia, presenting from adult day care after an
episode of hypotension with SBP 90. Per family, patient has
been in usual state of health, including this morning, though
perhaps ate slightly less for breakfast. While at adult day
care today, he reported headache and malaise. Was felt to be
dehydrated and noted to have SBP 90. Given tylenol and sent to
ED for eval.
On arrival to the ED, initial vitals were 99.8 60 117/55 20 97%.
On exam, was oriented to person/place (baseline). Noted to have
guaiac neg brown stool. Labs notable for Hct 30.0 (down from 37
in ___, but close to previous baseline of ___. UA not
suggestive of UTI, and CXR not suggestive of PNA. EKG showed
sinus rhythm with 1st degree AV conduction delay. Ocasionally
argumentative, but per report can be quickly redirected.
Received risperidone 0.5 mg PO x1. Admitted to Medicine for
observation given hypotension. VS prior to transfer 66 136/72 16
98%.
Currently, patient reports headache has resolved. He is not
able to provide much history, but family that is with him is
able to answer questions. Of note, started sertaline less than
one week ago.
ROS: Positive as per HPI. No recent fever, chills, sweats,
vision changes, sore throat, cough, shortness of breath, chest
pain, abdominal pain, nausea, vomiting, diarrhea, constipation,
BRBPR, dysuria, or gross hematuria.
Past Medical History:
PAST MEDICAL HISTORY:
1. Dementia, likely mixed Alzheimer's/vascular.
2. Hypertension.
3. History of paroxysmal atrial fibrillation.
4. History of prostate cancer, on Lupron injections in past.
5. Lumbar spinal stenosis.
6. Charcot arthroplasty.
7. Diabetes mellitus type 2.
8. Thalassemia trait anemia.
9. Hearing loss, has hearing aids.
10. History of subdural hematoma.
PAST SURGICAL HISTORY:
1. Surgical evacuation of subdural hematoma ___.
2. Prostatectomy.
Social History:
___
Family History:
Notable for father who died in his ___ of Hodgkin's lymphoma.
Mother died age ___, complications of stomach ulcers.
Physical Exam:
ADMISSION EXAM:
VS: Temp 97.4F, BP 118/70, HR 61, RR 18, SpO2 95% RA
GENERAL - resting comfortably in bed, later agitated when
walking, but in NAD, oriented to name only
___ - NC/AT, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no cervical LAD
HEART - RRR, normal S1-S2, II/VI systolic murmur
LUNGS - CTAB, no wheezes/rales/rhonchi, respirations unlabored
ABDOMEN - bowel sounds present, soft/NT/ND, no rebound/guarding
EXTREMITIES - warm, well-perfused, 2+ pulses, trace edema
SKIN - no rashes or jaundice
NEURO - awake, oriented to person only, tremor RUE, able to move
all four extremities
DISCHARGE EXAM:
VS - Temp 97.9F, BP 129/64, HR 62, RR 18, O2-sat 97% RA
GENERAL - NAD, comfortable
___ - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - RRR, nl S1-S2, holosystolic murmur heard best at the
left sternal border
LUNGS - CTAB, respirations unlabored.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - Awake. AO x 1. Right upper extremity resting tremor. No
focal deficits.
Pertinent Results:
ADMISSION LABS:
___ 12:25PM BLOOD WBC-7.5 RBC-4.43* Hgb-9.6* Hct-30.0*
MCV-68* MCH-21.7* MCHC-32.0 RDW-15.7* Plt ___
___ 12:25PM BLOOD Neuts-70.9* ___ Monos-5.7 Eos-1.8
Baso-0.6
___ 01:17PM BLOOD ___ PTT-28.7 ___
___ 12:25PM BLOOD Glucose-90 UreaN-16 Creat-0.8 Na-142
K-3.9 Cl-108 HCO3-26 AnGap-12
___ 02:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
___ 02:20PM URINE RBC-25* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
___ 02:20PM URINE Mucous-MANY
DISCHARGE LABS:
___ 07:25AM BLOOD WBC-5.7 RBC-4.82 Hgb-10.2* Hct-33.1*
MCV-69* MCH-21.2* MCHC-30.8* RDW-16.1* Plt ___
___ 07:25AM BLOOD Glucose-102* UreaN-13 Creat-0.8 Na-142
K-3.9 Cl-108 HCO3-24 AnGap-14
___ 07:25AM BLOOD Calcium-9.3 Phos-3.6 Mg-2.2
MICROBIOLOGY:
Urine culture ___: MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
IMAGING:
CXR ___: Mild pulmonary vascular congestion with
retrocardiac atelectasis.
Leftward deviation of the superior trachea with fullness of the
right superior mediastinum could suggest the presence of
enlarged right thyroid gland. Clinical correlation is
recommended.
Brief Hospital Course:
___ male with h/o dementia, HTN, paroxysmal Afib,
prostate cancer, and thalassemia minor trait who presented after
having an episode of hypotension (SBP 90) at his adult day
program, with stable blood pressures in the ED, admitted to
medicine service for further blood pressure monitoring.
# Hypotension: SBP 90 at adult day program. Patient afebrile,
without leukocytosis or signs/symptoms of an infectious process.
Hct slightly lower than ___, but close to previous baseline
and remained stable. Hypotension may have been related to
slight dehydration, as family reported patient had decreased
appetite that morning and ate less for breakfast. ___ also have
been post-prandial hypotension, or possibly a medication effect
- on lisinopril and diltiazem, and also of note was recently
started on sertraline. Blood pressure was stable in the ED and
throughout his hospital stay. Home diltiazem and lisinopril
initially held. Diltiazem resumed on discharge. Lisinopril
also restarted, but at lower dose of 10 mg daily (rather than 40
mg daily).
# Anemia: History of thalassemia trait. On admission, Hct 30.0,
down from 37.2 on ___. Previously, however, he has had Hct
values down to ___, which appears to be his baseline. Guiac
negative in ED. Low suspicion for acute bleeding, though did
have hematuria noted on UA. Hct remained stable.
# Hematuria: RBC 25 on UA in the ED. Etiology unclear. UA not
suggestive of UTI, and urine culture showed mixed bacterial
flora c/w contamination. Has prior history of prostate cancer.
No recent instrumentation. DDx included nephrolithiasis,
malignancy. Should follow-up with PCP; consider repeat UA and
further evaluation if persistent.
# Dementia: Likely mixed Alzheimer's/vascular type. Continued
Aricept, Namenda, sertraline, risperidone. Did require
additional risperidone on night of admission for agitation.
# Hypertension: Given hypotension, held home meds on admission.
Restarted diltiazem on discharge, and restarted lisinpril at
lower dose as above.
# History of paroxysmal atrial fibrillation: Was in sinus rhythm
with first degree AV conduction delay. Continued aspirin.
Initially held diltiazem; resumed on discharge.
TRANSITIONAL ISSUES:
-Consider further adjustment of BP meds as outpatient.
Diltiazem dose unchanged, lisinopril decreased from 40 mg daily
to 10 mg daily.
-Needs outpatient follow-up for new hematuria.
-CXR on admission showed leftward deviation of the superior
trachea with fullness of the right superior mediastinum, which
could suggest the presence of enlarged right thyroid gland.
Consider further work-up as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 180 mg PO BID
2. Donepezil 5 mg PO BID
3. Lisinopril 40 mg PO DAILY
4. Memantine 10 mg PO BID
5. Risperidone 0.25 mg PO QAM
6. Risperidone 0.375 mg PO DAILY AT 11:30
7. Aspirin 81 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Donepezil 5 mg PO BID
3. Memantine 10 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Risperidone 0.25 mg PO QAM
6. Risperidone 0.375 mg PO DAILY AT 11:30
7. Acetaminophen 650 mg PO TID
8. Diltiazem Extended-Release 180 mg PO BID
9. Sertraline 50 mg PO DAILY
10. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Hypotension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking part in your care at ___
___. You were admitted here because you had
an episode of low blood pressure at your day program. Several
reasons may have been responsible for your low blood pressure,
including not eating or drinking enough fluids as well as
medications. While you were in the hospital, your blood pressure
increased back up to normal and you went home the next day. We
did decrease the dose of your lisinopril (a blood pressure
medication), and you should also ask your primary care doctor
about whether you should decrease your dose of diltiazem in the
future.
Followup Instructions:
___
|
19755076-DS-12
| 19,755,076 | 23,197,885 |
DS
| 12 |
2144-05-22 00:00:00
|
2144-05-25 22:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dizziness and nausea
Major Surgical or Invasive Procedure:
TEE
No atrial septal defect or patent foramen ovale seen by 2D,
color Doppler or saline contrast with maneuvers. Chiari network
(normal variant) in the right atrium. Overall normal left
ventricular systolic function.
History of Present Illness:
Mr. ___ is a ___ yo R-handed man with no significant past
medical history who presents as a transfer from ___ with dizziness, found to have ___ stroke.
Mr. ___ was in his usual state of health on awakening ___
am.
At approx. 0730, while driving to work, he had sudden onset of
dizziness, described as imbalance/disequilibrium. Denies
lightheadedness, room-spinning. He went back home and tried to
drink something and lie down, but had significant nausea. He has
had significant nausea and innumerable episodes of emesis. He
says he had episodes of emesis every few minutes, and that the
emesis occurred reliably with changes in position.
He presented to ___ with emesis and gait instability, where he
underwent CTA head/neck, which showed no significant vessel
stenosis nor occlusion and MRI brain, which showed scattered
infarcts in the ___ territory. He was treated with Zofran 4mg
x3, lorazepam 0.5 x2, and 1L NS, and transferred to ___ for
neurologic evaluation and treatment.
Mr. ___ does not regularly seek medical care. He does not
have
an established PCP.
He denies any palpitations.
Past Medical History:
HTN
Witnessed apneas during sleep, has never had a sleep study.
Social History:
___
Family History:
Mother with stroke (unknown details) in her late ___.
Otherwise NC.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.8 HR: 76 BP: 147/84 RR: 16 SaO2: 100% RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with normal grammar and
syntax. No paraphasic errors. Naming intact to low frequency
words. Repetition intact. Comprehension intact to complex
appendicular commands. Normal prosody.
-Cranial Nerves: PERRL 3->2. VFF to confrontation. EOMI with
fine
sustained R-beating nystagmus with rightgaze. Facial sensation
intact to light touch. Face symmetric at rest and with
activation. Hearing intact to conversation. Palate elevates
symmetrically. ___ strength in trapezii bilaterally. Tongue
protrudes in midline and moves briskly to each side.
- Motor: Normal bulk and tone. No drift. No tremor nor
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Abductors
L 2 2 3 2 1 +
R 2 2 3 2 1 +
Plantar response was flexor bilaterally.
-Sensory: Intact to LT, temp throughout. Proprioception intact
bilateral great toes.
- Coordination: Dysmetria with R FTN; fine RAM clumsy on R. No
dysmetria on L.
- Gait: deferred given significant nausea and emesis with
changing positions.
========================================
Discharge PPhysical Exam
Vitals: T: 37.1 °C (98.8 °F)
HR: 60-88 bpm sinus
BP: ___ mmHg
RR: 16 (16 - 33) insp/min
SPO2: 100%
Heart rhythm: SR (Sinus Rhythm)
General: Awake, cooperative, NAD.
HEENT: no scleral icterus, MMM, no oropharyngeal lesions.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: Skin warm, well-perfused.
Abdomen: soft, ND
Extremities: Symmetric, no edema.
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3, conversational.
Able
to relate history without difficulty. Speech is fluent with
normal grammar and syntax. No paraphasic errors. Naming intact
to
low frequency words. Repetition intact.
-Cranial Nerves: PERRL 3->2 bilaterally. No ptosis or miosis.
VFF
to confrontation. EOMI with no nystagmus to the left, no
nystagmus to the right. Facial sensation intact to light touch.
Face symmetric at rest and with activation. Hearing intact to
conversation. Palate elevates symmetrically. ___ strength in
trapezii bilaterally. Tongue protrudes in midline and moves
briskly to each side.
- Motor: Normal bulk and tone. No drift.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response was flexor bilaterally.
-Sensory: L FTN intact. No pronator drift.
- Coordination: No cerebellar rebound. No truncal titubation.
Left FTN intact with no dysmetria. Right finger to nose slight
dysmetria distally when approaching target, but hit target.
- Gait: patient able to walk steadily without any difficulties,
no nausea or dizziness
Pertinent Results:
___ 06:55AM BLOOD WBC-6.6 RBC-4.58* Hgb-14.0 Hct-41.1
MCV-90 MCH-30.6 MCHC-34.1 RDW-12.9 RDWSD-42.4 Plt ___
___ 01:00PM BLOOD ___ PTT-27.4 ___
___ 07:10AM BLOOD Glucose-97 UreaN-22* Creat-1.1 Na-139
K-4.0 Cl-102 HCO3-23 AnGap-14
___ 02:09AM BLOOD Triglyc-102 HDL-45 CHOL/HD-5.2
LDLcalc-168* LDLmeas-169*
___ 02:09AM BLOOD %HbA1c-5.6 eAG-114
Brief Hospital Course:
Mr. ___ is a ___ year old right handed man with no known past
medical history who was admitted to the Neurology stroke service
with dizziness and nausea secondary to an acute ischemic stroke
in the right cerebellum. The pattern of infarcts suggests a
large embolus to ___ which subsequently broke up with residual
smaller areas of infarction scattered throughout this vessel
territory. His stroke was most likely secondary to atheroembolic
vs cardioembolic event given high cholesterol. We did not
consider this a failure of ASA/Plavix. He was started on
aspirin, atorvastatin, and amlodipine. Mild to moderate
atherosclerosis of intracranial arteries was noted on CTA at
___. His deficits improved greatly prior to discharge and the
only notable deficit was mild ataxia on the right when testing
finger to nose. A TEE did not show a PFO or ASD
His stroke risk factors include the following:
1) Mild intracranial atherosclerosis
2) Hyperlipidemia: LDL 168. Patient started on atorvastatin
80mg.
3) Possible Sleep apnea - does not yet carry the diagnosis but
partner says patient snores
4) A TTE did not show a PFO
5) No atrial fibrillation was seen on telemetry monitoring
Started aspirin 81, atorvastatin 80mg, and amlodipine 5mg. TTE
and TEE performed to rule out PFO/ASD, neither seen. Patient
worked with physical therapy and occupational therapy.
Patient worked with ___ and OT, who had some concerns about his
driving. He should see PCP before resuming driving. Blood
pressure should be monitored, and amlodipine increased or other
agents added as PCP sees fit. Cholesterol should be rechecked
after ___ months on atorvastatin. Further hypercoaguability
workup needs to be checked: send protein C&S, antithrombin 3,
prothrombin gene mutation, factor V leiden. Consider holter
monitoring to look for occult atrial fibrillation. Patient was
also couseled on the importance of obtaining insurance so that
he can more easily see doctors and obtain the medications he
needs. He agreed to follow up with his girlfriend's PCP and pay
out of pocket within the next few weeks, and with neurology in
___ months. Patient remained stable for discharge on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*3
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cerebellar CVA
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 dizziness and nausea
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:
High blood pressure
High cholesterol
We are changing your medications as follows:
Added aspirin 81mg
Added atorvastatin 80mg daily
Added amlodipine 5mg daily
Please take your other medications as prescribed. Please try to
obtain insurance, so that you can more easily follow up with
physicians. You have experienced a major medical problem, and we
don't want you to have any more strokes. You need to follow up
with a primary care doctor regularly. Please do not drive until
you follow up with a primary care physician. Occupation therapy
worked with you and had concerns about you driving because you
get dizzy when you turn your head.
Please follow up with Neurology 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
It was a pleasure taking care of you!
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19755175-DS-12
| 19,755,175 | 25,792,862 |
DS
| 12 |
2150-02-23 00:00:00
|
2150-02-23 13:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left sided weakness and left facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old right-handed man with PMH
significant for BPH who presents with acute onset left sided
weakness. He was last known well around midnight, when he went
to the bathroom and checked the thermostat. He then went to
sleep. His wife heard him screaming on the floor of the bedroom
around 3:30 AM. He tried getting out of bed, but fell; the left
side of his face was noted to be drooping at that time and he
was unable to move the left side of his body. He vomited at
home. He was taken to ___, where it was noted
he arrived shortly after 5 AM. He vomited at OSH and received
Zofran. CT
scan performed there reportedly showed hyperdense R MCA and he
was transferred to ___ for further management. CODE STROKE
called 7:49 AM. Of note, his wife says that he was doing well
yesterday. Norecent infectious symptoms or evidence of any
illness. He didreportedly drink several beers and a few shots
yesterday. He has no history of vascular risk factors. He does
not smoke. He does; however, have a strong family history of
stroke; his father deceased from a stroke (believed to be in his
___ and his paternal aunt had a stroke as well.
Neuro ROS: He says he cannot feel his left arm and cannot move
the left side of his body. No headaches, vertigo,
lightheadedness, blurry or double vision. No dysphagia. No
difficulty with speech production or comprehension.
General ROS: Positive for nausea and vomiting earlier, nausea
improved. No recent infectious symptoms, fevers or chills. No
chest pain or tightness, palpitations, shortness of breath,
cough or abdominal pain.
Past Medical History:
-BPH
Social History:
___
Family History:
Father deceased from stroke. Paternal aunt also had a stroke.
Physical Exam:
Initial Physical Exam:
Vitals: T: 95.9 P: 79 R: 18 BP: 178/91 SaO2: 94%
___ Stroke Scale score was: 19
1a. Level of Consciousness: 1
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 1
3. Visual fields: 2
4. Facial palsy: 3
5a. Motor arm, left: 4
5b. Motor arm, right: 0
6a. Motor leg, left: 4
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 2
General: drowsy but easily arousable
HEENT: NC/AT, no conjuctival injection, dry mucus membranes, no
lesions noted in oropharynx
Neck: Supple
Pulmonary: lcta b/l
Cardiac: RRR, S1S2, II/VI systolic murmur
Abdomen: soft, NT/ND, +BS
Extremities: warm, well perfused
Neurologic:
Mental Status: drowsy but easily arousable, oriented to person,
month and year. Able to follow simple commands. No right-left
confusion. Left visual and sensory hemineglect- he could not
identify his own hand; however he is aware that he has no
feeling
in his left arm.
Language: speech is dysarthric. Intact naming, repetition and
comprehension.
Cranial Nerves: PERRL 2 to 1 mm and brisk. Left hemianopia.
Right
gaze preference in primary gaze, but able to look all the way to
the left; EOMs full. Left upper and lower facial weakness.
Motor: Normal bulk. Normal tone on right, left side flaccid.
Strength full on right side. Left hemiplegia.
Sensory: Absent light touch LUE. There was light touch sensation
present in LLE, but this extinguished.
Coordination: No intention tremor or dysmetria on F-N-F on left
Gait: deferred given left lower extremity plegia.
=
=
=
================================================================
Discharge Physical Exam:
Essentially unchanged except for improvement in his left-sided
neglect with ability to count people on his right and left side.
Able to identify his own hand.
His SBPs ranged 140s-160s.
Pertinent Results:
Admission Labs:
___ 08:00AM GLUCOSE-146* NA+-140 K+-3.9 CL--104 TCO2-24
___ 07:57AM CREAT-1.0
___ 07:45AM UREA N-17
___ 07:45AM WBC-11.8* RBC-4.53* HGB-13.8* HCT-39.7*
MCV-88 MCH-30.5 MCHC-34.8 RDW-12.8
___ 07:45AM NEUTS-87.9* LYMPHS-8.6* MONOS-3.1 EOS-0.3
BASOS-0
Other Pertinent Labs:
___ 03:19PM cTropnT-<0.01
___ 07:45AM cTropnT-<0.01
___ 08:57AM %HbA1c-6.1* eAG-128*
___ 07:45AM ALT(SGPT)-15 AST(SGOT)-21 ALK PHOS-51 TOT
BILI-0.2
___ 07:45AM ALBUMIN-4.1
___ 07:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:45AM PLT COUNT-364
___ 07:45AM ___ PTT-21.8* ___
___ 07:45AM ___
Pertinent Radiographic Studies:
___ CT BRAIN PERFUSION/CTA NECK & HEAD
FINDINGS:
HEAD CT: There is a large hypodense area in the right MCA
territory with loss of gray-white differentiation. The right M1
segment of the MCA is hyperdense and there are multiple
hyperdense branches in the sylvian fissure. These findings are
consistent with a large right MCA infarction with occlusion of
the M1 and Sylvian branches. There is no evidence of hemorrhage,
or mass. There is no shift of midline structures. The
ventricles and sulci are prominent, consistent with age-related
atrophy. No suspicious osseous lesions are identified. The
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
CT PERFUSION: There is a large area of increased transit time in
the right
MCA distribution, extending into the anterior cerebral and
posterior cerebral distributions. There is decreased cerebral
blood volume in the right MCA territory. Thus, there is a
matched deficit in the MCA distribution, with penumbra in the
adjacent right ACA and MCA distributions.
HEAD AND NECK CTA: The right internal carotid artery is occluded
from its
bifurcation to the petrous portion of the internal carotid
artery, where flow is reconstituted. The left internal carotid
artery is patent throughout its course. The right vertebral
artery is patent, and the left vertebral artery may be stenosed
at its origin from the left subclavian artery. This finding may
also be due to artifact. 3D reconstructions demonstrate
occlusion of the right MCA in the distal M1 region. There is no
evidence of aneurysm formation. There are atherosclerotic
changes in the bilateral cavernous portions of the internal
carotid arteries.
There is a 14mm nodule in the left lobe of the thyroid (4:71),
and a
calcification in the right lobe. There is no cervical
lymphadenopathy. There are multilevel degenerative changes of
the cervical spine.
IMPRESSION:
1. Large infarct involving most of the right MCA territory.
There is
evidence of poor flow in the right ACA and PCA territories.
2. Occlusion of the right internal carotid artery from the
carotid
bifurcation to proximal to the petrous portion.
3. No evidence of intracranial hemorrhage.
4. 14mm thyroid nodule. This finding can be better assessed on
ultrasound.
Brief Hospital Course:
___ year-old right-handed man with PMH significant for BPH who
presents with acute onset left sided facial droop and left
hemiplegia, NIHSS 19. Initial exam was notable for left neglect
(visual and sensory), right gaze preference (but full EOMs),
left facial weakness, left hemiplegia, and left sensory defecits
greater in upper than lower extremity.
On CT, there was a large hypodensity noted in the right MCA
territory. CTA showed complete occlusion of the right internal
carotid artery at the bifurcation with reconstitution distally
as well as an occluded right middle cerebral artery. He did not
receive tPA upon arrival as he was outside of the therapeutic
time window. He was started on ASA 325mg and atorvastatin 80mg
and admitted to the neuro ICU.
His symptoms improved, with decreased neglect and slight finger
flexion on left arm and ___ proximal and 4+/5 distal strength in
the lower extremities. Given the stability of his neurologic
deficits he was transferred to floor on ___.
On the floor, he continued to have headaches and c/o nausea
requiring IV ondansetron. He was tolerating ground solid food,
but severe nausea and depression precluded appropriate oral
nutritional intake. His nausea was aggressively managed and he
was encouraged to eat.
Given the severity of his deficits, it was determined that he
would benefit from rehabilitation. We assessed his treatable
stroke risk factors: LDL 127, HbA1C 6.1%. He was continued on
atorvastatin 80mg daily. He will require continued monitoring
and treatment of his lipids and sugars in order to decrease
future stroke risk.
==========================================================
.
Transitional issues:
.
1. Stroke: he will be transfered to rehab for an undetermined
amount of time. He follow up with neurology, Dr. ___ in ___
weeks to further assess improvement and recovery.
2. Thyroid nodule: incidental finding that should be followed by
his PCP.
3. HTN: his BP was first allowed to autoregulate over the first
48hrs, it was then kept between 140-160 systolic with lisinopril
5mg daily. His systolic BP goal should be 140-160 for one week
(until ___, then decreased to <140 systolic likely with
the aid of further BP medications.
4. BPH: he did not remember the medication he was taking for
BPH, he might require initiation of BPH medication if he begins
having symptoms of urinary retention.
Medications on Admission:
-med for BPH (he does not recall name)
-___ C
___ Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right MCA embolism with infarction
Right ICA occlusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you during your hospital stay.
You had a stroke which affected the right side of your brain. We
have arranged for you to get rehabilitation during your
convalescence. In order to decrease your future risk of stroke,
we have started you on a daily aspirin and cholesterol-lowering
drug.
On imaging, you were found to have a 14mm nodule in your
thyroid. You should have this followed by your primary care
physician.
Please note the following medications changes:
START:
- aspirin 325mg daily
- atorvastatin 80mg daily
Followup Instructions:
___
|
19755374-DS-10
| 19,755,374 | 22,548,641 |
DS
| 10 |
2163-01-19 00:00:00
|
2163-01-22 14:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Intubation
RIJ CVL placement
Transesophageal echocardiogram
History of Present Illness:
Mr. ___ Critical ___, DOB ___ is a ___ year old
___ speaking male with a likely history of HCV cirrhosis and
IVDU who presented to ___ and was
transferred to ___.
Per ___ reports, he was seen there 10 days ago for an opioid
overdose. At that time he had leg swelling and JVD. He had a
normal TTE at that time. Today, he was complaining of constant
chest pain for the past 5 days. By their documentation, further
ROS was notable for absence of N/V, headache, neck stiffness,
abdominal pain. A murmur was appreciated which had not been
previously reported, prompting concern for endocarditis. He was
intermittently somnolent and agitated with desaturations. They
found he had an elevated CK concerning for rhabdo. Given his
questionable respiratory status and agitation, he was intubated
for airway protection. There was concern for meningitis given
his altered mental status. He was found to be tensing/releasing
his extremities. He was given lorazepam and fentanyl and
intubated. He received 1.5g vancomycin and 2g cefepime around
0500. A CT head was negative for intracranial abnormalities. He
was transferred to ___ because there were no ICU beds
available.
In our ED, initial vitals were: T 101, HR 89, BP 129/65, RR 15,
O2 98% Intubation.
Labs were notable for:
Urine toxicology screen positive for opiates, cocaine, and
amphetamines.
Cr 0.8, Lactate 0.8
CK 3360, Trop-T < 0.01, proBNP 159, AST 196, ALT 81, Alb 3.0
CBC: 12.2 > 10.5/32.3 < 151 (PMN: 74.1)
INR: 1.4
Patient was given:
___ 06:55 IVF NS
___ 08:24 IV Daptomycin (420 mg ordered)
___ 08:24 IV DRIP Fentanyl Citrate (100-200 mcg/hr
ordered)
___ 08:24 IV DRIP Midazolam ___ mg/hr ordered)
On arrival to the MICU, the patient was intubated and sedated.
He was comfortable appearing and stable.
Review of systems: Per HPI. Otherwise unable to obtain.
Past Medical History:
IVDU/cocaine/EtOH use
Hepatitis C cirrhosis with encephalopathy
Chronic Osteomyelitis
Epilepsy
Prolonged QT syndrome
Social History:
Homeless. ___ years of heroin use. 10 instances of rehab. 12
alcoholic beverages a day. Jailed recently.
Physical Exam:
ADMISSION EXAM
Vitals: T: 97.5 BP: 101/65 P: 75 R: 24 O2: 100% on ventilator
___: Intubated and sedated, no acute distress
HEENT: Sclera anicteric, pinpoint pupils, MMM
NECK: JVP not elevated
LUNGS: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, rhonchi
CV: Regular rate and rhythm, normal S1/S2, ___ systolic murmur
best heard at LUSB
ABD: soft, non-tender, non-distended, no rebound tenderness or
guarding, no organomegaly
EXT: Warm, well perfused, no clubbing, cyanosis or edema
SKIN: Track marks on arms, areas of pustules/abscesses on arms
NEURO: Deeply sedated
FOR DISCHARGE EXAM AND FURTHER DETAILS PLEASE SEE DISCHARGE
SUMMARY FROM ___
Pertinent Results:
ADMISSION LABS
___ 06:32AM BLOOD WBC-12.2* RBC-3.82* Hgb-10.5* Hct-32.3*
MCV-85 MCH-27.5 MCHC-32.5 RDW-14.6 RDWSD-45.1 Plt ___
___ 06:32AM BLOOD ___ PTT-27.6 ___
___ 06:32AM BLOOD Glucose-77 UreaN-13 Creat-0.8 Na-134
K-6.4* Cl-102 HCO3-19* AnGap-19
___ 06:32AM BLOOD ALT-81* AST-196* CK(CPK)-3360* AlkPhos-75
TotBili-0.9
___ 10:43AM BLOOD Calcium-7.7* Phos-2.4* Mg-1.7
___ 06:32AM BLOOD Albumin-3.0*
___ 02:47PM BLOOD HIV Ab-Negative
___ 06:32AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:36AM BLOOD Type-ART pO2-421* pCO2-37 pH-7.37
calTCO2-22 Base XS--3
___ 06:48AM BLOOD Glucose-74 Lactate-0.8 Na-135 K-4.4
Cl-104 calHCO3-22
FOR IMAGING AND FURTHER DETAILS PLEASE SEE DISCHARGE SUMMARY
FROM ___
Brief Hospital Course:
Mr. ___ is a ___ year old male with a PMHx of Hep C cirrhosis
and IVDU who presented from ___ with chest
pain, fevers, and concern for endocarditis. He was treated from
___, discharged AMA for several hours to attend an
important family event and then readmitted from ___.
For a detailed hospital course, please see most recent discharge
summary from ___.
The following is the Hospital course from the ___ discharge.
Mr. ___ is a ___ year old male with a PMHx of Hep C cirrhosis
and IVDU who presented from ___ with chest
pain, fevers, and concern for endocarditis. He was treated from
___, discharged AMA for several hours to attend an
important family event and then readmitted from ___.
# Bacterial Pneumonia, MRSA. Patient presented from ___ with
chest pain and question of endocarditis. He was intubated and
sedated on arrival and was maintained on intubation until ___.
CTA chest to rule out septic emboli was negative for embolism
but did show multifocal central peribronchial nodular opacities,
most severe in the right upper lobe, in addition to dense
consolidations with air bronchograms within the lower lobes
bilaterally, consistent with multifocal pneumonia or aspiration.
Sputum culture from ___ ___s sputum culture from ___ (by
report) growing MRSA. Initially placed on Cefepime, levofloxacin
and daptomycin (then vancomycin) and then narrowed to vancomycin
once sputum culture speciated. Legionella and Strep pneumo
antigen were both negative, blood cultures were negative >48
hours on discharge.
# Discitis. Patient with inflammation of L5-S1 disc space and
associated vertebral body enhancement on MRI L-Spine, concerning
for infection. He has a history of osteomyelitis that was
treated earlier this year 'with IV antibiotics for 6 weeks.'
Underwent ___ guided bone biopsy on ___, culture data and gram
stain not suggestive of active infection. PCR and final
pathology pending.
# Polysubstance abuse. Patient with history of IVDU and active
alcohol use. UDS positive for opiates, cocaine and amphetamines
on presentation. Initially managed on a phenobarbital taper in
the ICU and was started on Suboxone induction on ___ with
plans to continue at ___ and as an outpatient.
# Question of Pulmonic Valve Endocarditis. Mr. ___ presented
with chest pain and fevers. Initial concern was for
endocarditis, with TTE at ___ reportedly showing possible
pulmonic valve vegetation. However, TTE, and TEE done ___
showed no evidence of vegetation. Patient remained afebrile
after initial fever on ___ and showed no stigmata of
endocariditis.
# Toe pain. Patient complained of acute toe pain on ___
described as a crawling sensation, ___ in all toes with
possible parasthesia prior to the pain. He has a history of
L5-S1 osteomyelitis with associated neurologic deficits (tells
me he could not walk whent his occured) and endorsed subacute
back pain but no associated neurologic deficits. MRI was
negative for cord compression and patient showed no other
neurologic deficits. XR of toes showed no fracture. No
electrolyte abnormalities. B12 normal, B6 pending. Patient was
on phenobarbital at the time, no. Pain was managed with Tylenol,
ibuprofen and tramadol at first and then Tylenol and ibuprofen
once suboxone was considered.
#Hemoptysis. One episode of hemoptysis shortly after TEE. Likely
post-procedural. Induced sputum smears were negative for TB x 3.
# HCV Cirrhosis: Unknown if patient has been treated. No
evidence of acute decompensation at this time. Admission CT
abd/pelvis without any ascites
# Elevated CPK. Resolved. 3942 on presentation at ___. By report
was intoxicated with agitation and "tensing/releasing of
extremities" and thrashing around in bed. Elevation likely due
to this vigorous movement, with possibility of witnessed seizure
prior to presentation. Came down well with good PO and IV CPK 87
on ___.
TRANSITIONAL
==========
- Patient has pending pathology on bone biopsy. We have also
sent a universal PCR to see if anything is growing out of bone.
He has a history of osteomyelitis treated at ___
___ this year, with subsequent enhancement at L5-S1 on MRI
here on ___, with current bone biopsy growing nothing out of
culture. Final antibiotic course will be determined by
Infectious Disease team pending results of PCR.
- Patient complained of significant toe pain here. Radiographs
showed no fracture or acute process
- Patient was started on suboxone while in-house. He received
one dose of 2mg Buprenorphine/.5mg naloxone followed by a second
dose 2mg/.5 at 14:10 on ___. He will need another dose of
4mg/1mg at ___, and then 8mg/2mg the morning of ___.
If he tolerates this regimen he should be given a second dose of
8mg/2mg the evening of ___ and then transition to 8mg/2mg BID.
- Incidental findings on radiology:
-- Slight widening of the right AC joint could reflect an injury
to the acromioclavicular ligament
-- Moderate opacification of bilateral ethmoid air cells with
mucosal
thickening plus/ minus fluid, occluding the frontoethmoidal
recesses andextending into the inferior frontal sinuses.
# CONTACT: ___ (friend) ___ ___ (son)
___, secondary contact
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. TraMADol 50-100 mg PO Q8H:PRN Pain - Severe
3. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
4. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
3. Lisinopril 20 mg PO DAILY
4. HELD- TraMADol 50-100 mg PO Q8H:PRN Pain - Severe This
medication was held. Do not restart TraMADol until you have
finished suboxone
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
=======
MRSA Pneumonia
Discitis
Polysubstance abuse
HCV Cirrhosis
Rhabdomyolysis
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 at ___
___. You came to us from ___ with
concern for an infection of the valves of your heart. You were
found to have no infection in your heart, but you do have a
dangerous pneumonia (with a bug called Staphylococcus aureus,
MRSA). You did well here on IV antibiotics and will need to
continue for 2 more weeks. We also found evidence of
inflammation on imaging of your back. A biopsy of your bone
showed no infection here. You left on ___ against medical
advice to attend an important funeral. You were able to state
the risks and benefits of leaving and planned to come back to
___ ED later tonight for readmission. You are leaving with the
understanding that your PICC line must be removed and then
replaced again once you come back to ___, with all the risks
of an additional procedure.
Please take all of your medications as described in this
discharge summary. We have made an appointment with your primary
care provider so that you can start suboxone treatment if you
are lost to follow-up with us; otherwise we will start your
treatment here at ___. If you experience any of the danger
signs below, please come to the emergency department
immediately.
Best Wishes,
Your ___ Care Team
Followup Instructions:
___
|
19755487-DS-8
| 19,755,487 | 25,879,196 |
DS
| 8 |
2158-05-12 00:00:00
|
2158-05-12 15:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / Cipro / codeine / erythromycin base / Levaquin /
Penicillins / shellfish derived / tetracycline
Attending: ___.
Chief Complaint:
Aphasia, right sided weakness
Major Surgical or Invasive Procedure:
Intubated ___
Intubated ___
IVC via right IJ ___
History of Present Illness:
NEUROLOGY STROKE CONSULT NOTE
Neurology at bedside for evaluation after code stroke
activation/consult within: 5 minutes
Time (and date) the patient was last known well: 0800 AM
___ clock)
___ Stroke Scale Score:
t-PA given: --- Yes Time t-PA was given given at ___ 0920 AM
Thrombectomy performed: [] Yes [X] No
--- If no, reason thrombectomy was not performed or considered:
distal clot
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
The ___ was performed:
Date: ___
Time: 11:15 AM
(within 6 hours of patient presentation or neurology consult)
___ Stroke Scale score was : 17
1a. Level of Consciousness: 0
1b. LOC Question: 2
1c. LOC Commands: 2
2. Best gaze: 1
3. Visual fields: 0
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 3
6a. Motor leg, left: 0
6b. Motor leg, right: 1
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 3
10. Dysarthria: 2
11. Extinction and Neglect: 1
REASON FOR CONSULTATION: stroke
HPI:
___ is an ___ year old woman with a past medical
history of HTN, lower leg edema, lung cancer s/p surgery alone
in ___ now in remission, osteoarthritis who presents as a
transfer from ___ in ___ after receiving tpA at
9:25 AM for aphasia, R plegia and facial droop.
Limited history obtained from Daughter ___ (___).
Patient is at baseline very independent, occasionally walks with
a cane but otherwise fully independent and performs all of her
ADLs on her own. This morning at 8 am she was home with her
daughter and granddaughter who she lives with. She was in the
kitchen making breakfast when her daughter saw her and she
seemed fine. Her daughter then left the room and saw that the
patient started to do the dishes. A few minutes later she heart
a loud noise and came in to find her mother sitting on her
bottom, screaming out but confused and not able to say any
words. She also had a R facial droop and couldn't move her R
side. The family then immediately called EMS who arrived to her
home.
At ___ code stroke activated, NIHSS 21 (breakdown
not available). CT head only was done which did not reveal a
bleed and TPA was subsequently given at 9:25 AM and transferred
to ___.
On arrival the patient is very combative, screaming and only
tolerated a brief head CT. She then desaturated and required 6L
of 02 , likely due to aspiration. For respiratory purposes the
patient was intubated. CTA head and neck was done and showed a
distal thrombus bot no proximal LVO for thrombectomy.
ROS: Unable to obtain
Past Medical History:
1. Chronic Iron Deficiency Anemia
2. Sjogrens syndrome
3. Mitral valve regurgitation
4. SVT
5. Lung adenocarcinoma s/p left upper lobe resection with
recurrence
6. diastolic heart failure
7. gravity dependent edema
8. hypertension
9. osteoarthritis
10. cataract
Social History:
___
Family History:
No known family hx of strokes
Physical Exam:
EXAM ON ADMISSION:
==================
Physical Exam: (Exam prior to intubation)
Vitals: T96.6, HR 59, BP 103-135/52, RR 14, 100% ETT
General: Awake, screaming, combative , moving L side vigorously
HEENT: NC/AT, dried blood in oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: increased WOB, upper airway sounds
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: multiple abrasions/cuts on LEs, Large R hematoma
Neurologic:
-Mental Status: Awake, screaming but no formed words, unable to
follow any commands, does not maintain eye contact. Unable to
comprehend. Looks to L when called but not to the R.
-Cranial Nerves:
II, III, IV, VI: No R eye . L eye pupil is small irregular and
not reactive.
R facial droop present
brisk coreneals. Coughing.
-SensoriMotor:
Left arm and leg are full strength, patient frequently grabbing
pushing and pulling staff and examiner with L side. R leg is
also
moving spontaneously antigravity. R arm moves sponatneously in
the plane of the bed. To noxious in R arm patient grimaces and
moves in plane of bed briskly.
-DTRs:
Bi Tri ___ Pat
L 2 2 2 3
R 2 2 2 3
Plantar response was upgoing bilaterally.
-Coordination: deferred
-Gait: deferred.
EXAM ON DISCHARGE:
==================
Resting comfortably in bed, in no acute distress
Respirations unlabored.
Pertinent Results:
ADMISSION LABS:
===============
___ 11:03AM BLOOD WBC-10.0 RBC-2.85* Hgb-5.6* Hct-20.3*
MCV-71* MCH-19.6* MCHC-27.6* RDW-17.6* RDWSD-45.4 Plt ___
___ 11:03AM BLOOD ___ PTT-29.0 ___
___ 11:03AM BLOOD Fibrino-86*
___ 06:26PM BLOOD Glucose-98 UreaN-29* Creat-1.4* Na-141
K-5.2 Cl-113* HCO3-18* AnGap-10
___ 11:03AM BLOOD ALT-9 AST-38 AlkPhos-106* TotBili-0.3
___ 11:03AM BLOOD cTropnT-0.11*
___ 06:26PM BLOOD Hapto-151
___ 06:26PM BLOOD %HbA1c-5.3 eAG-105
___ 06:26PM BLOOD Triglyc-70 HDL-60 CHOL/HD-2.0 LDLcalc-47
___ 06:26PM BLOOD TSH-1.7
___ 11:03AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 04:36PM BLOOD Type-ART pO2-234* pCO2-38 pH-7.34*
calTCO2-21 Base XS--4
___ 06:43PM BLOOD Lactate-0.6
___ 11:03AM BLOOD WBC: 10.0 RBC: 2.85* Hgb: 5.6* Hct: 20.3*
MCV: 71* MCH: 19.6* MCHC: 27.6* RDW: 17.6* RDWSD: 45.___
___ 11:03AM BLOOD Neuts: 82.5* Lymphs: 7.9* Monos: 7.2 Eos:
1.1 Baso: 0.7 Im ___: 0.6 AbsNeut: 8.28* AbsLymp: 0.79*
AbsMono:
0.72 AbsEos: 0.11 AbsBaso: 0.07
___ 11:03AM BLOOD ___: 14.7* PTT: 29.0 ___: 1.4*
___ 11:03AM BLOOD ALT: 9 AST: 38 AlkPhos: 106* TotBili: 0.3
IMAGING:
========
CTH ___:
No hemorrhage.
Stable large left MCA distribution acute/early subacute infarct.
Chronic left occipital lobe infarct.
Right enophthalmos, small right globe.
TTE ___:
LVEF 55-60%. IMPRESSION: Multivalvular heart disease as noted.
Normal biventricular systolic function. Moderate to severe
pulmonary hypertension. No definite structural cardiac source of
embolism identified.
CTA H/N ___:
1. Within the region of the left parietal lobe, there is a
region of decreased cerebral blood flow with volume of 42 cc and
a region of increased T max of 64 cc, resulting in mismatch
volume of 22 cc and mismatch ratio 1.5. This is suggestive of
ischemia with surrounding penumbra.
2. Within the posterior branch of the left middle cerebral
artery, within the region of the left sylvian fissure, there is
an abrupt cutoff concerning for thrombosis.
CT Abdomen and Pelvis and Chest ___:
1. No evidence of an acute intrathoracic or intra-abdominal
bleed. Right hip and gluteal soft tissue edema; no frank
hematoma. The right thigh hematoma is not visualized.
2. Mild pulmonary edema. Small right pleural effusion. Debris
in the distal trachea. Aspiration or infection cannot be
entirely excluded.
3. A 4.3 cm soft tissue density in the left supraclavicular
region likely represents an enlarged potentially neoplastic
lymph node. Hematoma is less likely as it is well demarcated on
concurrent neck CTA.
4. A 2.8 cm elongated nodule in the right middle lobe of the
lung is of uncertain significance and could represent an
impacted dilated bronchus versus pulmonary nodule and/or
atelectasis. Three-month follow-up CT is recommended.
CT Head ___:
No hemorrhage.
Stable large left MCA distribution acute/early subacute infarct.
Chronic left occipital lobe infarct.
Right enophthalmos, small right globe.
CXR ___:
1. Interval retraction of the enteric tube, with side port close
to the
gastroesophageal junction. Recommend advancement.
2. Interval worsening of vascular congestion and pulmonary
edema.
CTA Chest ___:
Pulmonary embolus in a segment of the right inferior pulmonary
artery.
Cardiomegaly with predominant enlargement of the right chambers
and left
atrium.
Enlarged pulmonary arteries suggestive of chronic pulmonary
hypertension.
Given the above-mentioned chronic findings, right heart strain
evaluation is impaired.
Mild pulmonary edema most pronounced in the right upper lobe
suggestive of
associated mitral valve dysfunction.
Consolidations noted in the right lower and middle lobes
suggestive of
multifocal pneumonia.
Bilateral pleural effusions, right greater the left.
Mediastinal lymphadenopathy, likely reactive to both pulmonary
edema and
pneumonia.
CT Head ___:
1. No definite evidence of acute intracranial hemorrhage.
2. Evolving large left MCA distribution subacute infarct,
without definite
evidence of hemorrhagic transformation.
CT head w/o contrast ___:
1. No evidence of acute intracranial hemorrhage.
2. Continued evolution of the left MCA territory infarct. Mild
interval
decrease in effacement of the sulci and the left lateral
ventricle.
Brief Hospital Course:
PATIENT SUMMARY:
================
___ is an ___ woman with a past medical
history significant for hypertension, osteoarthritis, lung
adenocarcinoma s/p left upper lobe resection with likely disease
recurrence, CKD, diastolic heart failure, and ___
transferred from ___ s/p tpA at 0925 AM on ___
for left MCA infarct. CTA head and neck revealed a distal MCA
clot and she was thus not a candidate for thrombectomy given the
location of thrombus.
In the ___ ED, she had possible aspiration and desaturation
requiring intubation for respiratory decompensation. She was
initially admitted to the neuroscience ICU but was soon
extubated and transferred to the ___ intermediate care
unit for further monitoring. The patient was subsequently
transferred to the medicine service due to multifocal
respiratory failure.
On ___ while on the medicine floor, patient developed acute
hypoxemic respiratory failure in the setting of hypertensive
urgency while receiving oral care. Patient became tachypneic to
___, HR 160s. Patient was transferred to ___ given her
persistent tachypnea and respiratory distress. On arrival,
patient was given Lasix 80mg IV, trialed on BiPAP which she did
not tolerate, and ultimately required intubation. During
intubation she was found to have a large mucoid glob on her
vocal cords which was removed. She was successfully extubated
___.
On the floor she was stable but with neurology's input that she
would likely not recover function after this stroke, we had a
family meeting to discuss her goals of care. Her daughter
emphasized that ___ would want to be comfortable and to be
with family and thus the decision was made to transition to
___ focus care and patient was discharged to an inpatient
hospice house.
ACUTE ISSUES:
=============
# Goals of care
In discussion with patient's daughter, ___, the decision was
made to pursue comfort focused care and inpatient hospice. The
patient was given Haldol 0.2-2mg IV BID:PRN for agitation,
lorazepam 0.5mg IV q4h:PRN for anxiety, and morphine sulfate
___ IV q3h:PRN for pain.
# Left MCA infarct s/p tPA
Etiology of infarct is unknown at this time but can consider
cardio embolic vs hypercoagulability given known adenocarcinoma.
No atrial fibrillation was detected on the neurology service.
Her 24 hours post tPA CTH was stable. Stroke risk factors
include A1c of 5.3 and LDL of 47. TEE with no
structural/cardioembolic
source of infarct but no bubble used. She was continued on ASA
81 mg daily and her statin was held given LDL of 47. SBP was
controlled to <180 in post tPA setting but then liberalized to
SBP <200. Patient's neurological course complicated by delirium
for which she which repeat NCHCT on multiple occasions all of
which showed stable left MCA infarct without hemorrhagic
transformation. Seven day post-tPA scan, in particular, was
stable. From a stroke perspective, decision to anticoagulate was
deferred to the medicine team given concomitant PE/DVT (see
below). Of note, anticoagulation was initially held given size
of infarct, was initiated with heparin gtt then lovenox, then
discontinued as patient transitioned to CMO.
# Multifactorial Respiratory Failure
Patient transferred to medicine service due to multifactorial
respiratory failure. Based on CTA, patient was found to have
segmental PE on the right, multifocal pneumonia, right > left
pleural effusions, and mild pulmonary edema as well as acute on
chronic heart failure with BNP > 70,000. For the pneumonia, she
was treated with vancomycin and cefepime with plan for 7 day
course. MRSA swab was negative and vancomycin was thus
discontinued. ___ was initially made NPO and had an NGT
placed for tube feeds, which required restraints because she
would pull at her tubes. After discussion with family, it was
decided that she would be happier and more comfortable without
NGT, without restraints, and eating for pleasure despite risk of
aspiration.
# Non-occlusive deep venous thrombosis in bilateral common
femoral veins.
On ultrasound, deep venous thrombosis extends into the deep
femoral vein on the left. IVC filter placed with right IJ
approach on ___. Was on subcutaneous therapeutic lovenox but
this was ultimately stopped when she was transitioned to comfort
care.
# Hypertension
Patient was started on metoprolol 6.25 mg BID, which is less
than half her home dose. PRN labetolol was given in the neuro
ICU as needed to keep systolic pressure less than 200. She was
then started on amlodipine. However, when transitioned to
comfort care all of these medications were discontinued.
# Elevated troponins
Likely type 2 NSTEMI in setting of increased demand. Troponins
0.11 on admission, peaked at 0.23 before downtrending. EKG
without ST changes.
# Diastolic heart failure
Patient had severely elevated JVD on admission and with
bilateral lower extremity edema. She received 30 of IV Lasix for
two days and was then started on furosemide 20 mg PO daily (half
of home dose). Additional IV Lasix was given to keep patient net
even on daily ins and outs. Diuresis was cautious as she might
be preload dependent given pulmonary artery hypertension seen on
TTE.
# Acute Anemia
# Chronic Iron Deficiency Anemia, reported baseline of 7.4
Hg of 5.6 on arrival requiring 4 U PRBCs as was not correcting
appropriately. She had bright red blood coming from OGT in the
setting of intubation after tPA. IV PPI started (since switched
to daily) and hgb normalized to reported baseline. She had a
large hematoma on right flank, which was stable. CT abd/pelvis
did not reveal active bleeding.
# Guardianship: Unfortunately, Ms. ___ did not have a
health care proxy documented prior to her stroke and thus
guardianship was pursued this admission to help with surrogate
decision making with plan for appointment of ___
daughter, as guardian. Court date for guardianship pending at
time of discharge.
CHRONIC ISSUES:
===============
# Lung adenocarcinoma CA s/p resection in ___ with recurrence
of disease
Left supraclavicular mass seen on CT concerning for recurrence,
especially in context of bilateral DVTs and PE.
# Sjogrens syndrome
Continued home hydroxychloroquine 200 mg BID (listed as home
dose) then ultimately discontinued when transitioned to ___
care.
>30 minutes spent on discharge planning and care coordination on
day of discharge including direct face to face time with
patient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Potassium Chloride 20 mEq PO DAILY
5. Aspirin 81 mg PO DAILY
6. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
7. Hydroxychloroquine Sulfate 200 mg PO BID
8. flaxseed oil 1,000 mg oral DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Haloperidol 0.5-2 mg IV BID:PRN delirium, severe agitation
2. LORazepam 0.5 mg IV Q4H:PRN anxiety, agitation
3. Morphine Sulfate ___ mg IV Q3H:PRN Pain - Severe OR not
relieved by oral medication OR NPO/unable to tolerate PO
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Acute left MCA stroke
Pulmonary embolism
Pleural effusions
Multifocal pneumonia
Acute on chronic heart failure
Bilateral lower extremity DVT
SECONDARY DIAGNOSES
===================
Delirium
Encephalopathy
Neck mass
Anemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___,
___ was our pleasure to care for you at ___. You came to the
hospital because you had trouble 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.
WHAT HAPPENED IN THE HOSPITAL?
- You were found to have a blood clot in both of your legs and
in your lungs
- You were found to have a lung infection called pneumonia,
which we treated
- You went to the ICU twice because your breathing failed and
you needed intubation
- We worked with your daughter to determine what is most
important to you, and decided to focus all of you care on making
you as comfortable and happy as possible
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Spend time with your friends and family
We wish you the best.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19756011-DS-4
| 19,756,011 | 21,085,823 |
DS
| 4 |
2126-11-18 00:00:00
|
2126-11-24 08:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Haldol / Stelazine / Mellaril / Codeine
Attending: ___.
Chief Complaint:
Abdominal Pain / Anemia
Major Surgical or Invasive Procedure:
Colonoscopy
EGD
History of Present Illness:
Patient is a ___ female with PMH of seizure disorder,
borderline personality disorder, HTN, and polysubstance abuse
who presents with chief complaint of fatigue and shortness of
breath with new Hct drop to 25 from 30 in her PCP's office. She
was last in her usual state of health ___ mos prior to
presentation when she developed constipation. This was managed
with prn laxatives. Then for the past 2 mos she began to
experience abdominal pain and vomiting with food intermittantly.
She notes that this was relieved with prn TUMS. Then about 2
weeks prior to presentation she had surgery on her right ear for
a cyst. Since that time, she has stopped her suboxone under the
guidance of her physicians and took prn dilaudid prescribed for
surgical pain. Since then, the constipation is worse, and the
abdominal pain is persistant. The pain is located in the
epigastric area. An outpatient CT demonstrated signficant stool
burden and "gastric thickening." She has no fever, no vomiting,
and no previous abdominal surgery. She was sent from PMD due to
anemia and pain, as well as pt's significant anxiety and need
for endoscopy/colonscopy.
In the ED, initial VS were:98.5 79 142/79 16 100% RA. DRE
revealed brown guiac positive stool. She received fentanyl
100mcg x2 for pain. She received 1L IVNS. VS on transfer T97.8
HR79 BP123/74 RR16 O2sat:98% RA.
On arrival to the floor, VS were T98.6, BP139/80, HR78, RR18,
O2sat99%RA. She reports persistant epigastric pain and abdominal
fullness. She is afraid to take medications because of nausea
and vomiting with PO intake.
Past Medical History:
HTN
borderline personality disorder
seizure disorder
HLD
polysubstance abuse
s/p TAH
Social History:
___
Family History:
sister has depression, uncle with schizophrenia
aunt with heart disease,
father with prostate cancer
mother had ___ lymphoma, CVA, valvular heart disease
uncle with ___ lymphoma
aunt with breast cancer
Physical Exam:
ADMISSION EXAM:
VS: T98.6, BP139/80, HR78, RR18, O2sat99%RA
GENERAL: well appearing
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, obese
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric
DISCHARGE EXAM:
Vitals: 98.9 115/72 70 20 97%RA
General: Alert, oriented, no acute distress, anxious affect
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, NT/ND, NABS, no HSM
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: left forearm with area of induration which is
approximately same size as yesterday. no fluctuance. surrounding
tender, warm, erythema has receded significantly since prior
exam. No distal swelling of the forearm / hand.
Neuro: no focal deficits
Pertinent Results:
LABS:
___ 08:35PM BLOOD WBC-6.4 RBC-4.00* Hgb-8.9* Hct-29.1*
MCV-73*# MCH-22.1*# MCHC-30.5*# RDW-19.0* Plt ___
___ 02:30AM BLOOD WBC-4.8 RBC-3.56* Hgb-7.8* Hct-25.7*
MCV-72* MCH-22.0* MCHC-30.4* RDW-19.2* Plt ___
___ 06:55AM BLOOD WBC-3.7* RBC-3.52* Hgb-7.4* Hct-25.2*
MCV-71* MCH-21.1* MCHC-29.5* RDW-18.9* Plt ___
___ 05:40AM BLOOD WBC-5.6 RBC-3.48* Hgb-7.4* Hct-24.4*
MCV-70* MCH-21.3* MCHC-30.4* RDW-18.4* Plt ___
___ 05:50AM BLOOD WBC-5.1 RBC-3.44* Hgb-7.4* Hct-24.7*
MCV-72* MCH-21.6* MCHC-30.1* RDW-19.0* Plt ___
___ 02:30AM BLOOD Ret Aut-2.1
___ 08:35PM BLOOD Glucose-93 UreaN-15 Creat-0.8 Na-135
K-4.3 Cl-99 HCO3-26 AnGap-14
___ 05:40AM BLOOD Glucose-90 UreaN-7 Creat-0.7 Na-140 K-4.0
Cl-108 HCO3-25 AnGap-11
___ 05:50AM BLOOD Glucose-115* UreaN-13 Creat-0.8 Na-140
K-4.1 Cl-108 HCO3-23 AnGap-13
___ 08:35PM BLOOD ALT-13 AST-34 AlkPhos-46 TotBili-0.2
___ 02:30AM BLOOD Calcium-8.1* Phos-2.7 Mg-2.0 Iron-18*
___ 08:35PM BLOOD Albumin-4.6
___ 02:30AM BLOOD calTIBC-400 Ferritn-5.8* TRF-308
___ 02:30AM BLOOD TSH-2.9
___ 06:45AM BLOOD IgA-104
___ 06:45AM BLOOD tTG-IgA-2
___ 03:10PM BLOOD WBC-6.3 RBC-3.53* Hgb-7.6* Hct-26.1*
MCV-74* MCH-21.4* MCHC-29.0* RDW-18.3* Plt ___
___ 05:50AM BLOOD WBC-5.1 RBC-3.44* Hgb-7.4* Hct-24.7*
MCV-72* MCH-21.6* MCHC-30.1* RDW-19.0* Plt ___
___ 05:36AM BLOOD Glucose-90 UreaN-7 Creat-0.8 Na-139 K-4.0
Cl-107 HCO3-25 AnGap-11
___ 05:50AM BLOOD Glucose-115* UreaN-13 Creat-0.8 Na-140
K-4.1 Cl-108 HCO3-23 AnGap-13
MICROBIOLOGY:
___ 9:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
=================================================
IMAGING/OTHER STUDIES:
ABDOMINAL X-RAY ___:
No dilated loops of bowel concerning for obstruction. Contrast
is seen
passing through the ascending colon. New multiple air-fluid
levels are
identified, likely secondary to patient's recent enema
treatments.
ABDOMINAL X-RAY ___:
Two supine images of the abdomen demonstrate significant
interval
improvement in the fecal load, with evidence of a mild to
moderate fecal load throughout the ascending and descending
colon. Note is made of barium in the colon from the prior CT
scan. There are no dilated loops of bowel concerning for
obstruction. There is no free air or pneumatosis. Visualized
osseous structures demonstrate mild scoliosis, as well as a
compression deformity of L4 better evaluated on the CT from
___
EKG ___:
Normal sinus rhythm. Normal ECG. Compared to the previous
tracing of ___ sinus tachycardia is no longer present and
the non-specific T wave
abnormalities have resolved.
GI MUCOSAL BIOPSIES ___
A. Lower esophagus:
- Acute (neutrophilic) esophagitis with ulceration and
granulation tissue formation.
- A GMS stain demonstrates pseudohyphal and yeast forms
consistent with ___ sp.
- An HSV immunostain is negative.
B. Duodenum:
Small intestinal mucosa, within normal limits.
ABDOMINAL X-RAY ___:
No evidence of free air. Mild distention of the small and large
bowel not
unanticipated s/p recent colonoscopy.
L UPPER EXTREMITY VENOUS U/S ___:
1. No evidence of deep vein thrombosis in the left arm.
2. Small region of clot seen in a superficial vein in the left
forearm, at the level of the patient's induration. Edematous
adjacent soft tissues are noted.
Brief Hospital Course:
Patient is a ___ female with PMH of psychiatric disorders, HTN,
HLD, and constipation presenting from ___ office with abdominal
pain, nausea/vomiting, early satiety and worsening of chronic
anemia with guaiac+ brown stool found to have constipation/fecal
impaction.
#Constipation: The most likely etiology of patient's abdominal
pain, nausea, and early satiety is constipation ___ prolonged
opioid use and inadequate bowel regimen. The fact that there is
occult blood in her stool and she has never had a colonocopy
raised the possibility of colon cancer as a contributor to her
constipation. Outpatient abdominal CT showed "significant stool
burden". KUB here showed colon completely filled with stool,
with no evidence of obstruction. CT also mentions possible
gastric thickening, which raises suspicion for gastric CA, given
early satiety. However, this seemed very unlikely given the fact
that the patient has actually gained 30 lbs. in the past year
and has no systemic symptoms concerning for malignancy. On
___, patient received aggressive bowel regimen with colace,
senna, miralax, bisacodyl PO/PR, lactulose, and methylnaltrexone
without significant BM. Manual disimpaction was attempted, but
was only able to extrac 2 small/hard stool balls without
significant furthur BM. Patient received mag citrate and
MoviPrep between ___ and began having large loose stools
that eventually became clear, without evidence of blood. On
___, patient reported overall improvement in her abdominal
pain. Colonoscopy/EGD on ___ was unrevealing with exception
of mild esophagitis. Source of occult blood remained unclear.
Initially, abdominal pain was treated with Dilaudid; however, on
day of discharge, patient was transitioned back to Suboxone. She
will f/u with GI for consideration of capusle endoscopy to
identify source of fecal occult blood.
#Anemia: HCT was down from baseline of 30 on ___ to 25 on
___. Given guaiac + brown stool, this may represent slow GIB.
Patient was severely iron deficient with iron level of 18 and
ferritin of 5.8 HCT remained stable throughout admission.
Colonoscopy/EGD unrevealing with regards to source of fecal
occult blood. Patient was started on PO ferrous sulfate 325mg
TID with aggressive bowel regimen including daily senna, colace,
and Miralax. IV iron repletion may be a consideration once her
cellulitis clears. She is to followup with GI for possible
capsule endoscopy to identify source of bleeding.
#Thrombophlebitis/cellulitis: Likely ___ IV catheter. Given
rapid progression of surrounding erythema, initiated treatment
with IV vancomycin to cover MRSA, given hospitalization. By time
of discharge, cellulitis had essentially resolved; however
continued induration/erythema around site of IV insertion,
concerning for possible abscess vs. thrombus. Venous u/s of left
upper extremity showed no DVT/abscess, but small, non-occlusive
thrombus in superficial vein in forearm. Discharged on PO Keflex
and Bactrim with close PCP ___.
#Seizure disorder:
Continued clonazepam, trileptal
#Borderline personality disorder:
Continued seroquel, fluoxetine
#HTN: Continued Hctz, lisinopril
#HLID: continued simvastatin
===============================================================
TRANSITIONAL ISSUES:
#Blood cultures from ___ Pending
#Close followup of left arm thrombophlebitis / cellulitis
#Follow up GI biopsies
#Consider starting IV iron supplementation once infectious
cellulitis has resolved
___ be appropriate for PCP to discuss ___/ patient her use of the
hosptial system as a means of feeding her narcotic addiction as
she referred to her stay in the hospital as a "Dilaudid Party".
On day of discharge she stated that she wanted to go home now
that the "Dilaudid Party" is over.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxcarbazepine 300 mg PO BID
2. Ascorbic Acid ___ mg PO DAILY
3. Fluoxetine 80 mg PO DAILY
4. Lisinopril 30 mg PO DAILY
5. Cyanocobalamin 100 mcg PO DAILY
6. Calcium Carbonate 600 mg PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8. Zinc Sulfate 50 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Quetiapine Fumarate 600 mg PO QHS
11. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY
12. Clonazepam 2 mg PO BID
13. Tizanidine 4 mg PO QHS
14. Hydrochlorothiazide 12.5-25 mg PO DAILY
15. Senna 1 TAB PO BID:PRN constipation
16. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Clonazepam 2 mg PO BID
3. Fluoxetine 80 mg PO DAILY
4. Hydrochlorothiazide 12.5-25 mg PO DAILY
5. Lisinopril 30 mg PO DAILY
6. Oxcarbazepine 300 mg PO BID
7. Quetiapine Fumarate 600 mg PO QHS
8. Simvastatin 40 mg PO DAILY
9. Tizanidine 4 mg PO QHS
10. Ascorbic Acid ___ mg PO DAILY
11. Calcium Carbonate 600 mg PO DAILY
12. Cyanocobalamin 100 mcg PO DAILY
13. Vitamin D 400 UNIT PO DAILY
14. Zinc Sulfate 50 mg PO DAILY
15. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*20 Capsule Refills:*0
16. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [ClearLax] 17 gram 1 pack by mouth
daily Disp #*30 Packet Refills:*0
17. ValACYclovir 1000 mg PO Q12H Duration: 7 Days
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*6 Tablet Refills:*0
18. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
19. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0
20. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Abdominal pain
Constipation
Occult blood in stool
Cellulitis
Thrombophlebitis
Secondary:
borderline personality disorder
hypertension
hyperlipidemia
history of polysubstance abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ for abdominal pain and a small amount
of blood in the stool. Your abdominal pain was caused by severe
constipation. We used multiple laxatives and enemas and were
able to clean out your colon and your pain improved. You should
use over-the-counter Colace, Senna, and Miralax daily in order
to prevent constipation. You should be having a bowel movement
every ___ days to avoid this type of constipation.
You were found to have a small amount of blood in your stool.
The drop in your blood count was small and occured over several
months. Your blood counts were stable while you were here. A
colonoscopy and endoscopy did not show an obvious source of the
blood in your stool. You will followup as an outpatient with a
GI specialist to look into this furthur. You were found to have
very low iron levels, which is contributing to your anemia.
Your PCP ___ set up IV iron infusions as an outpatient.
You also developed an infection of your left forearm from the
site of your IV. This infection improved with antibiotics. You
had an ultrasound of the arm that showed a small superficial
clot. You will be discharged on oral antibiotics and followup
with your PCP to make sure that the infection is resolving.
It was a pleasure taking part in your care here at ___ and we
wish you a speedy recovery!
Followup Instructions:
___
|
19757198-DS-25
| 19,757,198 | 28,680,884 |
DS
| 25 |
2193-06-23 00:00:00
|
2193-06-23 10:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Erythromycin Base / Penicillins / Aspirin / Levaquin / Metformin
/ citrus / doxycycline / Bactrim
Attending: ___.
Chief Complaint:
Left back/buttock pain
Major Surgical or Invasive Procedure:
OPERATION: ___, Dr. ___
1. Revision laminectomy of L2 and 3.
2. Fusion L2-L3.
3. Instrumentation L2-L3.
4. Removal of previous instrumentation.
5. Autograft.
History of Present Illness:
___ y/o F with HTN, DM and chronic back pain followed by pain
clinic sent in from pain clinic today after failed steroid
injection. Patient reports chronic back pain followed by the
pain clinic for over ___ year, had multiple injections in the past
in various locations, mostly in the right side. Last injection
~4 weeks ago, was supposed to go back to the pain clinic on
___, but cancelled appointment because she was feeling better.
However, over over last 3 days has become acutely worse in the
left buttock area, very focal, legs are not involved. Worsened
by any movement. Reports progressive pain without relief from
steroid injection. Today went for Left L5 transforaminal
epidural steroid injection and had worsening pain despite
injection and one dose toradol. No weakness or numbness. No
saddle parasthesias. No bowel/bladder incontinence or urinary
retention. Sent in from pain clinic for MRI and surgery
consultation. No f/c. No CP/SOB. No n/v/d. No midline spine TTP.
In the ED, initial VS were pain ___ T98.6 HR63 BP178/86 RR18
satting 98% on RA. Physical exam noted for patient to be
neurologically intact with normal rectal tone and perianal
sensation. Basic labs were all WNL. Received 1 PO Percocet. ED
discussed with Dr. ___ MD) who agreed with
nonemergent MRI as inpatient with Dr. ___ as
inpatient. Patient was admitted as she did not feel safe going
home. VS prior to transfer were T 97.3|HR70| RR 18 BP 149/61.
On the floor patient was sleepy and pain is ___.
Past Medical History:
Hypertension
Hyperlipidemia
COPD
Obesity
Osteoarthritis
Sciatica
Lumbar spinal stenosis s/p total laminectomy L2-L5 and fusion
___
s/p left total shoulder arthroplasty ___
s/p right carpal tunnel release ___
s/p TAH/BSO
BPV previously seen by Dr. ___ position dependent irregular tremors of the
proximal
left leg previously seen by Dr. ___ vaginitis
___
Right sided breast mass
Kidney Stones
Right abdominal lipoma
Social History:
___
Family History:
No family history of stroke.
mother - colon cancer
father - unknown
Physical ___:
ADMISSION EXAM
VITALS: T97.3| BP 170\87| HR 64| RR 20| satting 93% on RA
GENERAL: Laying flat on the stomach. NAD
HEENT: PERRL, EOMI. Vitiligo around eyes. MMM.
NECK: no carotid bruits, JVD cannot be assessed
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3 although mildly drowsy from Percocet in ED.
MAE. No focal CN deficits. 1+ patellar and bicipital reflexes
B/L. No gross sensory deficits. focal tenderness in the left
L5-S1 paraspinal area
Pertinent Results:
ADMISSION LABS
___ 02:30PM BLOOD WBC-7.6 RBC-4.38 Hgb-14.1 Hct-42.2 MCV-96
MCH-32.3* MCHC-33.5 RDW-14.5 Plt ___
___ 02:30PM BLOOD Neuts-69.8 ___ Monos-5.9 Eos-0.4
Baso-0.3
___ 02:57PM BLOOD ___ PTT-29.0 ___
___ 02:30PM BLOOD Glucose-160* UreaN-9 Creat-0.6 Na-141
K-3.4 Cl-103 HCO3-30 AnGap-11
DISCHARGE LABS
IMAGING
MR ___ & W/O CONTRAST Study Date of ___ 7:36 ___
Multilevel degenerative cahgnes and post-surgical changes.
L5-S1; Mild canal stenosis from disc bulge and ligamentum flavum
thcikening. Posterior to L2 body ( se 9, im 9)), there is a new
small intermediate focus in the left paracentral location -
likely disk extrusion/ sequestered fragment indenting the thecal
sac. No abnormal enhancement allowing for post-surgical changes.
Brief Hospital Course:
___ F PMhx chronic back pain p/w acute on chronic back pain and
lumbar MRI showing new fragment and disc protrusion from L2
posteriorly.
# Acute on Chronic Back pain: The patient has chronic back pain
and is s/p an extensive laminectomy and fusion in ___. She
receives regular steroid injections, but achieved no relief from
these injection for this current episode. Her pain was managed
with heat packs and standing oxycodone 2.5mg as patient was
often unwilling to ask for prn and frequently in ___ pain when
only prn was available. She prefered to remain very still in bed
and was unable to OOB due to significant pain. Lumbar MRI showed
a new fragment and disc extrusion from L2 posteriorly, c/w her
left thigh pain. She went to the OR with Dr. ___ on ___
for a lumbar laminectomy and fusion at L2-3. The previous
instrumentation l3-5 was removed and revised. She tolerated this
procedure well. Her radicular pain resolved after surgery. Her
wound was healing well with no signs of infection at time of
discharge.
# HTN: Her BP was initially elevated to 170s/80s, thought to be
secondary to pain. However, her BP remained elevated to
140s-160s/70s-80s even after adequate pain control. Her home
lisinopril was increased from 30mg to 40mg QD. A plan was made
to leave consideration of additional antihypertensive agents to
outpatient follow-up with her PCP.
# DM: Her home januvia as it was nonformulary. She was
well-controlled on a Humalog sliding scale
# s/p CVA: She had no residual deficits noted on neuro exam. Her
home atorvastatin was continued. Her plavix was held for the OR
with plans to restart post-op at the discretion of the surgery
team. This was to be started on transfer to ___.
Transitional issues
-Code status: full
-Medication changes:
-Pending studies:
-Follow-up with PCP for adjustment of antihypertensive regimen.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath,
wheezing
3. Atorvastatin 20 mg PO DAILY
4. Pulmicort Flexhaler *NF* (budesonide) 180 mcg/actuation
Inhalation BID
5. Clopidogrel 75 mg PO DAILY
6. Lisinopril 30 mg PO DAILY
7. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
8. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath, wheezing
2. Atorvastatin 20 mg PO DAILY
3. Lisinopril 30 mg PO DAILY
4. Vitamin D 5000 UNIT PO DAILY
5. Omeprazole 40 mg PO DAILY
RX *Prilosec 40 mg 1 capsule(s) by mouth once a day Disp #*40
Tablet Refills:*0
6. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
hold for sedation or RR<10
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*100 Tablet Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath,
wheezing
8. Clopidogrel 75 mg PO DAILY
9. Januvia *NF* (sitaGLIPtin) 100 mg Oral daily
10. Pulmicort Flexhaler *NF* (budesonide) 180 mcg/actuation
Inhalation BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L2-3 disc herniation /spondylosis
Discharge Condition:
Awake and alert/ ambulating with walker
Discharge Instructions:
Keep incisions clean and dry/ ambulate as tolerated
Physical Therapy:
Ambulate as tolerated/ corset for comfort only
Treatments Frequency:
Keep incision and dry/ ambulate as tolerated
Followup Instructions:
___
|
19757198-DS-27
| 19,757,198 | 22,941,828 |
DS
| 27 |
2194-10-02 00:00:00
|
2194-10-02 09:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Erythromycin Base / Penicillins / Aspirin / Levaquin / Metformin
/ citrus / doxycycline / Bactrim / tramadol / ibuprofen /
escitalopram / Plavix / pravastatin
Attending: ___
Chief Complaint:
left face tingling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an ___ year old right-handed woman who
presents with two weeks of left face tingling and numbness and
one day of left leg (and possibly left arm) numbness. Her
clinical history is very confusing; the patient reports that she
is a poor historian and "I don't have to remember that" (i.e.
information about her medical issues), "I put it out of my mind
so I don't worry so much about it." The history is partly aided
by her daughter who arrived at the bedside halfway through the
interview. They both describe (after some discussion) that she
has had left face numbness and tingling "like Novocaine wearing
off" beginning either two or three weeks ago. She first noticed
this affecting her tongue and the left side of her mouth, and
she
thought it might be an "allergic reaction" to Ibuprofen which
she
takes for bilateral hand pain. Over days it seems to have spread
to the left side of her face on the outside (all three
trigeminal
divisions); she did not think it affected the back of her head,
neck, shoulder, or upper arm. She has baseline, severe and
constant "tingling" and pain in both hands which she attributes
to "carpal tunnel syndrome." These symptoms waxed and waned
until
yesterday when she developed the same sensation in her left leg.
She claims this is just below the knee and circumferential
around
the foot (top and bottom, lateral and medial). With the leg
numbness yesterday, she started developing more instability of
gait: she has been tripping and stumbling (without any injury);
she walks with a walker at baseline, but this has been more
difficulty. She denies weakness, dizziness, vertigo, or other
neurologic symptoms. She is not on any antiplatelet therapy
because of a long "allergy" list described below. Previously,
she
has hematochezia while taking aspirin and ibuprofen (q4h for her
pain); she had nausea with clopidogrel. Her daughter describes
that she has a long history of "atypical allergies" to various
medications.
Past Medical History:
Hypertension
Hyperlipidemia
COPD
Obesity
Osteoarthritis
Sciatica
Lumbar spinal stenosis s/p total laminectomy L2-L5 and fusion
___
s/p left total shoulder arthroplasty ___
s/p right carpal tunnel release ___
s/p TAH/BSO
BPV previously seen by Dr. ___ position dependent irregular tremors of the
proximal
left leg previously seen by Dr. ___ vaginitis
___
Right sided breast mass
Kidney Stones
Right abdominal lipoma
Social History:
___
Family History:
No family history of stroke.
mother - colon cancer
father - unknown
Physical ___:
VS T: not measured HR: 85 BP: ___ RR: ___ SaO2:
94-100% RA
General: NAD, lying in bed comfortably, well-appearing elderly
woman. / Head: NC/AT, no conjunctival icterus, no oropharyngeal
lesions / Neck: Supple, no nuchal rigidity, no meningismus, no
carotid/subclavian/vertebral bruits / Cardiovascular: RRR, no
M/R/G / Pulmonary: Equal air entry bilaterally, no crackles or
wheezes / Abdomen: Soft, NT, obese, no guarding / Extremities:
Warm, no edema, palpable radial/dorsalis pedis pulses / Skin:
Right eyelid vitiligo, otherwise no apparent rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented x name, place, month.
Attention to examiner easily attained and maintain, but she is
very circumferential in her history. Concentration maintained
when recalling months forwards and backwards. Poor historian.
Structure of speech demonstrates fluency with full sentences,
intact repetition, and intact verbal comprehension. Content of
speech demonstrates intact naming (high and low frequency) and
no
paraphasias. Normal prosody. No dysarthria. No evidence of
hemineglect. No left-right agnosia.
- Cranial Nerves - [II] PERRL 4->2 brisk. VF full to number
counting. [III, IV, VI] EOMI, no nystagmus. [V] Decreased pin
and
light touch on the left face (V1-V3) compared to the right,
detailed more under the sensory exam below. [VII] Left
nasolabial
fold flattening, and decreased lower face movement with
volitional smile. [VIII] Hearing intact to finger rub
bilaterally. [IX, X] Palate elevation symmetric. [XI]
SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline.
- Motor - Decreased bulk of the thenar eminences, EDBs. No
pronation, no drift. No tremor or asterixis.
[ Direct Confrontational Strength Testing ]
Arm
Deltoids [C5] [R 5-] [L 5-]
Biceps [C5] [R 5-] [L 4+]
Triceps [C6/7] [R 5] [L 5]
Extensor Carpi Radialis [C6] [R 5] [L 5]
Extensor Digitorum [C7] [R 5] [L 5]
Flexor Digitorum [C8] [R 5] [L *severely pain limited]
Interosseus [C8] [R 4+] [L 4+]
Abductor Digiti Minimi [C8] [R 4+] [L 4+]
Abductor Pollicis Brevis [C8] [R 4] [L 4]
Leg
Iliopsoas [L1/2] [R 5-] [L 5-]
Hip Adductors [L3] [R 5] [L 5]
Hip Abductors [S1] [R 5] [L 5]
Quadriceps [L3/4] [R 5] [L 5]
Hamstrings [L5/S1] [R 4+] [L 4+]
Tibialis Anterior [L4] [R 5] [L 5]
Gastrocnemius [S1] [R 5] [L 5]
Extensor Hallucis Longus [L5] [R 5-] [L 5-]
Extensor Digitorum Brevis [L5] [R 5-] [L 5-]
Flexor Digitorum Brevis [S1] [R 5] [L 5]
- Sensory - Markedly decreased pin sensation on the left face
(all three trigeminal divisions) not splitting the midline
(beginning ___ centimeters toward the left from midline), head
(posterior), neck, chest/back), arm and leg: decreased to 50%
compared to the right except the leg which is even more numb and
feels like "wood." The sensory loss is circumferential and not
in
a radicular or peripheral nerve pattern. Currently, she does not
endorse a length-dependent pin sensory gradient. Similar
distribution of sensory loss to light touch. Left leg severe
proprioceptive loss, ___ correct, whereas right leg
proprioception intact ___ correct).
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 1 1 1 1 0
R 1 1 1 1 0
Plantar response mute bilaterally.
- Coordination - No dysmetria with finger to nose or heel-shin
testing. Good speed and intact cadence with rapid alternating
movements.
- Gait - Normal initiation. Narrow base. Short stride length.
Moderately unstable. Positive Romberg.
Exam on discharge:
Unchanged except improved sensation (to all modalities) on the
left hemibody
Pertinent Results:
___ 10:30AM ___ PTT-30.4 ___
___ 10:30AM PLT COUNT-304
___ 10:30AM NEUTS-60.9 ___ MONOS-6.4 EOS-1.3
BASOS-0.6
___ 10:30AM WBC-11.3* RBC-4.57 HGB-14.5 HCT-43.2 MCV-95
MCH-31.8 MCHC-33.6 RDW-13.7
___ 10:30AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 10:30AM ALBUMIN-4.4
___ 10:30AM cTropnT-<0.01
___ 10:30AM ALT(SGPT)-18 AST(SGOT)-42* ALK PHOS-127* TOT
BILI-0.4
___ 10:30AM estGFR-Using this
___ 10:30AM GLUCOSE-210* UREA N-18 CREAT-0.7 SODIUM-137
POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-22 ANION GAP-20
___ 11:40AM K+-3.9
___ 11:40AM COMMENTS-GREEN TOP
ECHO
The left atrium is mildly dilated. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). 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 appears structurally normal with
mild [1+] mitral regurgitation. There is no mitral valve
prolapse. The estimated pulmonary artery systolic pressure is
top normal. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mild mitral
regurgitation with normal valve morphology. Increased PCPW. No
definite structural cardiac source of embolism identified.
Compared with the prior study (images reviewed) of ___, a
mid-cavitary gradient is no longer identified and the left
ventricular systolic function is less dynamic. The other
findings are similar.
MRI brain
IMPRESSION:
Acute right thalamic infarct. No intracranial hemorrhage.
Mild narrowing of both proximal internal carotid arteries.
Small aneurysm of the cavernous right internal carotid artery.
White matter signal abnormalities are most likely the sequela of
chronic small vessel ischemic disease.
Brief Hospital Course:
Mrs. ___ was admitted to the Stroke service and underwent MRI
of her brain which demonstrated new infarct in the right
thalamus. This was thought to be at the origin of her new
sensory deficits.
She was found to have an elevation in several stroke risk
factors including increased LDL, elevated A1c. She had been on
aspirin briefly in the past but this was stopped because of a GI
bleed (unspecified blood loss, patient does not remember the
event)
She was restarted on aspirin 81mg, started on rosuvastatin and
placed on insulin sliding scale. Her blood pressure was allowed
to autoregulate after the first 24hrs given her stroke. She was
then restarted on some of her blood pressure lowering
medications.
Given her chronic significant bilateral arthritic hand pain (for
which she takes ibuprofen at home), she was restarted on a
restricted doses (BID instead of QID) given the risk for aspirin
-induced bleeding and GI mucosal damage and instructed to avoid
taking the medications with empty stomach.
ECHO did not reveal thrombosis or source of embolic stroke.
She was evaluated by ___ who recommended rehabilitation.
TRANSITIONAL ISSUES
- crestor was started for HLD. Please recheck LDL in 3 months
and adjust statin as needed, goal LDL < 100
- please continue ISS for diabetes. Consider discharging the
patient on insulin at home (would need teaching) vs. oral
diabetic agents
- please monitor blood pressure and adjust medications as
needed. Goal SBP 100-140
- continue ASA 81 for stroke prevention
- minimize use of NSAIDS to avoid GI bleeding
- follow up with Neurology Dr. ___ in 1 month (scheduled)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 15 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Ibuprofen 200 mg PO BID:PRN pain
4. Omeprazole 20 mg PO DAILY
5. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
3. Glucose Gel 15 g PO PRN hypoglycemia protocol
4. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
5. Aspirin 81 mg PO DAILY
6. Acetaminophen 325-650 mg PO Q6H:PRN pain
7. Rosuvastatin Calcium 5 mg PO DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Ibuprofen 200 mg PO BID:PRN pain
10. Lisinopril 15 mg PO DAILY
11. Vitamin D 800 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis
1. ischemic stroke
Secondary diagnosis
1. hypertension
2. diabetes
3. hyperlipidemia
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 caring for you at ___
___. You were admitted for L sided tingling and
numbness, and you were found to have a R thalamic stroke. You
were started on aspirin to reduce your risk of a future stroke.
It is important not to take too much ibuprofen with the aspirin
to prevent GI bleeding.
Your stroke was due to vascular risk factors including diabetes,
hypertension, and hyperlipidemia. It is important to control
these risk factors in order to prevent future stroke.
It is important to take all medications as prescribed, and keep
all follow up appointments.
Followup Instructions:
___
|
19757268-DS-11
| 19,757,268 | 23,226,336 |
DS
| 11 |
2143-04-11 00:00:00
|
2143-04-12 15:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
Confusion, rigors
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with hx. cirrhosis ?___ NASH, ___ s/p TACE
___ (segment VII lesion) and RFA ___ (segment III
lesion), diabetes presenting with malaise, dizziness, confusion,
fatigue. Started yesterday. Endorses dark urine, chills, rigors,
abdominal distention, nausea, vomiting. Denies fevers, cough,
CP, dyspnea, dysuria. Tolerating POs until yesterday when he did
not have an appetite. Taking his lactulose as scheduled.
Of note, he had a recent UTI ___ with similar symptoms. At
that time cultures grew out enterococcus and enterobacter.
In the ED, Initial vitals were 97.6 60 129/64 14 99% RA. Labs
were significant for WBC of 4.4, Hgb 12.9, platelets 46, Inr
1.4, PT15.4, PTT 24.8, Lactate 1.8. US showed no The main and
rightanterior portal veins have reversed flow. He was given
ceftriaxone and lactulose x2.
Past Medical History:
#CIRRHOSIS:
-Dx ___ ___ during workup for thrombocytopenia
-Etiology ?___
-EGD ___ with grade I esophageal varices, reports history
of hepatic encephalpathy ___ while in ___, never had
paracentesis
-HBV immune (___)
-HAV immune
-HCV negative
-normal ceruloplasmin, ferritin, autoimmune hep serologies
#HCC:
-___ MRI ___: two hepatic lesions concerning for hepatoma
-TACE ___ (segment VII lesion 3.2cm)
-RFA ___ (segment III lesion 2.2cm)
#DIABETES TYPE 2
#HERNIA - UMBILICAL
#THROMBOCYTOPENIA, UNSPEC
#HX OF LYME DISEASE
#NEUROPATHY - GENERALIZED
#HYPERTENSION - ESSENTIAL, UNSPEC
#HEMATURIA
#OBESITY
#VITILIGO
Social History:
___
Family History:
Denies family history of Liver Disease
Physical Exam:
ADMISSION:
VS: 98.1 129/68 66 18 100% RA
General: NAD pleasant male resting in bed
HEENT: mild scleral icterus, clear oropharynx, EOMI
CV: RRR, no m/r/g
Lungs: CTA b/l, no w/r/r
Abdomen: distended, soft (+) BS. nontender
GU: no foley
Ext: trace pitting edema
Neuro: (+) asterixis, AAOx2(name, ___
Skin: vitiligo of face
.
DISCHARGE:VS: 98.1 118/66 68 18 100% RA
General: NAD
HEENT: slight scleral icterus, EOMI, PERRL, Oral mucosa moist,
clear oropharynx,
CV: S1 and S2, RRR, no m/r/g
Lungs: CTAB
Abdomen: distended, Soft, nontender, presence of Bowel sounds
GU: no foley
Ext: No edema.
Neuro: asterixis positive , AAOx3, and able to have conversation
about ___ soccer in detail
Skin: vitiligo on face
Pertinent Results:
ADMISSION LABS:
___ 01:42PM BLOOD WBC-4.4 RBC-3.51* Hgb-12.9* Hct-38.1*
MCV-109* MCH-36.8* MCHC-33.9 RDW-14.2 Plt Ct-46*
___ 01:42PM BLOOD Neuts-75.0* ___ Monos-4.1 Eos-2.4
Baso-0.3
___ 01:08PM BLOOD ___ PTT-24.8* ___
___ 12:30PM BLOOD Glucose-150* UreaN-16 Creat-0.9 Na-136
K-8.1* Cl-107 HCO3-22 AnGap-15
___ 12:30PM BLOOD ALT-36 AST-145* AlkPhos-207* TotBili-4.6*
___ 12:30PM BLOOD Albumin-3.1*
___ 05:42AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.7
___ 12:35PM BLOOD Lactate-1.8 K-4.7
.
DISCHARGE LABS:
___ 05:41AM BLOOD WBC-3.2* RBC-3.21* Hgb-11.5* Hct-34.7*
MCV-108* MCH-35.7* MCHC-33.0 RDW-14.4 Plt Ct-46*
___ 05:41AM BLOOD ___ PTT-40.7* ___
___ 05:41AM BLOOD Glucose-141* UreaN-16 Creat-0.7 Na-140
K-3.7 Cl-111* HCO3-20* AnGap-13
___ 05:41AM BLOOD ALT-31 AST-82* AlkPhos-193* TotBili-5.5*
___ 05:41AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.5*
.
REPORTS:
- LIVER U/S ___ IMPRESSION:
1. Limited Doppler evaluation of the portal veins. The main and
right
anterior portal veins are patent with reversed flow. The left
portal vein is not well assessed.
2. Limited evaluation of cirrhotic liver, which was better
assessed on prior MRI.
3. Splenomegaly.
.
- CXR ___ IMPRESSION: Low lung volumes with bibasilar
opacities most compatible with atelectasis.
.
MICRO:
- Urine cx: negative
.
- Blood cx x2: NGTD
Brief Hospital Course:
___ M w/ ___ cirrhosis c/b HCC s/p TACE ___ (segment VII
lesion) and RFA ___ (segment III lesion) currently not
transplant candidate here due to outside ___ criteria, DM,
who presented with malaise, dizziness, confusion, fatigue found
to have grade 1 hepatic encephalopathy and a UTI in the setting
of inadequate lactulose intake (only 2 BMs daily).
.
# HEPATIC ENCEPHALOPATHY: Patient has history of hepatic
encephalopathy in the past presenting now with Grade 1 HE which
is resolving with treatment. Though patient endorses compliance
with lactulose, 2BM a day is most likely not enough. Likely
precipitated in setting of UTI. Mental status quickly improved
w/ lactulose and ceftriaxone for UTI. Strongly encouraged
patient to have 3 BMs daily, and wife in agreement with
monitoring him to ensure uptitration of lactulose. Started
Rifaximin.
.
# UTI- Patient presents with rigors, malaise found to have dirty
UA. Recent UTI in ___ with enterococcus and enterobacter.
Ceftriaxone transitioned to po Cipro 500mg BID x4 days as
outpatient to complete 7 day course.
.
# DM type II: Unclear level of control, no HgbA1c in our
records. Discharged back on home oral meds. No insulin.
.
# VARICES: patient has history of grade I varices on last EGD
___. Continue home nadolol.
.
# ASCITES: Patient complained of distention, but ultrasound in
ED, showed no clear pocket for paracentesis. Continue home lasix
and spironolactone.
.
# CIRRHOSIS: Cirrhosis ___ NASH w/ history of ___ s/p TACE and
RFA.
-- MELD score of 16
-- TBili 5.5 / Cr 0.7 / INR 1.8
.
# COAGULOPATHY: Patient has history of thrombocytopenia with
platelets on admission of 46. PTT is 24.8, INR is 1.4
.
#CODE: Full (confirmed)
#CONTACT: ___- wife Cell ___ home #
___
#DISPO: discharged home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Spironolactone 50 mg PO DAILY
3. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
4. Acarbose 25 mg PO TID
5. GlipiZIDE XL 2.5 mg PO DAILY
6. Nadolol 20 mg PO DAILY
7. Lactulose 15 mL PO TID
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Lactulose 15 mL PO TID
3. Nadolol 20 mg PO DAILY
4. Spironolactone 50 mg PO DAILY
5. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
6. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth Twice a day
Disp #*60 Tablet Refills:*2
7. Acarbose 25 mg PO TID
8. GlipiZIDE XL 2.5 mg PO DAILY
9. Ciprofloxacin HCl 500 mg PO Q12H
Take 1 tablet every 12 hours or twice a day for 4 days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth Twice a day Disp
#*8 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic encephalopathy
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___, you were admitted due to confusion caused by most
likely a Urinary tract infection or not enough lactulose intake.
Please take enough lactulose to ensure you are having 3 or more
bowel movements a day. You should follow up with your PCP and
the ___ doctor in the next ___ weeks.
Followup Instructions:
___
|
19757554-DS-11
| 19,757,554 | 26,771,325 |
DS
| 11 |
2140-03-08 00:00:00
|
2140-03-11 19:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / cefepime
Attending: ___
Chief Complaint:
HTN/dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ only female with a past medical
history CAD (s/p LAD stenting ___, s/p
inferolateral STEMI ___, s/p primary LCx PCI (DES) on ___,
CHF (EF 40-45% ___, hyperlipidemia, hypertension, mitral
regurg, peripheral vascular disease status post femoral to
popliteal bypass, carotid stenosis status post carotid
endarterectomy presents to ED with DOE.
The patient is a somewhat poor historian, and currently states
that she is in the hospital for her leg wound, and does not feel
short of breath. She states that she is not on oxygen at home,
and is unsure why she needs it currently. Per ED records,
patient was initially complaining of worsening DOE. She has
recently been treated for a surgical site infection on her RLE
with vancomycin and ciprofloxacin, and has a PICC line in place.
Per records, she is currently in rehab, and has been noted to
have orthopnea, tachypnea, and was noted to be speaking in ___
word sentneces. Also with worsening bilateral lower ext edema.
Patient denies chest pain, SOB, fevers/chills.
In the ED initial vitals were: 97.9 70 196/75 16 91% RA
EKG: NSR rate of 64, normal intervals, LVH, slight STD in I,
and STE in V2, and TWI V4, V5
Labs/studies notable for: H/H ___, K 3.2, Cr 0.8, Mg 1.7,
normal coags, Trop<0.01, proBNP ___, UA normal
CXR: Mild to moderate pulmonary edema, small bilateral pleural
effusions, and persistent enlargement of the cardiac silhouette.
RLE US: -No evidence of deep venous thrombosis in the right
lower extremity veins, with the exception of the peroneal veins
which are not well seen.-Persistent common femoral graft 3.0 cm
fusiform aneurysm/pseudoaneurysm.
Vascular consulted, and felt that the wound appeared to be
stable. Recommending admitted as needed for SOB.
Patient was given Vanco at 750mg IV
Vitals on transfer: 97.9, 78, 180/75, 20, 100% Nasal Cannula
On the floor patient states that her leg feels much better,
denies SOB.
Past Medical History:
. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY: occluded RCA and s/p DES to LAD
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD ___
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
peripheral vascular disease s/p right fem-pop bypass ___
s/p L CEA ___
arthritis
bladder incontinence--? overflow incontinence
Social History:
___
Family History:
NC
Physical Exam:
ADMISSION EXAM:
VS: T97.7, HR 67, BP 183/92, RR 22, O2 97% 4L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple, unable to appreciate JVP due to body habitus
CARDIAC: RR, 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. Bibasilar crackles
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness.
EXTREMITIES: Edema past knees bilaterally. R leg wound dressed
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE EXAM:
PHYSICAL EXAM:
VITALS: 98.6PO 133 / 76 76 20 92 RA
I/O: ___ (net ~1100 positive)
GENERAL: Awake in bed
HEENT: NCAT. Sclera anicteric.
NECK: Supple, unable to appreciate JVP due to body habitus
CARDIAC: RR, distant heart sounds, 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. Clear to auscultation
bilaterally
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness.
EXTREMITIES: No ___ edema. R leg wound dressed (underneath, well
healing, no open surface)
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABs:
___ 05:24PM BLOOD WBC-7.4 RBC-3.77* Hgb-10.3* Hct-33.5*
MCV-89 MCH-27.3 MCHC-30.7* RDW-15.1 RDWSD-49.1* Plt ___
___ 05:24PM BLOOD Neuts-67.9 Lymphs-17.9* Monos-9.2 Eos-4.3
Baso-0.4 Im ___ AbsNeut-5.03 AbsLymp-1.33 AbsMono-0.68
AbsEos-0.32 AbsBaso-0.03
___ 05:24PM BLOOD ___ PTT-30.9 ___
___ 05:24PM BLOOD Glucose-89 UreaN-14 Creat-0.8 Na-140
K-3.2* Cl-96 HCO3-31 AnGap-16
___ 05:24PM BLOOD ___ 05:24PM BLOOD cTropnT-<0.01
___ 10:40AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:24PM BLOOD Calcium-8.4 Phos-4.5 Mg-1.7
___ 06:35AM BLOOD Vanco-16.4
___ 05:24PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:24PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:24PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE Epi-1
MICROBIOLOGY:
___ URINE CULTURE (Final ___: NO GROWTH.
PERTINENT RESULTS: ___ 11:00AM URINE RBC-6* WBC-15*
Bacteri-FEW Yeast-NONE Epi-1 TransE-<1
___ 11:00AM URINE Hours-RANDOM UreaN-673 Creat-123 Na-<20
___ 05:30AM BLOOD Vanco-24.8*
___ 02:20PM BLOOD D-Dimer-3921*
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-6.2 RBC-3.42* Hgb-9.5* Hct-30.0*
MCV-88 MCH-27.8 MCHC-31.7* RDW-14.9 RDWSD-48.1* Plt ___
___ 06:30AM BLOOD Glucose-91 UreaN-41* Creat-1.9* Na-137
K-4.3 Cl-96 HCO3-31 AnGap-14
___ 06:30AM BLOOD Calcium-8.8 Phos-4.9* Mg-2.2
___ 06:30AM BLOOD Vanco-20.1*
STUDIES:
___ CXR: Mild to moderate pulmonary edema, small bilateral
pleural effusions, and persistent enlargement of the cardiac
silhouette.
___ R ___:
1. No evidence of deep venous thrombosis in the right lower
extremity veins. Right peroneal veins poorly visualized.
2. Unchanged 3 cm pseudoaneurysm arising from the proximal
bypass graft in the right groin.
___ RENAL ULTRASOUND: 1. Prominence of renal pelvis, which
may indicate chronic medical renal disease, otherwise normal
renal ultrasound.
2. Simple cysts in the left and right kidneys, as described
above.
___ TTE:
Conclusions
The left atrial volume index is severely increased. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thicknesses and cavity size are normal. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis/akinesis of the basal to mid inferior and
inferolateral walls. The anterolateral wall is hypokinetic. The
remaining segments contract normally (LVEF = 40-45 %). The
estimated cardiac index is borderline low (2.0-2.5L/min/m2).
Doppler parameters are most consistent with Grade I (mild) left
ventricular diastolic dysfunction. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity size with mild regional
left ventricular systolic dysfunction c/w CAD (RCA/LCx
distribution). Mild pulmonary artery systolic hypertension.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ ___ only female
with a past medical history CAD (s/p LAD stenting ___, s/p
inferolateral STEMI ___, s/p primary LCx PCI (DES) on ___,
CHF (EF 35% ___, hyperlipidemia, hypertension, mitral regurg,
peripheral vascular disease status post femoral to popliteal
bypass, carotid stenosis status post carotid endarterectomy
presented to ED with HTN, hypoxia, and dyspnea on exertion
initially concerning for hypertensive urgency, decompensated
heart failure and possible worsening CAD/stent occlusion. She
was diuresed with IV Lasix with good effect in terms of her
dyspnea and hypoxia. Medications were also adjusted for better
BP control. EKG had changes from prior, however, troponins were
negative x2 and TTE revealed no significant changes compared to
prior in ___. She also had an acute kidney injury, likely from
combination of over-diuresis and too rapid lowering of her blood
pressure.
#Dyspnea on exertion/hypoxia: Likely multifactorial from
pulmonary edema, decompensated heart failure, as well as
deconditioning. Hypoxia resolved with diuresis. Dyspnea back to
baseline. Initially also suspected that dyspnea may be angina
equivalent given EKG changes, however, TTE revealed no
significant changes compared to ___. PE was also on the
differential, however, RLE Doppler was negative for PE and EKG
had no signs of right heart strain.
#Acute on chronic systolic heart failure: Pt presented with
hypoxia, elevated BNP, pleural effusion & pulmonary edema.
Etiology includes hypertensive urgency vs dietary
non-compliance. Last EF 35% in ___. Repeat TTE on admission
revealed EF 45% and no new wall motion abnormalities. She
received 20 mg IV Lasix x2 with good effect (likely
over-diuresed given ___. Lasix held on discharge due to ___.
#CAD: s/p LAD stenting ___, s/p inferolateral STEMI ___, s/p
primary LCx PCI (DES) on ___. EKG did have new biphasic T
waves on EKG compared to prior, however, patient denied chest
pain and troponins were negative x2. TTE revealed no new wall
motion abnormalities. In order to optimize her medically,
nitrates were added to medical regimen. Additionally, home
metoprolol was changed to carvedilol for added hypertension
control. She continued home ASA and atorvastatin.
#HTN: Patient was reportedly hypertensive to SBP 200s at rehab.
She initially continued valsartan, doxazosin. Home metoprolol
was changed to carvedilol for added hypertension control and
nitrates were added for both CAD/hypertension control. Valsartan
held on discharge given ___. New medication includes imdur 30 mg
qd.
#Acute kidney injury: Creatinine doubled on day 3 of admission.
Etiology suspected to be pre-renal from over-diuresis and too
rapid correction of her hypertension. Renal US revealed no
obstruction. Urine lytes were consistent with pre-renal
etiology. Creatinine plateaued at discharge.
___ Cellulitis: She continued vancomycin/cipro for ___ wound that
ID has been following as an outpatient. Vancomycin/cipro
adjusted given ___. Vancomycin held on discharge (see below for
details). Last day ABx ___.
# Hyperlipidemia
- continued Atorvastatin 40 mg PO QPM
# Depression
- continued home citalopram
# Hypothyroidism
- continued Levothyroxine Sodium 50 mcg PO DAILY
TRANSITIONAL ISSUES:
-Vancomycin held due to supratherapeutic levels ___ vanco 24,
___ vanco 20.1) and acute kidney injury. Please give 500 mg IV
on ___ and check level on ___. Re-dose vancomycin
accordingly
-Ciprofloxacin dosing changed based on ___. Re-dose based on Cr
on ___.
-Needs repeat creatinine on ___
-Last day ABx (vanco/cipro) ___
-Discharge weight 100.7 kg
# CODE: Full (confirmed)
# CONTACT:
Name of health care proxy: ___
Relationship: daughter
Phone number: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. albuterol sulfate 90 mcg/actuation inhalation TID:PRN
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Citalopram 20 mg PO DAILY
6. Cyanocobalamin 500 mcg PO DAILY
7. Doxazosin 2 mg PO HS
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Valsartan 320 mg PO DAILY
11. diclofenac sodium 1 % TOPICAL BID:PRN joint pain
12. Furosemide 20 mg PO DAILY
13. melatonin 3 mg oral QHS
14. TraZODone 12.5 mg PO QHS:PRN Insomnia
15. Vitamin D ___ UNIT PO DAILY
16. Docusate Sodium 100 mg PO BID
17. Levothyroxine Sodium 50 mcg PO DAILY
18. Senna 17.2 mg PO HS
19. Vancomycin 1000 mg IV Q 12H
20. Bisacodyl ___AILY
21. Ciprofloxacin HCl 500 mg PO Q12H
22. Milk of Magnesia 30 mL PO Q6H:PRN constipation
23. Nystatin Cream 1 Appl TP BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
Acute on chronic systolic heart failure
Hypertensive urgency
Acute kidney injury
Secondary
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___.
Why were you here:
-You had shortness of breath and high blood pressure
What was done:
-We changed your medications to lower your blood pressure and
take off some extra fluid
-You had some stress to your kidneys that was likely from the
medications/too much fluid was removed. Your kidneys have
stabilized and will likely improve.
What to do next:
-Take all your medications and follow-up with your doctors
-___ yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you all the best!
Your ___ team
Followup Instructions:
___
|
19757554-DS-12
| 19,757,554 | 28,236,217 |
DS
| 12 |
2140-06-28 00:00:00
|
2140-06-29 13:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / cefepime
Attending: ___.
Chief Complaint:
Dyspnea, weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of CAD (c/b STEMI s/p stent x2), HFrEF (EF
40-45%), PVD s/p femoral->AT graft c/b graft infection who
presents with cough, weakness and admitted due to altered mental
status.
Patient is coming in for confusion, cough, feeling ill. She
went to an urgent care yesterday and received a dx with
pneumonia based on clinical symptoms. She had a CXR that was
read as no infiltrate, but due to clinical suspicion for
pneumonia she was started on levofloxacin. Over past 24 hours
she reports feeling worse and increasingly confused per family.
In the ED, she was interviewed with an in person ___
interpreter and her daughter at bedside. Both felt she did not
make sense and seemed confused.
-Her initial VS were T 97.7, HR 66, BP 128/61, RR 18, SaO2: 100%
on NC.
-Exam notable for crackles and expiratory wheezes at right base.
-Labs showed a WBC count of 4.0, Na 132, BUN 34, and Cr 1.3.
FluA and FluB were negative. Lactate was 1.4.
-Imaging showed mild cardiomegaly, no edema or pneumonia.
Received 750 levofloxacin 750mg.
-Transfer VS were T: 98.2, HR 68, BP: 106/76, RR 18, 98% RA.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports that she generally
feels well. She has been having some mild SOB that she
describes as generalized shortness of breath that is worse on
exertion. She also describe mild weakness. She says that she
has had SOB for several years, but she does have a newly
developed cough that has been present for a week and is
sometimes productive of sputum. She says that her memory has
been worse over the past several years and she can easily forget
things. She denies pleuritic chest pain, pain with deep
breathing, fever, swollen painful lymph nodes, sore throat,
nasal discharge, dysphagia or odynophagia.
Past Medical History:
- PVD s/p R profunda femoris --> AT in situ vein bypass graft
(___)
- Graft c/b pseudoaneurysm with Viabahn stent graft placement
___ infected hematoma ___, s/p I&D and woundVAC placement
and subsequent wound infection with MRSA and ?CoNS. On lifelong
Bactrim suppression.
- CAD s/p STEMI and stents placed in ___ and ___
- HFrEF (EF 40-45%) in ___
- HLD
- HTN
- Vitamin D deficiency
- Vit B12 deficiency
- Urinary incontinence
- Hypothyroidism
- Depression
- Diabetes mellitus
- S/p fall in ___ w/ left forehead hematoma
- Suspected meningioma
- bladder incontinence
PAST SURGICAL HISTORY:
- angio RLE w/ placement of 2 Viabahn stents within the vein
bypass graft of the right lower extremity. I&D of right medial
knee hematoma with subsequent wound infection ___ Dr.
___
- Left CEA ___ ___
- Umbilical Hernia repair approximately ___ years ago
- RT CARPAL TUNNEL SURGERY ___
- CAD s/p DES->LAD ___
- Left knee surgery
Social History:
___
Family History:
Mother has history of breast cancer and uterine cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: T: 97.6, 164-177/70-74 HR: 59-65 RR: 16 SaO2: 96%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, dentures, resolving left forehead hematoma
NECK: nonten___ supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, diffuse end expiratory wheezes that are best heard
at the lung bases and anteriorly, no rales, rhonchi, not using
accessory muscles
ABDOMEN: protuberant abdomen, small midline scar with dense
tissue at the site of a prior hernia repair, nondistended, +BS,
nontender in all quadrants, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: long vertical scar on right leg from previous
venous bypass graft, no cyanosis, clubbing or edema
PULSES: 1+ DP pulses bilaterally and 2+ radial pulses
bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
======================
VS: Tm: 98.0, Tc: 97.6, 148/77 HR: 61 RR: 18 SaO2: 93%RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, dentures, resolving left forehead hematoma
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, diffuse end expiratory wheezes, no rales, rhonchi,
not using accessory muscles
ABDOMEN: protuberant abdomen, small midline scar with dense
tissue at the site of a prior hernia repair, nondistended, +BS,
nontender in all quadrants, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: long vertical scar on right leg from previous
venous bypass graft, no cyanosis, clubbing or edema
PULSES: 1+ DP pulses bilaterally and 2+ radial pulses
bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LAB RESULTS
===================
___ 03:53PM BLOOD WBC-4.0 RBC-3.12* Hgb-8.9* Hct-27.9*
MCV-89 MCH-28.5 MCHC-31.9* RDW-16.0* RDWSD-52.8* Plt ___
___ 03:53PM BLOOD Neuts-48.6 ___ Monos-9.3 Eos-1.8
Baso-0.3 Im ___ AbsNeut-1.95# AbsLymp-1.58 AbsMono-0.37
AbsEos-0.07 AbsBaso-0.01
___ 11:56AM BLOOD Glucose-118* UreaN-34* Creat-1.3* Na-132*
K-4.7 Cl-97 HCO3-22 AnGap-18
___ 07:55AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1
___ 12:25PM BLOOD Lactate-1.4
DISCHARGE LAB RESULTS
====================
___ 07:55AM BLOOD WBC-3.5* RBC-3.20* Hgb-9.1* Hct-28.6*
MCV-89 MCH-28.4 MCHC-31.8* RDW-15.9* RDWSD-52.8* Plt ___
___ 07:55AM BLOOD Glucose-99 UreaN-27* Creat-1.1 Na-131*
K-5.0 Cl-97 HCO3-23 AnGap-16
___ 07:55AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.1
IMAGING/STUIDES
==============
___ CXR:
Mild cardiomegaly, no edema or pneumonia.
MICROBIOLOGY
============
___ Urine Culture: negative
___ Blood Culture: pending at time of discharge
Brief Hospital Course:
___ history of CAD (c/b STEMI s/p stent x2), HFrEF (EF 40-45%),
PVD s/p femoral->AT graft c/b graft infection who presented with
altered mental status.
# Cough
# Shortness of Breath
# Myalgias
Patient reports approximately one week of a newly productive
cough that has been stable, and dyspnea that has been present
for year. Patient denies any signs of systemic illness
including pleuritic chest pain, sore throat, or fever. Physical
exam was only notable for end expiratory wheezes and patient is
afebrile. The day before admission she had been seen in urgent
care and prescribed levofloxacin. In the ED she was felt to be
confused and off her baseline and was therefore admitted.
Patient was not felt to have a pneumonia given normal white
count with no left shift, clear CXR, and no fevers. Levofloxacin
was discontinued. Patient's altered mental status was felt to be
delirium secondary to levofloxacin with possible poor substrate
due to baseline dementia. Her altered mental status quickly
resolved to baseline after admission to floor. Also given
bisacodyl for constipation and duonebs for mild wheezing.
# Altered Mental Status
Collateral from in person ___ interpreter and family members
suggests that the patient was altered from baseline in the ED.
Chart review suggests that PCP was concerned for vascular vs
Alzheimer's dementia and had planned to refer for cognitive
testing. In addition she has a history of a fall with head
strike in ___ with forehead hematoma and 8mm lesion
suggestive of meningioma. Current neurologic exam is reassuring,
nonfocal and only notable for only decreased delayed recall that
was likely effort related. Given the reassuring exam this is
possible to be delirium (with levofloxacin being the likely
trigger) with a waxing and waning course, related to her her
meningioma, or possibly a TIA given improvement upon arriving to
the floor.
# Lower extremity graft and pseudoaneruysm: h/o severe graft
infection with MRSA and CoNs. Followed by ID here at ___ in
clinic. On lifelong suppressive therapy with Bactrim.
# HLD: Continued Atorvastatin 40mg.
# HTN: Continued Carvedilol 6.25mg BID, Continued Isosorbide
Mononitrate 30mg PO Daily, Continued Valsartan 160mg PO daily.
# HFrEF: Echo from ___ shows EF of 40-45%. Continued
Furosemide 20mg, valsartan, carvedilol.
# Incontinence: Continue Doxazosin 2mg.
# Depression: Continued citalopram 20mg.
# Hypothyroidism: Continued levothyroxine 50mcg.
# CAD: Continued ASA 81mg.
# Vitamin Deficiency. Continued cyanocobalamin 500mcg PO Daily
and Vitamin D ___ units daily.
TRANSITIONAL ISSUES
==================
- Levofloxacin discontinued
- Patient discharged with albuterol inhaler due to wheezing on
exam
- Discharged with bisacodyl suppositories PRN for constipation
- Patient with ___ distant recall on memory testing. Per PCP
notes, cognitive testing has been discussed in the past for
possibility of dementia. Please continue to discuss this with
patient.
# Code status: Full
# Contact: ___ (daughter) Phone: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 40 mg PO QPM
2. Carvedilol 6.25 mg PO BID
3. Citalopram 20 mg PO DAILY
4. Doxazosin 2 mg PO HS
5. Furosemide 20 mg PO DAILY
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Sulfameth/Trimethoprim DS 1 TAB PO BID
10. Valsartan 160 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Cyanocobalamin 500 mcg PO DAILY
15. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 1 puff INH q6h:prn
Disp #*1 Inhaler Refills:*0
2. Bisacodyl 10 mg PR QHS:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*6
Suppository Refills:*0
3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Carvedilol 6.25 mg PO BID
7. Citalopram 20 mg PO DAILY
8. Cyanocobalamin 500 mcg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Doxazosin 2 mg PO HS
11. Furosemide 20 mg PO DAILY
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Levothyroxine Sodium 50 mcg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Sulfameth/Trimethoprim DS 1 TAB PO BID
16. Valsartan 160 mg PO DAILY
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Delirium
SECONDARY DIAGNOSIS:
Coronary artery disease
Systolic heart failure
Peripheral vascular disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you seemed confused. We
thought this was most likely due to Levaquin, the antibiotic you
were given at urgent care. We stopped this and you improved. We
reviewed your chest X-ray and blood tests and we do not think
you have a pneumonia. You should stop taking levofloxacin.
Please take note of the following:
- Please continue taking all your other medications as you
regularly do
- Please follow up with your primary care doctor as below
- ___ gave you an albuterol inhaler, please use if short of
breath and wheezing
- We discharged you with bisacodyl suppositories to be used if
you continue to be constipated
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
We wish you all the best!
- Your ___ care team
Followup Instructions:
___
|
19757554-DS-13
| 19,757,554 | 21,026,054 |
DS
| 13 |
2140-07-12 00:00:00
|
2140-08-12 14:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Percocet / cefepime / oxycodone
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ Left incarcerated femoral hernia repair
History of Present Illness:
Ms. ___ is an ___ with cardiac history (PCI ___ and ___
and peripheral vascular diasease who was referred in earlier
today complaining of nausea and mild but diffuse, crampy
abdominal pain. She reports a history of intermittent diarrhea
and constipation and had an episode of diarrhea this morning.
She
was hypertensive to the 190s and they referred her to the ED for
a cardiac workup. The cardiology service saw her and cleared her
from a cardiac perspective given a stable EKG without ischemic
changes and a normal troponin. Her abdomen was then scanned and
demonstrated a left femoral hernia.
On interview, she is cooperative and pleasant and discusses
crampy abdominal pain that started today. She notes it is more
in her lower abdomen.
Past Medical History:
- PVD s/p R profunda femoris --> AT in situ vein bypass graft
(___)
- Graft c/b pseudoaneurysm with Viabahn stent graft placement
___ infected hematoma ___, s/p I&D and woundVAC placement
and subsequent wound infection with MRSA and ?CoNS. On lifelong
Bactrim suppression.
- CAD s/p STEMI and stents placed in ___ and ___
- HFrEF (EF 40-45%) in ___
- HLD
- HTN
- Vitamin D deficiency
- Vit B12 deficiency
- Urinary incontinence
- Hypothyroidism
- Depression
- Diabetes mellitus
- S/p fall in ___ w/ left forehead hematoma
- Suspected meningioma
- bladder incontinence
PAST SURGICAL HISTORY:
- angio RLE w/ placement of 2 Viabahn stents within the vein
bypass graft of the right lower extremity. I&D of right medial
knee hematoma with subsequent wound infection ___ Dr.
___
- Left CEA ___ ___
- Umbilical Hernia repair approximately ___ years ago
- RT CARPAL TUNNEL SURGERY ___
- CAD s/p DES->LAD ___
- Left knee surgery
Social History:
___
Family History:
Mother has history of breast cancer and uterine cancer.
Physical Exam:
Discharge Physical Exam:
Vitals: afebrile, VSS
Gen: A&Ox3, well-appearing female, in NAD
HEENT: No scleral icterus, mucus membranes moist
Pulm: CTAB, no w/r/r
CV: NRRR, no m/r/g
Abd: soft, NT/ND, no rebound/guarding, no palpable masses, L
groin incision c/d/i without palpable/pulsatile mass, no
induration/erythema/drainage
Ext: WWP bilaterally, no c/c/e, no ulcerations
Neuro: moves all limbs spontaneously, no focal deficits
Pertinent Results:
==============
ADMISSION LABS
==============
___ 05:00PM BLOOD WBC-8.2# RBC-3.85* Hgb-11.1* Hct-34.4
MCV-89 MCH-28.8 MCHC-32.3 RDW-16.1* RDWSD-52.5* Plt ___
___ 05:00PM BLOOD Neuts-84.6* Lymphs-10.7* Monos-4.0*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.89*# AbsLymp-0.87*
AbsMono-0.33 AbsEos-0.01* AbsBaso-0.01
___ 05:00PM BLOOD ___ PTT-29.9 ___
___ 05:00PM BLOOD Glucose-106* UreaN-29* Creat-1.1 Na-129*
K-8.0* Cl-95* HCO3-21* AnGap-21*
___ 05:00PM BLOOD ALT-17 AST-43* AlkPhos-90 TotBili-0.5
___ 05:00PM BLOOD Lipase-43
___ 05:00PM BLOOD Albumin-4.2
___ 01:18AM BLOOD Calcium-8.9 Phos-4.9* Mg-2.4
___ 05:19PM BLOOD Lactate-2.2* K-6.2*
___ 05:00PM BLOOD cTropnT-<0.01
___ 01:18AM BLOOD cTropnT-<0.01
___ 01:30PM BLOOD cTropnT-<0.01
=============
MICROBIOLOGY
=============
___ blood/urine cultures - all negative
========
IMAGING
========
___ CT A/P with IV contrast:
IMPRESSION:
1. Left femoral hernia containing a short segment of
fluid-filled small bowel. Distension of proximal bowel loops
without frank dilation may reflect early obstruction in the
correct clinical setting. Correlation for focal pain in the
left groin and hernia reduction advised.
2. Large anterior abdominal wall ventral hernia containing
nondilated
transverse colon present in ___, unchanged.
3. Unchanged hepatic hypodensities previously characterized as
hemangiomas.
4. Renal cortical hypodensities, many of which are too small to
characterize. A left interpolar region cortical lesion is
indeterminate, likely a cyst with proteinaceous or hemorrhagic
content, could be further evaluated with non-emergent
ultrasound.
4. Coronary atherosclerosis, partially imaged.
================
OPERATIVE REPORT
================
Name: ___ Unit No: ___
Service: Acute Care Surgery Date:
___
Date of Birth: ___ Sex: F
Surgeon: ___, ___
PREOP DIAGNOSIS: Femoral incarcerated hernia, left.
POSTOP DIAGNOSIS: Femoral incarcerated hernia, left.
NAME OF OPERATION: Left incarcerated femoral hernia repair.
FIRST ASSISTANT: Dr. ___ and Dr. ___.
INDICATIONS: This woman has had nausea and a CT scan
demonstrated the presence of a femoral hernia and with
collapsed bowel coming out of it and more dilated bowel going
into it. She was taken to the operating room, placed in
supine position, given a general anesthetic. The abdomen was
prepped and draped using ChloraPrep. After chlorhexidine
wash, and after appropriate time-out, we made a linear
incision along the inguinal ligament, deepening it down to
the level of the fascia. We exposed the external oblique,
exposed the inguinal ligament, and then incised the fascia of
the thigh. This allowed us to identify the hernia sac. This
was opened. We entered the sac and found that there was
omentum as well as small bowel in it. The small bowel and
omentum were reduced after the opening was made wider using
pressure on the arcuate ligament. This allowed us to reduce
it. There was no evidence of any dead bowel. The sac being
reduced, we turned our attention to closure. Closure was
carried out by placing a plug in place and we sutured it to
the inguinal ligament as well as Cooper ligament posteriorly
with ___ Prolene in an interrupted fashion. This allowed for
a good repair. We then closed with ___ Vicryl on the
Scarpa's layer and ___ Monocryl was used to close the skin at
the dermal-epidermal junction. Steri-Strips were applied.
Dry dressing was applied.
ESTIMATED BLOOD LOSS: 20 mL.
==============
DISCHARGE LABS
==============
___ 07:10AM BLOOD WBC-7.9 RBC-3.04* Hgb-8.8* Hct-28.1*
MCV-92 MCH-28.9 MCHC-31.3* RDW-15.9* RDWSD-53.9* Plt ___
___ 07:10AM BLOOD Glucose-98 UreaN-28* Creat-1.2* Na-133
K-4.6 Cl-100 HCO3-25 AnGap-13
___ 07:10AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.3
Brief Hospital Course:
Mrs. ___ was admitted to the Acute Care Surgery Service
under Dr. ___ for operative management of her
incarcerated left femoral hernia. She was taken to the operating
room on ___ and underwent an open left femoral hernai repair
with plug placement, which was well tolerated and without
immediate complications (for further details regarding the
procedure, please refer to the operative report).
Postoperatively, the patient was extubated successfully and
transferred to the PACU and then to the surgical floor in stable
condition. Her pain was initially managed with IV pain
medications and she was successfully transitioned to a PO pain
medication regimen when she tolerated PO intake with subsequent
adequate pain control. Her diet was slowly advanced until she
was able to tolerate a regular diet without difficulty. Her
Foley catheter was removed and she began voiding spontaneously.
Additionally, she was evaluated by Physical Therapy, who
recommended discharge home with physical therapy services.
On the afternoon of POD2, the patient was tolerating a regular
diet, voiding without difficulty and ambulating well with
assistance, her pain was well controlled with PO pain
medications, her incision was clean, dry and intact, and she
remained afebrile and hemodynamically stable. She was thus
deemed ready for discharge home with physical therapy services
and with instructions to follow up in clinic in ___ weeks to
assess appropriate recovery following surgery.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Carvedilol 6.25 mg PO BID
5. Citalopram 20 mg PO DAILY
6. Cyanocobalamin 500 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Doxazosin 2 mg PO HS
9. Furosemide 20 mg PO DAILY
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Sulfameth/Trimethoprim DS 1 TAB PO BID
14. Valsartan 160 mg PO DAILY
15. Vitamin D ___ UNIT PO DAILY
16. Bisacodyl 10 mg PR QHS:PRN constipation
17. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Bisacodyl 10 mg PR QHS:PRN constipation
6. Carvedilol 6.25 mg PO BID
7. Citalopram 20 mg PO DAILY
8. Cyanocobalamin 500 mcg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Doxazosin 2 mg PO HS
11. Furosemide 20 mg PO DAILY
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Levothyroxine Sodium 50 mcg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Sulfameth/Trimethoprim DS 1 TAB PO BID
16. Valsartan 160 mg PO DAILY
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Femoral incarcerated hernia, left
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with an incarcerated left femoral hernia. Because the bowel was
entrapped in the hernia you were taken to the operating room and
had the hernia repaired. You are now doing better, tolerating a
regular diet, and pain is better controlled.
You are now ready to be discharged to home to continue your
recovery from surgery:
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.
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.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19757554-DS-9
| 19,757,554 | 23,782,916 |
DS
| 9 |
2139-12-28 00:00:00
|
2139-12-28 20:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Aneurysm of the vein bypass graft in the right lower extremity.
Major Surgical or Invasive Procedure:
___: RLE angio, placement of Viabahn PTA/stent x2 (7 x 10
distally, 8 x 15 proximally) and I&D of hematoma
History of Present Illness:
___ s/p right fem->AT ___ in ___ now presents with increasing
pulsatile mass just below the knee with 1 day of pain and small
amount of spontaneous bleeding that has stopped. Patient reports
that 2 days ago she had some aching pain in her knee. She
reports that the bulge around her knee over the graft has
increased in size in the last ___ months. She also reports some
oozing of blood that spontaneously stopped yesterday. She denies
any fevers, chills, trauma or infection to the area. She has
been followed in clinic for her bypass graft and was last seen
this ___. She last had a duplex of the graft in ___ which
noted stenoses as well as an area with adjacent thrombus but no
overt pseudoaneursym at that time. She currently ambulates with
a walker and can walk only a 100 feet or so before stopping
because she is tired and out of breath. She has had bilateral
leg pain for years that does not resemble rest pain. she denies
non healing ulcers of the feet. She does have chronic bilateral
edema which is not worse today than previously.
Past Medical History:
. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY: occluded RCA and s/p DES to LAD
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: DES to LAD ___
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
peripheral vascular disease s/p right fem-pop bypass ___
s/p L CEA ___
arthritis
bladder incontinence--? overflow incontinence
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM ON DISCHARGE:
VS: T: 98 HR: 89 BP: 158/84 RR: 16 ___: 94RA
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR,
PULM: no respiratory distress
BACK: no vertebral tenderness, no CVAT
ABD: soft, NT, ND, no mass, no hernia
EXT: right leg below knee overlying graft is 2cm incision from
the incision and drainage that is non-bleeding, b/l 1+ edema,
b/l venous varicosities
NEURO: no focal deficits, answers questions appropriately
through daughter translation
___:
___ Pop Dp ___
R Palp graft P Palp D
L Palp D Palp D
Pertinent Results:
Femoral US (___)
IMPRESSION:
1. Patent right common femoral artery graft.
2. 3.6 cm fusiform aneurysm or pseudoaneurysm arising from the
mid right
common femoral artery graft which is likely not amenable to
thrombin injection
given morphology.
3. Possible small AV fistula connecting the proximal common
femoral artery
graft to the common femoral vein. During readout the CTA was
reviewed and no
AVF was identified.
CTA Aorta/Bifem/Iliac Runoff (___)
IMPRESSION:
1. Infrarenal abdominal aortic aneurysm measuring up to 3.1 cm.
2. Left lower extremity: Moderate to severe stenosis of the
left superficial femoral artery with limited evaluation of the
left popliteal artery. Intermittent areas of severe stenosis of
the anterior and posterior tibial artery with anterior tibial
artery patent to the level of distal tibia. Patent posterior
tibial artery and peroneal artery throughout their course.
3. Right lower extremity: Occlusion of the native vessels
distal to the
proximal right superficial femoral artery with reconstitution of
the distal posterior tibial artery via retrograde filling from
graft.
4. Right common femoral artery to posterior tibial artery bypass
graft: 3 cm minimally thrombosed graft aneurysm just distal to
the common femoral artery proximal graft anastomosis. 1.4 cm
graft aneurysm along the popliteal level. 5 cm thrombosed graft
aneurysm with ulcerating plaque at level of proximal calf.
Patent graft with severe focal stenosis along the distal aspect
of the graft at the level of a focal dissection.
5. No AV fistula.
6. Cholelithiasis without additional signs of cholecystitis.
7. Large transverse colon containing ventral hernia without
evidence of strangulation.
8. Small fat containing left femoral hernia.
OPERATIVE REPORT (___)
================
PREOPERATIVE DIAGNOSIS: Aneurysm of the vein bypass graft in
the right lower extremity.
POSTOPERATIVE DIAGNOSIS: Aneurysm of the vein bypass graft
in the right lower extremity.
PROCEDURES:
1. Ultrasound-guided access to the left common femoral artery.
2. Selective catheterization of the right lower extremity vein
bypass graft, ___ order vessel.
3. Right lower extremity angiogram.
4. Placement of 2 Viabahn stents within the vein bypass graft of
the right lower extremity.
5. Incision and drainage of right medial knee hematoma.
CONTRAST VOLUME: 50 cc Visipaque.
FLUOROSCOPY TIME: 26.3 minutes.
RADIATION DOSE: 378 mGy.
INDICATIONS: This is an ___ woman who had a history of
a right profunda to AT in situ vein bypass graft done more than
a decade ago. She recently presented with oozing of blood at
the medial aspect of her knee and on CTA it was discovered that
her graft was aneurysmal in several places. It was very close to
the skin at the site where she was oozing and free rupture of
the vein graft was imminent. She was therefore consented for
right lower extremity angiogram and placement of a stent across
this area.
DETAILS OF PROCEDURE: The patient was brought to the operating
room and placed supine on the OR table. Both groins were
prepped and draped in usual sterile fashion. Monitored sedation
was provided with divided doses of fentanyl and Versed. A
time-out was performed. We began by evaluating the left common
femoral artery under ultrasound. This was noted to be patent
with minimal calcifications. Therefore under direct
visualization we accessed the left common femoral artery with a
micropuncture needle. Images of our ultrasound guidance were
stored in the ___ medical record for documentation
purposes. We confirmed our stick location using fluoroscopy
which was noted to be over the left femoral head.
We then placed a ___ sheath within the left groin and
advanced an Omni Flush catheter into the abdominal aorta. We
performed an abdominal aortogram which revealed an infrarenal
aortic aneurysm and patent bilateral iliac systems. We attempted
to get up and over the aortic bifurcation however this is proved
difficult given the patient's aneurysm as well as the tortuosity
of her iliac vessels. After several attempts, using both a
___ and Glidewire as well as using a rim catheter, we
decided to upsize our sheath to a ___ short sheath and
using this and a ___ Omniflush catheter we were finally
able to get up and over the aortic bifurcation. We were able to
select the right external iliac artery with our catheter and
then performed a right lower extremity angiogram. This revealed
multiple aneurysms of the right lower extremity vein bypass
graft, most notably the proximal anastomosis of the graft was
markedly dilated lower down at the knee where the patient's
graft was starting to erode through the skin. We identified the
area with extravasation of contrast. Above and below this
lesion there were 2 focal areas of stenosis. At this point, we
elected to intervene.
We therefore upsized the sheath in the left groin to a ___
sheath and using a combination of wires and catheters we
advanced the 18 wire into the distal AT vessel. Before we
upsized to the ___ sheath and insert 10,000 units of
heparin were then administered and ACT's were checked throughout
the remainder of the case. Over this we placed 2 Viabahn stents.
More distally we placed a 7 x 10 cm Viabahn stent and more
proximally we placed an 8 x 15 Viabahn stent with a small
amount of overlap. We post dilated with a 7 x 80 mm Pacific
balloon using this balloon to angioplasty the 2 areas of
stenosis above and below the area of
the graft that seemed to be extravasating. Completion angiogram
showed a technically successful result and the angio completion
angiogram of the foot showed a patent graft down to the distal
AT. The AT was patent into the foot. However, there was an
abrupt change in caliber within the foot. We did not know
whether this was iatrogenic because we had not shot the foot
prior to the intervention. At this point, we elected to
terminate the procedure.
Therefore all wires and catheters were removed and the ___
sheath was backed out into the left iliacs. The ___ wire
was advanced into the abdominal aorta and the ___ sheath
was removed. We closed the arteriotomy within the left common
femoral artery with a Perclose closure device with resultant
good hemostasis. There was no evidence of hematoma and the
groin was soft at the end of the case. The patient tolerated
the
procedure well. There were no immediate complications. Dr.
___ was present for the entirety of the case.
We then used a Perclose device in the groin and at this point,
the right medial knee was prepped with ChloraPrep and draped
with blue towels. 1% lidocaine was instilled and a 1 cm
incision was made overlying the hematoma. Old blood and
thrombus was expressed from this hematoma. There was no evidence
of active bleeding or bright red blood. A dry sterile dressing
was then placed over the site of incision and drainage.
Angiographic findings:
1. Patent infrarenal abdominal aorta, patent bilateral common
iliac and external iliac arteries.
2. Patent right profunda to AT in situ vein bypass graft with
multiple areas of aneurysmal dilation most notably at the
proximal anastomosis.
3. Extravasation of contrast in the bypass graft at the level of
the knee. There were 2 areas of focal stenosis above and below
this extravasated area.
4. Placement of 2 Viabahn stents, a 7 x 10 cm distally and an 8
x 15 cm more proximally with overlap. These were used to
encompass both the area of extravasation as well as the 2 areas
of focal stenosis.
Brief Hospital Course:
Ms. ___ is an ___ female s/p right fem->AT SVG in ___
presented with increasing pulsatile mass below the knee. She was
found to 3.6 cm fusiform aneurysm or pseudoaneurysm arising from
the mid right common femoral artery graft. She went to the OR on
___ RLE angio, placement of Viabahn PTA/stent x2 (7 x 10
distally, 8 x 15 proximally) and I&D of hematoma. She did well
in the post operatively period. She was placed on vancomycin to
prevent wound infection and graft infection. On POD1 her wound
from the I&D was clean and dry and her groin incision was stable
without evidence of hematoma. Her IV Vancomycin was switched to
Augmentin PO for a total course of 14 days. She was stable to
discharge and was discharged home on POD1.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 320 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Lidocaine 5% Ointment 1 Appl TP ONCE
5. TraZODone 12.5 mg PO QHS:PRN Insomnia
6. diclofenac sodium 1 % topical BID:PRN
7. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
8. albuterol sulfate 90 mcg/actuation inhalation TID:PRN
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 40 mg PO QPM
11. Citalopram 20 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
13. Cyanocobalamin 500 mcg PO DAILY
14. Carbamide Peroxide 6.5% 5 DROP LEFT EAR TID
15. Doxazosin 2 mg PO HS
16. Furosemide 20 mg PO DAILY
17. Levothyroxine Sodium 50 mcg PO DAILY
18. Lidocaine-Prilocaine 1 Appl TP BID
19. melatonin 3 mg oral QHS
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*28 Tablet Refills:*0
2. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
3. albuterol sulfate 90 mcg/actuation inhalation TID:PRN
4. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM
6. Carbamide Peroxide 6.5% 5 DROP LEFT EAR TID
7. Citalopram 20 mg PO DAILY
8. Cyanocobalamin 500 mcg PO DAILY
9. diclofenac sodium 1 % TOPICAL BID:PRN joint pain
10. Doxazosin 2 mg PO HS
11. Furosemide 20 mg PO DAILY
12. Levothyroxine Sodium 50 mcg PO DAILY
13. Lidocaine 5% Ointment 1 Appl TP ONCE
14. Lidocaine-Prilocaine 1 Appl TP BID
15. melatonin 3 mg oral QHS
16. Metoprolol Succinate XL 50 mg PO DAILY
17. Omeprazole 20 mg PO DAILY
18. TraZODone 12.5 mg PO QHS:PRN Insomnia
19. Valsartan 320 mg PO DAILY
20. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Aneurysm of the vein bypass graft in the right lower extremity.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after a
peripheral angiogram. To do the test, a small puncture was
made in one of your arteries. The puncture site heals on its
own: there are no stitches to remove. You tolerated the
procedure well and are now ready to be discharged from the
hospital. Please follow the recommendations below to ensure a
speedy and uneventful recovery.
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
Take Aspirin 81 mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and 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
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower tomorrow (let the soapy water run over groin
incision, rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
WOUND CARE:
Please keep your puncture wound on the left groin clean and dry.
You may put a gauze dressing over the wound if noticing
drainage.
The incision from your incision and drainage procedure, please
change the dressing daily with gauze and tape. Please watch for
signs of bleeding, redness, or increased in drainage.
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site or wound
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
Followup Instructions:
___
|
19757915-DS-13
| 19,757,915 | 22,181,569 |
DS
| 13 |
2150-10-04 00:00:00
|
2150-10-04 16:58:00
|
Name: ___ ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ y/o female with a history of hypertension and
CHF who presents with two weeks of worsening dyspnea on exertion
and lower extremity edema. Over the past 4 months her weight has
increased by 20lbs, and over the past two weeks her dyspnea on
exertion significantly worsened to the point that she felt SOB
after walking only a few steps. She saw her PCP two weeks ago
for worsening DOE and increasing ___ edema, at that time her
lasix was increased to 40mg and her metoprolol succinate was
uptitrated to 100mg daily. Her symptoms continued to worsen
despite the increase in medications, additionally she has a
chronic RLE ulcer which she says has been present for ___ years
which has worsened recently as well. She denies any associated
chest pain, does endorse some abdominal distension but denies
any abdominal pain. Has associated b/l ___ pain in the areas of
the edema, also complaining of generalized weakness and fatigue.
Also complaining of a cough productive of ___ sputum, but
denies any fever/chills, chest pain, n/v/d. Also, when she
recently had her labs checked her Cr had increased to 1.2 from a
baseline of 1.0. Given her symptoms had continued to worsen she
was referred into the ER for furthe management.
.
In the ED, initial vitals were 98.4, 60, 160/78, 22, 98% on
2LNC. Labs and imaging significant for a BNP of 2794, troponin
of 0.02, CK-MB of 4, Cr of 1.7, platelets of 89. Chest x-ray
showed mild pulmonary edema with pulmonary arterial enlargment
that was concerning for possible pulmonary hypertension. EKG
looked like AF at 61bpm, RBB, q waves in III, aVF, poor
baseline. She was seen by cardiology in the ER, a bedside echo
showed mostly right sided heart failure with a preserved EF, she
was given 80mg of IV lasix and admitted for a CHF exacerbation.
Vitals on transfer were HR 57, BP: 147/76, RR: 18, O2Sat: 97,
O2Flow: 2L.
.
On arrival to the floor initial VS were: T=98.1 BP=144/79 HR=57
RR=20 O2 sat=98% on ___. Currently says her breathing is
alright and she able to lay mostly flat, however she says that
most of her symptoms previously occurred with exertion.
Continues to have pain in her lower extremities bilaterally.
.
REVIEW OF SYSTEMS: unable to fully obtain due to language
barrier
On review of systems, she denies any prior history of stroke,
hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. All of the other review of systems
were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
Hypertension
Social History:
___
Family History:
___ family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. ___ family history of blood disorders or
clots.
Physical Exam:
ON ADMISSION:
VS: T=98.1 BP=144/79 HR=57 RR=20 O2 sat=98% on 2___
GENERAL: WDWN female in NAD.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, ___
pallor or cyanosis of the oral mucosa. ___ xanthalesma.
NECK: Supple with JVD to earlobes at less than 30 degrees
CARDIAC: RR, + S1, S2.
LUNGS: ___ chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, ___ accessory muscle use. Mild crackles
throughout, ___ wheezes/rhonchi.
ABDOMEN: Soft, mildly distended. ___ tenderness.
EXTREMITIES: 3+ pitting edema
SKIN: + stasis dermatitis, RLE ulcer
.
AT DISCHARGE:
VS 98.7 120-130s/50-70s ___ 18 99%RA
EXTR: 1+ pitting edema,, wrinkled skin without turgor,
significantly improved
NECK: JVD improved
PULM: LCTAB
exam otherwise unchanged.
Pertinent Results:
LAB RESULTS:
ON ADMISSION:
___ 08:11PM BLOOD WBC-5.6 RBC-3.84* Hgb-12.5 Hct-36.7
MCV-96 MCH-32.6* MCHC-34.1 RDW-15.5 Plt Ct-89*
___ 08:11PM BLOOD ___ PTT-28.9 ___
___ 08:11PM BLOOD Glucose-181* UreaN-44* Creat-1.7* Na-139
K-3.5 Cl-100 HCO3-27 AnGap-16
___ 08:11PM BLOOD ALT-27 AST-45* CK(CPK)-200 AlkPhos-114*
TotBili-1.0
___ 08:47AM BLOOD CK(CPK)-146
.
CARDIAC ENZYMES:
___ 08:11PM BLOOD CK-MB-4 proBNP-2794*
___ 08:11PM BLOOD cTropnT-0.02*
___ 08:47AM BLOOD CK-MB-3 cTropnT-0.02*
.
OTHER PERTINENT LABS:
___ 08:47AM BLOOD calTIBC-293 TRF-225
.
DISCHARGE LABS:
INR on discharge was 1.3
.
MICROBIOLOGY:
Urine Culture: ___ growth
.
ECG ___ on adm:
Atrial fibrillation with moderate ventricular response. Possible
inferior
wall myocardial infarction of indeterminate age. Poor R wave
progression.
Consider anterior wall myocardial infarction of indeterminate
age. Diffuse
ST-T wave changes which are non-specific. Low QRS voltages in
the precordial leads. ___ previous tracing available for
comparison.
.
TTE ___
The left atrium is mildly dilated. The right atrium is
moderately dilated. The estimated right atrial pressure is at
least 15 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). The right ventricular cavity is moderately dilated
with mild global free wall hypokinesis. There is abnormal
diastolic septal motion/position consistent with right
ventricular volume overload. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is ___ aortic valve
stenosis. Moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Moderate (2+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is ___ pericardial effusion.
IMPRESSION: Mild symmetric LVH. Normal LV function and size.
Dilated RV with mild global HK and volume overload. Moderate AR.
Moderate MR. ___ pericardial effusion
.
___ CXR
Mild pulmonary edema with pulmonary arterial enlargement, which
could be
related to pulmonary hypertension.
.
___ LENIS
___ DVT in either lower extremity. Mild subcutaneous calf edema
in both limbs.
.
___ ABDOMINAL U/S
Brief Hospital Course:
Ms. ___ is an ___ y/o ___ speaking female who presents
with two weeks of worsening DOE and lower extremity edema
consistent with a heart failure exacerbtion.
.
#) diastolic heart failure - Pt presented with SOB and
significant lower extremity edema. PCP had started 40mg daily po
lasix several weeks ago for similar symptoms, but with
progressive worsening referred her to the ER. Echo showed a
preserved EF of 55%. Along with dilated RV with mild global
hypokinesis and volume overload. Moderate AR, moderate MR,
mod-severe TR. ___ pericardial effusion. Pt without cardiac
history or known hyperlipidemia, cardiac enzymes were flat, and
her preserved EF all pointed away from an ischemic
cardiomyopathy. Pt was in Afib on presentation. PCP stated that
she had ___ history of Afib and was not in irregular rhythm when
seen in the office. Accordingly, onset of Afib most likely
eliminated atrial kick and significantly reduced diastolic
filling, reducing preload and forward flow.
Restrictive/infiltrative diseases were also considered,
particularly because her ECG was notable for very low voltage in
all leads, although the patient herself was quite cachectic. Pt
without any known history of family cardiac problems or blood
disorders. TIBC and ferritin were normal, and total protein to
albumin gradient was not significantly elevated, which it could
be in paraproteinemia. Pt was continued on home dose of
metoprolol. Pt was diuresed aggressively and day of discharge
her weight was down 20 pounds from admission. Concurrently pt
demonstrated significant improvement in lower extremity edema
and lungs became clear to auscultation. pt was monitored on
telemetry which exhibited atrial fibrilation and asymptomatic
bradycardia with HR in the 50-60s. Due to bradycardia her home
metoprolol was changed from 50BID to 37.5mg BID. Aspirin was
held as this was not felt to be ischemic in origin. Team was in
constant contact with the PCP who was made aware of all of these
issues. It would be prudent to follow up with SPEP/UPEP as an
outpatient which, if elevated, would suggest possibility of
amyloidosis. ___ will also need to be followed by a cardiologist.
.
#Atrial Fibrillation - Pt presented in atrial fibrillation and
remained in this rhythm for the duration of her hospital course.
PCP stated that pt had not been in atrial fibrillation
previously when he saw her in the office, even within the last
several weeks. It was felt that new onset afib was exacerbating
underlying cardiac pathology and was likely responsible for this
acute episode of decompensation. CHADs score of 3 for CHF,
hypertension, and age, and pt was started on warfarin after
discussion with the PCP. Pt was not bridged as heparin was not
ideal in the setting of unexplained thrombocytopenia, and her
___ precluded safe use of enoxaparin. As noted above, metoprolol
dose was lowered in setting of bradycardia. Pt will need to be
established with an outpatient cardiologist. INR on discharge
was 1.3. Pt was sent out on 4mg daily warfarin.
.
#acute on chronic kidney disease - per PCP, pt has had
creatinine of 1.0 with GFR in the ___ in the past. More recently
in the last several weeks her creatinine went up to 1.2. On
presentation to ___, Cr was elevated, and peaked at 2.0 after
aggressive diuresis. Creatinine then trended down as volume
status was optimized. It was felt that her ___ was due to poor
forward flow in the setting of heart failure. At discharge her
last measured creatinine was 1.4.
.
# transaminitis - alk phos slightly elevated, likely ___
hepatic congestion. pt without abdominal pain or RUQ tenderness.
AST also mildly elevated. Pt was monitor with serial abdominal
exams. Abdominal u/s showed possible cirrhosis (could not
exclude) but ___ evidence of splenomegaly. Final report pending
at time of discharge.
.
#thrombocytopenia - unclear baseline, and unknown etiology. PLTs
in the 80-90s range throughout hospitalization. ___ prior
exposure to heparin. ___ signs of bleeding. Should consider
workup of thrombocytopenia in the outpatient setting. SC
heparin prophylaxis was held in an effort to avoid exposing her
to agents that could potentially lower platelets further.
Abdominal U/S was performed, preliminary report did not note any
splenomegaly but could not rule out cirrhosis. Final report will
need to be followed up.
.
#) Hypertension: blood pressure mildly elevated on admission,
likely related to volume overload. BP normalized with diuresis
and home dose of metoprolol was actually decreased as pt was
somewhat bradycardic in the ___ which was felt too low to
optimize her volume status. Pt discharged on metoprolol XL 75mg
daily.
.
#) Vitamin D Deficiency: continue home vitamin D supplementation
.
================================
TRANSITIONAL ISSUES
- for restrictive/diastolic heart failure, pt should have
SPEP/UPEP ordered as an outpatient for eval for possible
paraproteinemia/amyloidosis
- thrombocytosis of unknown etiology: this should be worked up
further as an outpatient
- pt needs to establish herself with a cardiologist, phone
number for ___ heart failure clinic is above
- Pt needs to see Dr. ___ in ___ clinic for
her thrombocytopenia
___ to make an appointment.
- furosamide dosage should be adjusted as needed for further
diureses to euvolemia
- please call ___ and have Dr. ___ paged to
follow up on the final abdominal ultrasound report.
Medications on Admission:
Lasix 40mg daily
Metoprolol Succinate 100mg daily
Vitamin D 1000 units daily
Multivitamin 1 tablet daily
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): take one in the morning and one at 4pm .
Disp:*90 Tablet(s)* Refills:*0*
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
4. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO once a day.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
diastolic heart failure
atrial fibrillation
SECONDARY:
acute on chronic kidney disease
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you during your recent
hospitalization. You were admitted with heart failure. Your
heart was not pumping as well as it should, so fluid got backed
up into your lungs and your legs. We gave you medications to
help your body urinate out this fluid. We also noticed that your
heart was in an abnormal rhythm called atrial fibrillation. This
rhythm can be dangerous because when the heart is not working
properly blood clots can develop in the heart. These clots can
then get pumped with the blood up into the brain and cause a
stroke. In order to prevent this, we started a medication called
warfarin to thin your blood. It is very important that the
levels of warfarin remain within a certain range, so you will
have your blood checked frequently - at least every week - while
on this medication. While you were in the hospital we also
checked for blood clots in your legs but we didn't find any. We
gave you medication to help your body urinate out the extra
fluid. We sent you home with lasix, the medicine you had been
taking, but with instructions to take this twice a day now
instead of only once a day.
Please weigh yourself at home. If your weight goes up more than
3 pounds call your primary care doctor.
.
We made the following CHANGES to your medications
CHANGED your metoprolol from 100mg daily to 75mg daily. You
should now take 75mg of metoprolol daily.
CHANGED your lasix from 40mg daily to 40 mg twice a day. Take
one 40mg pill in the morning and another 40mg pill in the
evening.
STARTED warfarin 3mg - take 3 of the 1mg tablets daily
STARTED colase twice daily for constipation
STARTED senna daily as needed for constipation
Followup Instructions:
___
|
19757915-DS-15
| 19,757,915 | 24,665,073 |
DS
| 15 |
2151-01-14 00:00:00
|
2151-01-14 20:36:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right leg pain and redness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ ___ speaking woman with MMP
including
severe right sided heart failure and wide open TR, HTN, Afib,
chronic right lower extremity ulcer, CKD, thrombocytopenia, and
fatty liver, who presents with a worsening of her ___ ulcer and
concern for cellulitis. History at admission obtained through
the patient's daughter via ___ interpreter.
She was recently admitted for worsening of her ___ ulcers and
facial rash. Her ulcers were managed conservatively and she was
not given antibiotics on the floor as there was not thought to
be evidence of infection. Her rash was worked up with lupus
serologies, all of which were negative. She was given
hdrocortisone cream for the rash and discharged with outpatient
follow-up.
She reports that for the few days prior to admission, ___ noted
that the right ___ was warmer than usual and had clear fluid
draining from the surface of the skin. Denies fever or chills at
home, no description of recent purulent discharge from the skin
lesions, however she notes that 2 weeks ago there was some
yellow discharge. She reports that her mother has sensation in
her feet and has been having intermittent pain over her RLE.
In the ED, initial VS: 98.5 64 113/58 16 99%. She had LENIs
which showed no evidence of DVT. She received 1g vancomycin
prior to arrival to the medicine floor.
Currently, she is feeling with minimal pain. Her dauighter
reports that she started feeling better in the ED when she was
gvien IVF.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
- T2DM (A1c=6.6% in ___, not on medications)
- hypertension
- atrial fibrillation on warfarin
- diastolic heart failure (EF >55%)
- pulmonary hypertension: on tadalafil
- chronic right lower extremity ulcer
- Chronic kidney disease (baseline Cr 1.5-1.8)
- thrombocytopenia
- transaminitis
- fatty liver, small right pleural effusion and a small amount
of ascites
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. NO family history of blood disorders or
clots.
Physical Exam:
Admission exam:
VS - Temp 98 BP 120/60, HR 65 RR 20 SpO2 95/RA
GENERAL - elderly woman in NAD
HEENT - dry MMM, no rash noted on face
LUNGS - CTA bilat, no r/rh/wh
HEART - PMI non-displaced, irreg irreg, ___ systolic murmur at
the LLSB
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - Chronic venous stasis changes bilat, R>L. 2 skin
ulcers located adjacent to the medial and lateral malleoli.
Warmth over the RLE. There is erythema around the lower RLE as
well as a more maculopapular rash wich is confluent with the
erythema around the ulcers but extends proximally almost to the
knee. Mild maculopapular rash on LLE as well, no warmth. 1+ DP
pulse on the right, 2+ on the left.
NEURO - awake, conversing with daughter in ___, CNs II-XII
grossly intact, no focal deficits
Discharge exam - unchanged from above, except as below:
EXTREMITIES: Improvement in RLE erythema surrounding the leg
ulcers.
Pertinent Results:
Admission labs:
___ 03:10PM BLOOD WBC-6.2 RBC-3.94* Hgb-12.8 Hct-39.7
MCV-101* MCH-32.4* MCHC-32.1 RDW-16.5* Plt ___
___ 03:10PM BLOOD Neuts-60.8 ___ Monos-11.1*
Eos-3.9 Baso-2.8*
___ 08:20AM BLOOD ___ PTT-34.6 ___
___ 03:10PM BLOOD Glucose-67* UreaN-46* Creat-1.8* Na-136
K-3.3 Cl-96 HCO3-30 AnGap-13
___ 08:20AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1
___ 03:13PM BLOOD Lactate-2.5*
Discharge labs:
___ 07:50AM BLOOD WBC-5.6 RBC-3.65* Hgb-11.9* Hct-36.4
MCV-100* MCH-32.5* MCHC-32.6 RDW-16.6* Plt ___
___ 07:50AM BLOOD Neuts-61.0 ___ Monos-11.0
Eos-6.3* Baso-2.1*
___ 07:50AM BLOOD ___ PTT-35.5 ___
___ 07:50AM BLOOD Glucose-89 UreaN-42* Creat-1.5* Na-142
K-3.6 Cl-105 HCO3-27 AnGap-14
___ 07:50AM BLOOD Calcium-8.2* Phos-2.7 Mg-2.2
Micro:
-BCx (___): NGTD
-RLE ulcer swab:
WOUND CULTURE (Preliminary):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
STAPH AUREUS COAG +. HEAVY GROWTH.
Imaging:
-Right LENIs (___): No evidence of right lower extremity
deep vein thrombosis. Extensive soft tissue swelling of the
calf is present.
Brief Hospital Course:
___ year old ___ woman with MMP including chronic
right lower extremity ulcer, severe right sided heart failure,
HTN, Afib on warfarin, and CKD, who presents with worsening of
her RLE ulcers and cellulitis.
# Right ___ ulcers and cellulitis: Ulcers most likely to be ___
venous stasis as she has palpable pulses bilaterally and
evidence of chronic venous stasis changed on her lower extremity
skin. There was marked erythema of the RLE but it was unclear
how much of this was from a potential cellulitis versus severe
chronic venous stasis changes. She remained afebrile with no
leukocytosis or purulent discharge from the ulcers. Given
concern for infection, she was started on vancomycin in the ED
which was transitioned to PO Bactrim/Keflex after 24 hours. The
erythema around her RLE ulcers slightly improved this admission
and she will continue a total 7 day course of antibiotics as an
outpatient. She was seen by the wound nurse who left
recommendations for wound dressings and recommended ACE wraps
with leg elevation. Vascular surgery was also consulted given
that she is followed by Dr. ___ as an outpatient and they
agrees with the above management. She will follow-up with
vascular surgery and her PCP after discharge
# Disposition: Patient was seen by ___ who initially recommended
home with ___, which was subsequently changed to rehab after
patient had more pain with ambulation on HD3. A discussion was
had with the patient and her daughter (___) via ___
interpreter and they were informed that we recommended rehab.
They declined and wanted the patient to return home. They were
informed of and understood the risks of declining rehab
placement against the advice of the medical team, including
risks for falls at home, worsening infection and potentially
death. The patient was competent to make her own medical
decisions and was discharged home with ___ and home ___.
# Elevated lactate: Lactate 2.5 at presentation to the ED and
received IV fluids first night of admission, we initially held
torsemide. Her lactate normalized with IVF and she was restarted
on her home torsemide prior to discharge.
--Inactive issues--
# Chronic kidney disease: Cr remained near her baseline of
1.5-1.8 this admission. Her antibiotics were renally dosed.
# Diastolic Heart Failure/Pulmonary HTN: Patient recently
started on tadalafil for the pulmonary HTN, and DOE seemed to
have improved. She was continued on sildenafil 20mg tid as an
inpatient as tadalafil is non-formulary. On torsemide as an
outpatient which was held given that she appeared volume
depleted and had an elevated lactate. Torsemide was restarted
prior to discharge and she appeared euvolemic.
# Hypertension, benign: Normotensive this admission. She was
continued on her home metoprolol and torsemide was restarted at
discharge as above.
# Diabetes mellitus type 2: A1c last admission was 6.6%, which
makes the diagnosis of T2DM. She does not currently take any
medications for her diabetes and does not check her blood sugar
at home. She will follow-up with her PCP regarding further
management of her T2DM.
# Atrial Fibrillation: CHADS2 is 3 at admission (CHF, HTN, Age).
INR was subtherapeutic this 1.7. Her warfarin was increased to
4mg daily. HR remained well controlled on her home dose of
metoprolol. We have asked her to have her INR checked ___
___ and faxed to her PCP, ___ manages her warfarin.
#Facial rash: Malar facial rash noted during recent
hospitalization. ___, anti-histone and anti-DS DNA negative at
that time which argues against lupus as a cause. There was some
concern about a reaction to taldalafil as the rash appeared
after initiation of this medication. She was prescribed
hydrocortisone cream last admission and currently has no notable
facial rash this admission.
# Thrombocytopenia: Plt remained in the low 100s, which is
slightly above her baseline. Cause of her thrombocytopenia is
unclear.
# Code status this admission: FULL (confirmed)
# Emergency contact: ___ (daughter) - ___
# Transitional issues:
-Warfarin dose changed to 4mg daily, will check INR on ___
___ and results will be faxed to her PCP ___ continue an additional 5 days of Bactrim/Keflex as an
outpatient for total 7 day course
-Patient and daughter were informed of concerning signs/sx that
would require medical attention: fever, chills, worsening
erythema, worsening pain, or purulent discharge
-Will need monitoring of her A1c and glycemic control as an
outpatient, patient unaware that she is diabetic
-Notable labs on last check here: Platelets 103, Eosinophils
6.3%, INR 1.1, Creatinine 1.5
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/CaregiverwebOMR.
1. Multivitamins 1 TAB PO DAILY
2. Warfarin 3 mg PO DAILY16
3. Hydrocortisone Oint 0.5% 1 Appl TP TID
Apply to facial rash, avoid skin around eyes
4. Cetirizine *NF* 10 mg Oral Daily
5. tadalafil *NF* 20 mg Oral bid
6. Torsemide 20 mg PO BID
Hold for SBP <100
7. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5
8. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
2. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5
3. Warfarin 4 mg PO DAILY16
RX *warfarin 4 mg daily Disp #*30 Tablet Refills:*0
4. Cephalexin 500 mg PO Q8H Duration: 5 Days
Last dose on ___
RX *cephalexin 500 mg Every 8 hours Disp #*15 Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
Last dose on ___
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg twice daily Disp
#*10 Tablet Refills:*0
6. Cetirizine *NF* 10 mg Oral Daily
7. Hydrocortisone Oint 0.5% 1 Appl TP TID
Apply to facial rash, avoid skin around eyes
8. Metoprolol Succinate XL 25 mg PO DAILY
9. tadalafil *NF* 20 mg Oral bid
10. Torsemide 20 mg PO BID
Hold for SBP <100
11. Outpatient Lab Work
___ - ___. Diagnosis: atrial fibrillation. Fax
results to Dr. ___ at ___.
1. Multivitamins 1 TAB PO DAILY
2. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5
3. Warfarin 4 mg PO DAILY16
RX *warfarin 4 mg daily Disp #*30 Tablet Refills:*0
4. Cephalexin 500 mg PO Q8H Duration: 5 Days
Last dose on ___
RX *cephalexin 500 mg Every 8 hours Disp #*15 Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
Last dose on ___
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg twice daily Disp
#*10 Tablet Refills:*0
6. Cetirizine *NF* 10 mg Oral Daily
7. Hydrocortisone Oint 0.5% 1 Appl TP TID
Apply to facial rash, avoid skin around eyes
8. Metoprolol Succinate XL 25 mg PO DAILY
9. tadalafil *NF* 20 mg Oral bid
10. Torsemide 20 mg PO BID
Hold for SBP <100
11. Outpatient Lab Work
___ - ___. Diagnosis: atrial fibrillation. Fax
results to Dr. ___ at ___.
Discharge Disposition:
Home With Service
Facility:
___.
Discharge Diagnosis:
Primary diagnoses:
Cellulitis
Secondary diagnoses:
Chronic venous stasis with skin ulceration
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 admission to
___ for leg pain and swelling. Your leg ulcers are due to
chronic venous stasis, which is impaired blood blod returning
through the veins of your leg. You were also found to have a
cellulitis, or skin infection over the leg which we treated with
antibiotics. You will continue antibiotics after discharge and
will follow-up with the vascular surgeons. Please keep your
legs wrapped and elevated as much as you can. The visitin nurse
___ help you with dressing changes and wound care.
Your dose of warfarin was increased to 4mg daily because your
INR was low. Please have your INR re-checked on ___ and
discuss your warfarin dosing with your PCP.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
The following changes were made to your medications:
START Keflex ___ every 8 hours for 5 more days
START Bactrim DS 1 tab every 12 hours for 5 more days
CHANGE warfarin 4mg daily
Followup Instructions:
___
|
19757915-DS-16
| 19,757,915 | 26,505,439 |
DS
| 16 |
2151-02-27 00:00:00
|
2151-02-27 20:09:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cephalexin / Bactrim / Amoxicillin
Attending: ___.
Chief Complaint:
Right leg pain and redness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ y/o ___ speaking F with h/o severe
right-sided CHF and moderate TR, HTN, Afib, chronic right lower
extremity ulcer, CKD, thrombocytopenia, and fatty liver who
presents with worsening of left leg pain, swelling and redness.
The patient was recently discharged on ___ after a two day
admission with similar complaints concerning the right leg.
History obtained from patient's family member who had limited
___.
The patient was discharged after her last admission with 7 days
of bactrim and keflex. She was also instructed on wound care and
given ACE bandages for compression. She was seen by a visiting
nurse. On ___ the patient was seen in vascular surgery clinic
where it was noted that her legs remained edemtous with
erythema. Her ___ was given updated recommendation on leg care.
Since that time the patient's symptoms have continued to worsen;
especially on the left over the past 3 days. She also describes
L breast and abdominal swelling as well. The patient endorses
complaince with all prescribed treatments and no dietary
indescretions. She reports no CP and states that her DOE is at
her baseline. No fevers/chills.
Of note, the patient's family member describes what may have
been a drug rxn to the keflex/bactrim. She has multiple healing
leasions over her back and chest. The exam noted by vasc surg on
___ also notes a rash c/w drug eruption on patient's legs and
trunk.
In the ED, initial vitals were 97.6 60 129/73 20 97%. Labs were
notable for trop of 0.02 which is a chronic elevation for her.
Potassium was low at 3.1 and this was repleted. BNP 1687, Cr
1.4. INR supratherepeutic at 4.7. ECG shows afib w/o ischemic
change. She was given 40mg IV furosemide and admitted to
medicine. On transfer vitals were 98.0 66 18 129/75 97%ra.
On arrival to the floor the patient appeared well. No SOB and
saturating well on RA. Pain controlled.
REVIEW OF SYSTEMS: Could not perform due to language barrier.
Past Medical History:
- T2DM (A1c=6.6% in ___, not on medications)
- hypertension
- atrial fibrillation on warfarin
- diastolic heart failure (EF >55%)
- pulmonary hypertension: on tadalafil
- chronic right lower extremity ulcer
- Chronic kidney disease (baseline Cr 1.5-1.8)
- thrombocytopenia
- transaminitis
- fatty liver, small right pleural effusion and a small amount
of ascites
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. NO family history of blood disorders or
clots.
Physical Exam:
VITALS: 98.2 130/88 65 98%RA 155lb
GENERAL: Well appearing. In no acute distress.
HEENT: PERRL, EOMI
NECK: no carotid bruits, JVP noted above the angle of the jaw
CHEST: Good air entry b/l, mild crackles at the bases. No edema,
erythema or atypical lesions over the left breast on my exam.
HEART: Irregularly irregular, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly. Mildly distended.
EXTREMITIES: ___ b/l L>R. Pulses intact.
Hyperpigmented areas and ulcerations without surrounding
erythema on the right leg and ankle. Left leg is markedly
edemetous with macular erythema to the mid-shin. No focal area
of infection.
NEUROLOGIC: Could not completely assess due to language barrier.
Strength is intact throughout. CN II-XII grossly intact.
On discharge weight was down 5 kg. Redness and erythema of L
lower extremity considerably improved.
Pertinent Results:
on admission
___ 05:15PM BLOOD WBC-7.2 RBC-3.64* Hgb-12.1 Hct-37.2
MCV-102* MCH-33.1* MCHC-32.4 RDW-16.6* Plt ___
___ 05:15PM BLOOD ___ PTT-48.0* ___
___ 05:15PM BLOOD Glucose-143* UreaN-46* Creat-1.4* Na-142
K-3.1* Cl-101 HCO3-32 AnGap-12
___ 07:15AM BLOOD ALT-28 AST-56* LD(LDH)-345* AlkPhos-152*
TotBili-1.8*
___ 05:15PM BLOOD proBNP-1687*
___ 05:15PM BLOOD cTropnT-0.02*
___ 05:15PM BLOOD Calcium-8.4 Phos-2.8 Mg-2.2
___ 11:00AM BLOOD Hapto-91
on dc
___ 12:44PM BLOOD WBC-5.5 RBC-3.64* Hgb-12.2 Hct-37.8
MCV-104* MCH-33.5* MCHC-32.3 RDW-16.3* Plt ___
___ 06:30AM BLOOD Glucose-91 UreaN-33* Creat-1.5* Na-143
K-3.5 Cl-102 HCO3-35* AnGap-10
___ 11:00AM BLOOD LD(___)-389* TotBili-2.0* DirBili-1.0*
IndBili-1.0
___ 07:17AM BLOOD ALT-31 AST-64* AlkPhos-171* TotBili-1.9*
DirBili-1.0* IndBili-0.9
___ 07:10AM BLOOD Phos-3.2 Mg-2.2
Atrial fibrillation with controlled ventricular response.
Prolonged
Q-T interval. Delayed R wave progression with decreased QRS
voltage,
particularly in the precordial leads. Cannot exclude prior
anterior wall
myocardial infarction. Non-specific ST-T wave abnormalities.
Compared to the previous tracing of ___ the rate is a little
faster. Overall, no diagnostic
change.
CXR- No evidence of acute disease or significant change.
Enlargement
of the main pulmonary artery, worrisome for pulmonary arterial
hypertension.
___ L leg No evidence of deep vein thrombosis.
RUQ US
IMPRESSION:
1. Diffusely increased echogenicity of the liver is most likely
related to passive hepatic congestion in this patient with
history of CHF, elevated LFTs, pulsatile portal vein and
distended IVC and hepatic veins. Other forms of liver disease
and more advanced liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study. No focal
liver lesions.
2. No sonographic evidence of cholelithiasis, acute
cholecystitis, or biliary
ductal dilatation.
3. Simple right renal cyst.
Brief Hospital Course:
summary
Ms. ___ is an ___ year old ___ speaking woman with a
complicated medical history including R heart failure and
chronic venous stasis who presents with worsening edema and
erythema of her LLE, now resolving on antibiotics, with drug
rashes from keflex and now amox.
active issues
#L leg cellulitis-
She was treated initially treated with IV vanc, then PO amox and
doxy. Switched to clindamycin for new drug rash likely from
amox. Initial dose of vanc given ___. Final dose of
clindamycin will be ___. Her legs were dressed and
compressed with ACE bandages and kept elevated as much as
possible during her stay. On discharge the erythema and edema
of her L leg was resolved. She should follow up with vascular
next ___, and with Dr. ___ on ___.
#Fatty Liver
Alk phos at 171, AST 64, ALT 31, total bili 1.9, dir bili 1.0.
History of transaminitis and diagnosis of fatty liver, had last
abdominal US ___ which showed reversal of flow in portal
vein during inspiration which may be related to heart failure -
this may be causing hepatic congestion and her transaminitis.
Her last US also showed an echogenic liver consistent with fatty
depostion however cirrhosis could not be excluded. Repeat US on
this admission was essentially unchanged. Patient currently
without abdominal pain or RUQ tenderness. Cholestasis from
antibiotics may also be contributing to her current
transaminits. She should follow up with her PCP.
#: Afib on Coumadin - was supratherapeutic, may be related to
recent course of bactrim. Coumadin was held and INR went down.
She was given 1mg coumadin ___ and 2mg ___. INR should be
drawn by her ___ and faxed to Dr ___ she sees him on
___.
#Chronic Right sided CHF
JVD is expected in the context of severe TR, no crackles on
exam. She was diuresed with extra torsemide and IV lasix once
and eventually her weight was down about 5kg from admission.
Her Cr began to rise along with bicarb suggesting she was dry
and developing contraction alkalosis. Torsemide was reduced to
20mg once daily dosing which is what she will be discharged on.
Chem 7 will be drawn by ___ and results sent to Dr. ___ that
he can raise her dose back to her previous home dose of 20mg
twice daily if indicated. She should follow up with Dr. ___
at her next scheduled appointment.
Inactive Issues:
#: DMII
Patient refused finger sticks, glucose was well controlled in
house and last A1C 6.6, insulin was discontinued.
#HTN - Continued on home metoprolol
Transitional Issues:
#Cellulitis - will follow up with Dr. ___ on ___ for any signs
of recurrent infection
#CHF - will follow up with Dr. ___ was down 5kg during
the course of this admission
#Afib on coumadin - will have INR drawn by ___ and sent to Dr.
___. She was d/c'd on 2mg coumadin qd which may need to be
adjusted.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/CaregiverwebOMR.
1. Multivitamins 1 TAB PO DAILY
2. Cetirizine *NF* 10 mg Oral Daily
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Torsemide 20 mg PO BID
Hold for SBP < 110
5. Calcium Carbonate 500 mg PO BID
6. Vitamin D 400 UNIT PO DAILY
7. Bacitracin Ointment 1 Appl TP BID
Apply to leg lesion
8. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Start:
In am
Hold for K > 4.5
10. Warfarin ___ mg PO DAILY16
Discharge Medications:
1. Bacitracin Ointment 1 Appl TP BID
Apply to leg lesion
2. Calcium Carbonate 500 mg PO BID
3. Cetirizine *NF* 10 mg Oral Daily
4. Multivitamins 1 TAB PO DAILY
5. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K > 4.5
6. Vitamin D 400 UNIT PO DAILY
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Outpatient Lab Work
Please draw INR to adjust coumadin dosage, chem7 to monitor
creatinine and adjust torsemide dosage. ICD-9 Codes: ___,
___.31 Please fax results ___ MD Phone:
___ Fax: ___
9. Warfarin 2 mg PO DAILY16
10. Sarna Lotion 1 Appl TP BID:PRN pruritus
11. Hydrocortisone Cream 0.5% 1 Appl TP TID:PRN itch, rash
12. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth three times a
day Disp #*4 Tablet Refills:*0
13. Torsemide 20 mg PO DAILY
Hold for SBP < 110
Discharge Disposition:
Home With Service
Facility:
___.
Discharge Diagnosis:
Cellulitis
Discharge Condition:
Improved, mental status at baseline, ambulatory
Discharge Instructions:
You were admitted to the hospital because of an infection in
your left leg. You were treated with IV antibiotics and then
switched to oral antibiotics. You were allergic to keflex,
bactrim, and amoxicillin and are now on clindamycin. It is very
important that you finish taking all of these antibiotics;
tomorrow will be your last day. Your coumadin dose is 2mg per
day, your blood will be drawn on ___ and the results faxed to
Dr. ___. You should follow up with Dr. ___ on ___ to adjust
your coumadin dose and check on your leg. Until ___ if Dr.
___ otherwise, you should only take your torsemide once a
day.
You should also follow up with vascular surgery (appointment
below), cardiac services (appointment below)
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. If you notice itching all over your body, a rash,
or difficulty breathing or swelling in your mouth or throat you
should call your doctor immediately.
Followup Instructions:
___
|
19758005-DS-8
| 19,758,005 | 25,835,989 |
DS
| 8 |
2174-04-26 00:00:00
|
2174-04-26 22:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Prozac / Zoloft / clindamycin / Bactrim / trazodone / tree nut /
apple / shrimp / shellfish derived / raw vegetable / raw fruit /
animal dander / Flexeril / diclofenac
Attending: ___.
Chief Complaint:
Tachypnea
Major Surgical or Invasive Procedure:
Femoral line placement ___
Intubated ___
Extubated ___
History of Present Illness:
History of presenting illness: ___ with a history of angioedema
requiring multiple prior intubations who presents with tongue
swelling. The patient arrived to the ED in acute respiratory
distress and was unable to provide the team with a verbal
history. She was given Epi and Icatibant with no improvement.
She had a femoral line placed. She was intubated with anesthesia
at the bedside via awake fiberoptic method. She was admitted to
the ___ for close airway monitoring. Upon arrival, the patient
is on Propofol for sedation but able to follow commands and type
on her phone. States she has pain from the tube. According to
the mother on the phone she has been to multiple hospitals over
the past year and had multiple admissions with intubations
lasting from 1 day to 13 days. She has an appointment with an
Allergist and a complex Psych diagnosis at ___ next week.
Past Medical History:
Angioedema
Prolonged QT
Tachycardia (has loop monitor in place)
Tourettes
PTSD
Anxiety
OSA
asthma
Migraines
Social History:
___
Family History:
Adopted from ___. Nothing is known about her birth parents.
Physical Exam:
ADMISSION:
Constitutional / General appearance: Intubated, Awake and alert
HEENT: Endotracheal tube in place
Neurologic: Moves all limbs, Follows commands
Cardiovascular: Regular rate and rhythm
Respiratory: Good symmetric air entry throughout
GI / Abdomen: Soft, nontender
GU / Renal: Clear urine
DISCHARGE:
PO 146 / 86 L Lying ___ Ra
GENERAL: NAD
HEENT: Sclerae anicteric, conjunctivae noninjected, MMM, no
tongue
swelling, 1 cm laceration on palate
NECK: nontender supple neck, no LAD
HEART: Tachycardic, regular rhythm, S1/S2, no murmurs, gallops,
or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles; no stridor
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: warm, no edema
NEURO: Alert and oriented, moving all extremities
Pertinent Results:
ADMISSION:
___ 02:01PM GLUCOSE-132* UREA N-12 CREAT-0.7 SODIUM-139
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-20* ANION GAP-8*
___ 02:01PM CALCIUM-8.8 PHOSPHATE-2.8 MAGNESIUM-1.6
___ 02:01PM WBC-14.7* RBC-3.78* HGB-8.9* HCT-29.0*
MCV-77* MCH-23.5* MCHC-30.7* RDW-19.4* RDWSD-54.1*
___ 02:01PM PLT COUNT-221
___ 12:20PM ___ PO2-47* PCO2-48* PH-7.31* TOTAL
CO2-25 BASE XS--2 INTUBATED-INTUBATED
___ 12:20PM O2 SAT-74
___ 12:15PM GLUCOSE-107* UREA N-14 CREAT-0.5 SODIUM-145
POTASSIUM-3.6 CHLORIDE-111* TOTAL CO2-23 ANION GAP-11
___ 12:15PM estGFR-Using this
___ 12:15PM WBC-12.7* RBC-3.68* HGB-8.4* HCT-28.5*
MCV-77* MCH-22.8* MCHC-29.5* RDW-19.5* RDWSD-54.1*
___ 12:15PM NEUTS-77.6* LYMPHS-12.2* MONOS-5.0 EOS-0.3*
BASOS-0.2 NUC RBCS-0.2* IM ___ AbsNeut-9.87* AbsLymp-1.55
AbsMono-0.64 AbsEos-0.04 AbsBaso-0.03
___ 12:15PM PLT COUNT-220
___ 11:17AM ___ PO2-33* PCO2-46* PH-7.36 TOTAL
CO2-27 BASE XS-0
___ 11:17AM O2 SAT-54
NOTABLE:
___ 05:17AM BLOOD PEP-PND IgG-309* IgA-34* IgM-90
___ 05:17AM BLOOD C3-170
___ 04:02PM BLOOD C4-37
DISCHARGE:
___ 05:17AM BLOOD WBC-10.9* RBC-3.56* Hgb-8.0* Hct-27.1*
MCV-76* MCH-22.5* MCHC-29.5* RDW-19.9* RDWSD-55.2* Plt ___
___ 05:17AM BLOOD ___ PTT-21.2* ___
___ 05:17AM BLOOD Glucose-83 UreaN-27* Creat-0.7 Na-146
K-3.4* Cl-108 HCO3-26 AnGap-12
___ 05:17AM BLOOD TotProt-5.2* Calcium-8.3* Phos-5.3*
Mg-2.0
Brief Hospital Course:
This is a ___ year old female with past medical history of PTSD,
Tourette's syndrome, OSA on CPAP, recurrent angioedema of
unclear
etiology who was admitted ___ with angioedema and acute
hypoxic respiratory failure requiring intubation and ICU care,
subsequently extubated and improving able to be discharged home
# Angioedema:
Patient described acute onset of tongue swelling following
eating chicken fingers and ___ fries. She presented to the
ED where she was found to have tongue swelling and to be unable
to speak. She was treated with H1/H2 blockers, dexamethasone,
IM epinephrine and icatibant and was intubated for airway
protection. On intubation she was noted to have minimal airway
edema and cuff leak. She was extubated 24 hours later. Allergy
was consulted and felt that etiology was likely histaminergic
rather than bradykinin mediated with possible contribution from
recent psychosocial stressors. C3 and C4 were checked and were
normal. Immunoglobulin levels were checked and were notable for
low IgG (309) and low IgA (34). She was discharged on her home
regimen of Benadryl BID cetirizine, and singulair. She has
scheduled allergy follow up at ___ with Dr. ___ on ___.
# Sinus Tachycardia: Patient with history of tachycardia of
unclear
etiology for which she follows with cardiology and has a loop
monitor in place. Her metoprolol was held in the ICU and she
subsequently developed HRs to the 130s (sinus on ECG). She was
given 2.5 mg IV metoprolol and her home metoprolol was
restarted with improvement in her HRs.
# Difficult IV access: Femoral CVL placed with sterile
technique in ED due to inability to place PIV. Multiple
attempts made at upper extremity peripheral IV access in the
ICU as well, unsuccessful. Midline placement attempted by ___
RN, unsuccessful. Given extremely difficult access and likely
short length of stay decision made to leave femoral vein triple
lumen catheter in place for transfer to floor with plan to
pursue ___ guided venous access if long-term access needed.
Femoral line was pulled on the day of discharge.
TRANSITIONAL ISSUES
[] Patient reports that she had QT prolongation and can not
take Zofran or other QT prolonging meds. QTc normal on ECG here
and is on Seroquel at home. Would clarify patient's ability to
take QT prolonging medications with outpatient providers.
[] Per allergy, could consider Xolair as an outpatient
[] Patient found to have low IgG (309) and low IgA (34) levels;
consider repeat check and additional management as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. QUEtiapine Fumarate 25 mg PO QHS
2. LORazepam 2 mg PO QHS:PRN anxiety
3. Montelukast 10 mg PO DAILY
4. Cetirizine 10 mg PO BID
5. Ranitidine 150 mg PO BID
6. DiphenhydrAMINE 25 mg PO TID
7. DiphenhydrAMINE 25 mg PO DAILY:PRN itching/allergies
8. Latuda (lurasidone) 80 mg oral DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. melatonin 20 oral QHS
12. Zolpidem Tartrate 5 mg PO QHS
13. Promethazine 12.5 mg PO DAILY
14. Promethazine ___AILY
15. TraMADol 50 mg PO DAILY:PRN migraine
16. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
17. Albuterol Inhaler 2 PUFF IH PRN wheezing
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH PRN wheezing
2. Cetirizine 10 mg PO BID
3. DiphenhydrAMINE 25 mg PO DAILY:PRN itching/allergies
4. DiphenhydrAMINE 25 mg PO TID
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
6. Latuda (lurasidone) 80 mg oral DAILY
7. LORazepam 2 mg PO QHS:PRN anxiety
8. melatonin 20 oral QHS
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Montelukast 10 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Promethazine ___AILY
13. Promethazine 12.5 mg PO DAILY
14. QUEtiapine Fumarate 25 mg PO QHS
15. Ranitidine 150 mg PO BID
16. TraMADol 50 mg PO DAILY:PRN migraine
17. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Angioedema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because you were having tongue swelling
and trouble breathing. This was likely an episode of angioedema.
You had a breathing tube placed and were given mediations to
treat your angioedema. You improved and the breathing tube was
removed. You have close follow up with an allergist and with
your PCP and should keep those appointments.
It was a pleasure participating in your care. We wish you all
the best in the future.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19758044-DS-4
| 19,758,044 | 21,130,068 |
DS
| 4 |
2156-05-03 00:00:00
|
2156-05-04 08:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram (___)
Peripherally inserted central catheter (PICC) placement (___)
Chest tube placement by ___
CT-guided abscess drainage by ___ (___)
Chest tube removal (___)
History of Present Illness:
This is a ___ female with history of IV drug use who
presents with five-day history of gradually worsening chest pain
who was transferred from ___ for concern for
epidural abscess.
She initially presented to ___ with complaints of
chest pain. At ___, EKG showed no ischemic events. Labs were
notable for WBC 21.7, hyponatremia 128, hyperglycemia of 588, no
anion gap, lactate of 2.5, and negative troponin x1. Her urine
tox screen was positive for cocaine and opiates. A CT was
performed that showed a right upper lobe lung abscess. Decision
was made to transfer to ___ because patient was complaining of
midline back pain and given her drug use there was a concern for
an epidural abscess.
At ___, lactate improved to 1.7. UA notable for leuks/glucose
1000/ketones 10. MRI of back was performed and did not show
abscess, Interventional pulmonary was consulted for lung abscess
and recommended conservative management with IV antbiotics.
Patient was given morphine, hydromorphone, and started on
vancomycin/cefepime.
On the floor, she continues to have right-sided chest pain with
inspiration and expiration. Denies fevers or chills. Denies
shortness of breath. Denies pain elsewhere. Last heroin use ___
days ago about a "40" via IV in arms. Denies smoking or skin
popping heroin. Previously on suboxone and methadone, but have
been on neither in years.
Past Medical History:
IV drug use previously on methadone and suboxone
anxiety
depression
PTSD
Social History:
___
Family History:
No cardiac history.
Physical Exam:
Admission physical exam:
========================
Vital Signs: T 99.7, BP 149/87, HR 103, O2 Sat 95% on RA
General: Alert, oriented, no acute distress at rest, grimacing
with movement.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2. Ejection murmur. No
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. Cutaneous abscess on left hand. Ulceration on right hand.
Scab on left ankle.
Neuro: CNII-XII intact, gross motor intact.
MSK: Right upper chest tender to palpation, reproducible pain.
Physical exam day of AMA:
=============================
Vitals: afebrile Tc 98.7, BP ___ (112/64), HR ___
(76), RR 18, 97% on RA
- Fasting glucose this AM: 219
- Chest tube output: ___ mL, ___ mL, ___ mL;
___ - negative 40; ___
Exam:
General: Lying in bed in NAD
HEENT: PERRL, MMM
Heart: RRR, no murmurs
Lungs: Diminished lung sounds on right, but improving. No
wheezes. R chest tube with serosanguinous drainage. (Removed by
IP prior to leaving AMA).
Abdomen: Soft, non-distended. Tender to right upper quadrant.
Bowel sounds present.
Extremities: WWP. (PICC removed from right arm before leaving
AMA).
Neuro: oriented x3, motor grossly intact
Skin: 2cmx3cm, erythematous abscess on dorsal surface of R hand
Pertinent Results:
Admission labs:
===============
___ 02:18AM WBC-24.3* RBC-3.94 HGB-11.0* HCT-32.7* MCV-83
MCH-27.9 MCHC-33.6 RDW-13.3 RDWSD-40.4
___ 02:18AM NEUTS-85.3* LYMPHS-8.3* MONOS-5.0 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-20.72* AbsLymp-2.03 AbsMono-1.22*
AbsEos-0.01* AbsBaso-0.07
___ 02:18AM PLT COUNT-425*
___ 02:18AM GLUCOSE-300* UREA N-10 CREAT-0.3* SODIUM-131*
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-20* ANION GAP-18
___ 02:19AM LACTATE-1.7
___ 02:19AM ___ RATES-/24 PO2-48* PCO2-31* PH-7.46*
TOTAL CO2-23 BASE XS-0 INTUBATED-NOT INTUBA
___ 01:10AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-MOD
___ 01:10AM URINE RBC-10* WBC-15* BACTERIA-FEW YEAST-NONE
EPI-6
___ 08:37AM CK-MB-<1 cTropnT-<0.01
Notable labs:
=============
___ 02:37AM %HbA1c-12.7* eAG-318*
___ 08:37AM TRIGLYCER-179* HDL CHOL-17 CHOL/HDL-9.5
LDL(CALC)-108 ___
___ 08:37AM CHOLEST-161
___ 03:45AM BLOOD Ret Aut-1.5 Abs Ret-0.05
___ 07:35AM BLOOD ALT-8 AST-11 AlkPhos-102 TotBili-<0.2
___ 07:35AM BLOOD Lipase-9
___ 03:45AM BLOOD Iron-13*
___ 07:35AM BLOOD VitB12-768 Folate-15.5
___ 04:51AM BLOOD HIV Ab-Negative
___ 04:51AM BLOOD HCV Ab-Positive*
___ 04:37PM BLOOD pH-6.49* Comment-PLEURAL FL
Imaging:
========
MRI spine ___:
1. Please note that the study had to be aborted because of
patient discomfort and no lumbar spine axial images or
postcontrast images were acquired.
2. Right apical lung abscess with surrounding pulmonary
parenchymal opacity, better evaluated on recent prior outside CT
chest.
3. Extensive soft tissue swelling in edema in the right lateral
neck extending from C1 inferiorly to supraclavicular fossa and
posteriorly along right paraspinal musculature to at least T6
level, with associated edema involving the right paraspinal
musculature. Findings are incompletely evaluated in the absence
of intravenous contrast, and are concerning for infectious
etiology, given presence of right upper lobe pulmonary abscess.
4. Mild degenerative disease involving the visualized cervical,
thoracic and lumbar spine without high-grade neural foramina or
spinal canal stenosis at any level, as described above.
Transthoracic echocardiogram ___:
- No echocardiographic evidence of endocarditis. Normal
biventricular wall thickness, cavity size and regional/global
systolic function. Normal diastolic function.
Transesophageal echocardiogram ___:
- No valvular vegetation or pathologic valvular flow.
Portable chest x-ray ___:
- Right apical opacity compatible with known lung abscess.
- Hazy opacity over the remainder of the right lung could
reflect asymmetric pulmonary edema or layering effusion.
Noncontrast chest CT ___:
- Interval enlargement of right apical lung abscess.
Consideration may be
given to percutaneous drainage if clinically appropriate.
- Moderate emphysema. New interlobular septal thickening in the
right lung
could reflect mild asymmetric pulmonary edema.
- Borderline enlarged right axillary lymph nodes, likely
reactive.
- 2.9 x 2.7 cm left adrenal nodule warrants further evaluation
with dedicated triphasic CT of the abdomen or MRI non urgently.
Chest CT with contrast ___:
- Right upper chest fluid collection is similar in size compared
to ___. While it is still centered in the lung, it
abuts the entire pleural surface, suggesting empyema.
- There appears to be slightly increased loculated fluid at the
right base
compared to ___, but difficult to compare accurately
due to previous noncontrast technique and may be due to
redistribution of fluid.
- Left adrenal mass is again seen.
- Moderate right basilar atelectasis.
CXR ___, ___, 14:
- No pneumothorax secondary to chest tube placement.
RUQ US ___:
- No evidence of cirrhosis.
- No cholelithiasis.
- Small right pleural effusion.
Discharge labs:
===============
___ 04:54AM BLOOD WBC-10.2* RBC-3.22* Hgb-9.0* Hct-28.2*
MCV-88 MCH-28.0 MCHC-31.9* RDW-13.9 RDWSD-44.6 Plt ___
___ 07:35AM BLOOD Glucose-138* UreaN-6 Creat-0.5 Na-140
K-4.0 Cl-103 HCO3-30 AnGap-11
___ 07:35AM BLOOD ALT-8 AST-11 AlkPhos-102 TotBili-<0.2
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of IV drug
use, who presents with worsening chest pain. She had a right
upper lobe lung abscess seen on CT scan and had multiple
cutaneous abscesses. She was found to have MRSA bacteremia and
was treated with IV vancomycin (day 1 = ___ and switched to IV
ceftaroline with inability to achieve therapeutic levels of
vancomycin at increasing doses. Transthoracic echocardiogram and
transesophageal echocardiogram were both negative for
endocarditis. During admission, developed a loculated
parapneumotic effusions at right lung base, which led to
drainage and chest tube placement on ___ and removal on ___.
An apical loculated pleural effusion developed adjacent to the
abscess and was aspirated with CT-guidance by ___ on ___. She
was also found to have DM2 during admission. The patient left
AMA prior to repeat CT to determine if she would need surgical
management of her empyema.
#ACUTE BLOOD STREAM INFECTION: MRSA bacteremia initially treated
with IV vancomycin(day ___ = ___ and switched to IV ceftaroline
with inability to achieve therapeutic levels of vancomycin at
increasing doses. Transthoraic and transesophageal
echocardiograms were negative for endocarditis. Blood cultures
were negative starting on ___. She was given a script for
linezolid when she left AMA. Of note, PICC was d/c'd prior to
leaving AMA.
#LUNG ABSCESS: Right upper lobe lung abscess seen on CT and MRI,
not requiring drainage on admission. Sputum culture positive for
staph aureus. Was treated with ceftaroline as discussed above.
Developed a loculated parapneumonic effusion at lung base, found
to be empyema that was drained and chest tube placed on ___ by
IP. Pleural fluid was exudative with MRSA and both anaerobic and
fungal cultures negative. Right upper lobe abscess was found to
be enlarged on repeat CT chest imaging (___). At that time,
thoracic surgery was consulted and felt that she was not a
surgical candidate for VATS with washout because of her social
history and felt increased risk for bronchopleural fistula with
___ drainage. Chest CT was again repeated on ___ that showed
abscess abutting pleural wall with concern for empyema. This was
aspirated with CT-guidance by ___ on ___. Pleural fluid again
exudative that grew staph aureus, coagulase positive. Chest tube
was removed by IP on ___. When left AMA, was discharged with
script for linezolid for 30 days. Of note, plan was for repeat
CT on ___ to re-address question of surgical management. Plan
had been for patient to be discharged to facility to complete
prolonged IV antibiotic course.
#NEWLY DIAGNOSED DM2 REQUIRING INSULIN: HbA1C = 12.7. She was
started on insulin and was on glargine 32 units at night, 9
units humulog standing at meals with insulin sliding scale. When
left AMA, was not discharged with insulin. She had been a new
start on insulin but had no teaching and did not know how to
self-administer, had no supplies, etc. We felt this was quite
high risk and decided not to provide prescriptionfor insulin due
to the potential adverse effects in an uneducated
use of this. The plan had been for patient to receive insulin
education at time of discharge.
#CHEST PAIN : Most likely secondary to lung abscess discussed
above. Not cardiac with no acute cardiac events on EKG and 2
negative troponins. Pain was being treated with ibuprofen q6h,
acetaminophen q6h, oxycodone 15 mg q4h, and lidocaine patches.
#RIGHT-SIDED ABDOMINAL PAIN: Most likely secondary to
right-sided pleural effusion. LFTs and right upper quadrant were
normal with no evidence of hepatitis or biliary colic. Less
likely renal colic with UA negative for blood, or ascending UTI
with UA negative.
#HCV: HCV viral load was 9,210,000 IU/mL. No cirrhosis seen on
RUQ US. Will need follow-up outpatient.
#CUTANEOUS ABSCESS: Numerous abscesses that were not drained.
Likely from non-sterile use of needles. treated with antibiotics
described above.
#IV DRUG USE: Had methadone 20 mg once for withdrawal and pain,
but was not continued. HIV negative. Was seen by both social
work and addiction team. Interested in restarting ___
clinic.
# AMA discharge: Ms. ___ left AMA on ___. PICC was removed
prior
to discharge. She was given a script for linezolid at time of
discharge. It was explained to Ms. ___ that she is very
high risk for worsening of her clinical condition and even death
if she were to leave. Ms. ___ was able to explain back to
me that she risked losing her life by leaving but felt that the
benefit of
being at her niece's side while she gave birth outweighed the
benefit of staying inpatient and continuing her medical
treatment. Ms. ___ exemplified that she had capacity to
make this medical decision.
Transitional issues:
====================
Patient left AMA.
[ ] Discharged on linezolid PO, per ID.
[ ] Was not discharged on insulin.
[ ] Needs weekly labs for CBC with diff, BUN, Cr, vanco trough
[ ] Follow up ID appointment on ___
[ ] Repeat chest CT in ___ weeks depending on abx course, per IP
[ ] Follow up with IP after abx course ___ wks)
[ ] Follow up newly diagnosed HCV, genotyping as outpatient
[ ] diabetes outpatient follow-up
[ ] psychiatry outpatient follow-up
[ ] primary care outpatient follow-up
[ ] Needs naloxone prescription (though is able to get at needle
exchange), this was brought to bedside for patient but she did
not take it when left AMA
[ ] f/u left adrenal nodule found on CT with dedicated CT or MRI
Medications on Admission:
This patient is not taking any preadmission medications
Discharge Medications:
1. Linezolid ___ mg PO Q12H
RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute blood stream infection
Lung abscess
Empyema
Newly diagnosed type 2 diabetes requiring insulin
HCV
Cutaneous abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
*** patient left AMA ***
Dear Ms. ___,
You left the hospital against medical advice. We explained to
you the risks of leaving (death), but you still insisted on
leaving the hospital. We cannot discharge you with all the
medicines you need because it is not safe. We will give you
antibiotics to take by mouth called linezolid.
It was a pleasure to take care of you at ___.
Why was I here?
- You had an infection in your blood, lungs and skin.
- The amount of sugar in your blood was high, which means you
have diabetes.
What was done while I was here?
- You received antibiotics to treat your infections.
- You had 2 chest tubes placed to drain the abscess and fluid
from the lung infection.
- You received insulin to treat your diabetes.
- A blood test showed that you (previously) had hepatitis C
What should I do when I get home?
- You should take your medicines as prescribed.
- Follow-up with your primary care provider.
- Find healthcare professionals to help you be sober.
- Go to a ___ clinic.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
19758044-DS-5
| 19,758,044 | 24,570,468 |
DS
| 5 |
2156-05-13 00:00:00
|
2156-05-15 15:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___ Peripherally inserted central catheter (PICC) ___ left arm
___ Right VATS (video assisted thoracoscopic surgery),
pneumolysis and decortication of lung
___ Removed chest tubes left during VATS
History of Present Illness:
Ms. ___ is a ___ year old female with a PMHx of IV drug use,
anxiety, depression, and MRSA bacteremia who recently left the
hospital AMA (on ___ while being treated for her
bacteremia and lung abscesses. She is representing with chest
pain and abdominal pain.
During her hospitalization, she was started on IV vancomycin but
switched to ceftaroline given inability to achieve therapeutic
vanc levels. A TTE and TEE were negative for endocarditis. She
developed loculated parapneumonic effusions leading to chest
tube placement on ___ and removal on ___. She was also started
on insulin for a new diagnosis of T2DM.
___ the ED, she had an elevated WBC 25.3 and elevated glucose
479. Repeated CT showed reaccumulation of right upper lobe
empyema since complete drainage on ___ and a new lower lobe
empyema at the site of previous pigtail drain. She received
fluids, ceftaroline, and clindamycin.
She is ___ moderate distress from her chest and abdominal pain
but is otherwise well appearing and pleasant. She denies IVDU or
cigarettes since leaving AMA. She was unable to take the
linezolid that she was discharged with when left AMA because it
required preauthorization.
Past Medical History:
IV drug use previously on methadone and suboxone
anxiety
depression
PTSD
Social History:
___
Family History:
No cardiac history.
Physical Exam:
Exam on admission:
==================
Vital Signs: T 97.4, BP 110/64, HR 70, RR 20, O2 100% on RA
General: Alert, oriented, smiling, ___ no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breaths ___ R base, otherwise clear
Abdomen: Soft, nontender, non-distended, bowel sounds present
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Exam on discharge:
==================
Vitals:
-Temp 97.5-98.4, currently 97.5
-HR 49-56, currently 49
-BP 142-154/74-78, currently 142/78
-RR 18
-SpO2 96% on RA
General: pleasant woman, laying ___ bed, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: RRR, no murmurs
Lungs: Inspiratory effect is limited by pain. Decreased breath
sounds ___ right lung base. Clear to auscultation on left.
Abdomen: Soft, nontender, non-distended, bowel sounds present
GU: No foley
Ext: WWP, no edema. L PICC ___ place.
Back: Dressing at site of removed R chest tubes is C/D/I.
Pertinent Results:
Labs on admission:
==================
___ 11:30AM BLOOD WBC-25.3*# RBC-3.35* Hgb-9.2* Hct-28.9*
MCV-86 MCH-27.5 MCHC-31.8* RDW-14.3 RDWSD-44.5 Plt ___
___ 11:30AM BLOOD Neuts-93* Bands-0 Lymphs-5* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-23.53*
AbsLymp-1.27 AbsMono-0.51 AbsEos-0.00* AbsBaso-0.00*
___ 11:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 11:30AM BLOOD ___ PTT-28.0 ___
___ 11:30AM BLOOD Glucose-479* UreaN-14 Creat-0.7 Na-128*
K-5.6* Cl-92* HCO3-25 AnGap-17
___ 11:30AM BLOOD Calcium-8.4 Phos-2.2* Mg-1.5*
___ 11:37AM BLOOD Lactate-4.1* K-4.0
___ 04:34PM BLOOD Lactate-1.8
___ 01:16PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
___ 01:16PM URINE RBC-5* WBC-33* Bacteri-FEW Yeast-NONE
Epi-20
___ 01:16PM URINE UCG-NEGATIVE
Microbiology:
=============
- Urine culture ___: negative
- Blood culture ___: no growth
- Blood culture ___: no growth
- Blood culture ___: no growth
- Blood culture ___: pending
- Blood culture ___: pending
- Pleural fluid ___:
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
FLUID CULTURE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
Imaging:
========
- Chest x-ray ___: Persistent posterior right apical loculated
pleural fluid of with probable air-fluid level, air-fluid level
more conspicuous as compared to the prior study, fluid component
appear similar. Chest CT would provide further assessment.
- CT chest with contrast ___:
1. Re-accumulation of a right upper lobe empyema, now with
air-fluid level
since prior complete drainage on ___, measuring 5.6 x 3.4
cm.
2. New 5.3 x 2.2-cm right lower lobe empyema at the site of
prior pigtail
drain.
3. Emphysema.
4. 2.9-cm heterogeneously enhancing left adrenal nodule for
which further
evaluation with nonemergent adrenal MRI is recommended.
- Interval CXR ___: Chest tubes ___ place ___ right lung
apices. No pneumothorax
Labs on discharge:
==================
___ 05:00AM BLOOD WBC-7.0 RBC-3.07* Hgb-8.8* Hct-27.7*
MCV-90 MCH-28.7 MCHC-31.8* RDW-15.1 RDWSD-47.8* Plt ___
___ 05:34AM BLOOD Glucose-73 UreaN-9 Creat-0.6 Na-143 K-4.0
Cl-106 HCO3-32 AnGap-9
Brief Hospital Course:
Ms. ___ is a ___ yo woman ___ IVDU who was transferred to
___ with lung abscess found to have bacteremia s/p VATs, also
with new diagnosis of diabetes (Hg A1c 12.5%). The patient was
admitted ___ and left AMA and then returned ___.
# MRSA Bacteremia: Patient was initially on vancomycin but
switched to ceftaroline when she was unable to achieve
therapeutic levels of vanc on last admission. A TTE and TEE were
both negative for endocarditis. Blood cultures were negative day
___ = ___. She was continued on ceftaroline 600 mg Q12H and will
continue for 4 weeks (day 1 = ___ from day of source control;
last day = ___.
# Lung abscesses: RUL abscess seen on CT and MRI during prior
admission that were subsequently drained. Repeat CT scan showed
reaccumulation of RUL abscess and new RLL abscess at the site of
the prior pigtail placement. She received VATS decortication and
pneumolysis on ___ with no complications. Two chest tubes were
left ___ the right apical area and removed on ___. She was
continued on ceftaroline 600 mg Q12H as described above.
# T2DM: Insulin dependent during prior hospitalization. HA1C
12.7%. She was discharged with glargine 40 units QHS and Humalog
12 units standing with meals ___ addition to sliding scale. She
had ___ consult, and they did diabetes education and
insulin teaching. They recommended transitioning her to ___
insulin 52 units ___ the morning and 26 units at dinner prior to
her discharge from hospital or rehab. Given that she is planned
to go to rehab, we did not change her insulin regimen. They also
recommended further work-up of her diabetes as described ___ the
transitional issues.
# Chest Pain: Most likely secondary to lung empyema as above.
Anxiety can exacerbate her pain.
# Anemia: Required transfusion of 2 units of RBCs following VATS
procedure with anemia from acute blood loss. Her hemoglobin
remained stable at 9.3, which is her baseline. Her baseline
anemia most likely anemia of inflammation, exacerbated by poor
nutritional intake. She can benefit from oral iron
supplementation when she does not have an active infection.
# Right abdominal pain: Most likely secondary to right-sided
pulmonary abscess. ALT and AST normal. Alk phos similar to
prior. Recent RUQ ultrasound from prior admission showed no
cholelithiasis and liver of normal appearance.
# IVDU: Had social work and addiction RN consult. Patient is
very motivated to start treatment.
# Tobacco: 3 cigarettes a day. Used a nicotine patch while she
was ___ hospital.
# HCV: HCV viral load was 9,210,000 IU/mL. No cirrhosis seen on
RUQ
US.
Transitional issues:
====================
- 4 weeks IV ceftaroline 600 mg q12h (day 1 = ___, last day =
___ via PICC.
- pain control: patient should NOT continue oxycodone and
diazepam beyond ___
- HCV genotyping and treatment as outpatient
- New diabetes, HgA1C 12.5%
- ___ regards to insulin, she will be discharged on ___: 48
units with breakfast and 20 units with dinner. Please uptitrate
as appropriate
- Could consider anti-GAD and anti-islet ab as well as a
c-peptide to see if she is possibly ___
- 2.9-cm heterogeneously enhancing left adrenal nodule for which
further evaluation with non-emergent adrenal MRI is recommended.
She needs outpatient workup, with priority given to 1 mg dex
suppression test if she ends up presenting as outpatient or when
more clinically stable at discharge.
- may need repeat CT chest ___ 6 weeks but will defer to thoracic
surgery team
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H pain
2. Ceftaroline 600 mg IV Q12H
3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
4. Diazepam 5 mg PO Q6H:PRN pain, anxiety
should not be continued beyond ___. Docusate Sodium 100 mg PO BID
6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
7. Glucose Gel 15 g PO PRN hypoglycemia protocol
8. Heparin 5000 UNIT SC BID
9. Ibuprofen 600 mg PO Q6H:PRN pain
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Nicotine Patch 14 mg TD DAILY
12. OxyCODONE (Immediate Release) 15 mg PO Q4H:PRN pain
13. Senna 8.6 mg PO BID:PRN constipation
14. TraZODone 50 mg PO QHS:PRN insomnia
15. ___ 48 Units Breakfast
___ 20 Units Dinner
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Lung abscess
Lung empyema
Secondary diagnosis:
Type 2 diabetes, newly diagnosed requiring insulin
HCV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___.
Why was I here?
- You had an infection ___ your blood, lungs and skin.
- The amount of sugar ___ your blood was high, which means you
have diabetes.
What was done while I was here?
- You received antibiotics to treat your infections.
- You had a VATS (video assisted thoracoscopic surgery)
procedure to clean out the infection ___ your lungs.
- You received insulin to treat your diabetes.
What should I do when I get home?
- You should take your medicines as prescribed.
- Go to your ___ appointments.
- Find healthcare professionals to help you be sober.
- Go to a ___ clinic.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
19758044-DS-7
| 19,758,044 | 25,426,406 |
DS
| 7 |
2156-10-06 00:00:00
|
2156-10-11 02:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dyspnea, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female with past medical history significant for
diabetes mellitus newly diagnosed, IV drug use, hepatitis C,
posttraumatic stress disorder, anxiety, depression, and anemia
presenting with dyspnea and cough productive of yellow sputum.
She describes that she has had poor lung function ever since her
multiple pulmonary infections this past ___. In general, she
finds it hard to take a deep breath, experiences dyspnea on
exertion and feels wheezy, crackly and tight in her lungs. These
symptoms are worsened by laying down and cold weather. There is
no pain like with her lung abscess, she says, just dyspnea.
For the past three days, she has been having an acute increase
in the severity of her cough including a change the color and
quantity of her sputum. She has no history of COPD or asthma in
her history, although she does have family history of asthma and
emphysema she says. She presented to outside hospital ED (___?)
where she was diagnosed with COPD exacerbation and given
prednisone, albuterol inhaler and azithromycin. She has been
taking the medicine but does not feel any better.
She received her flu shot this year. She denies sick contacts,
recent travel, fevers, chills, weight loss, nausea, vomiting,
diarrhea, constipation or changes in urinary habits. She denies
any recent relapse with drugs.
In ___ she initially presented with RUL lung abscess and
cutaneous abscesses, found to be secondary to MRSA bacteremia.
Evaluation was negative for endocarditis. She also had loculated
parapneumonic effusion, underwent chest tube drainage and
ultimately CT-guided ___ aspiration and drainage on ___. She
left AMA during that hospitalization but then represented two
days later with similar symptoms and was found to have repeat
RUL abscess and new RLL abscess. She had a repeat VATS with
cultures c/w prior MRSA infection. Infectious disease
recommended 4 weeks of antibiotics starting from the date of
source control (___), and she was discharged to ___ with
a plan to continue IV ceftaroline 600 mg q12h until ___.
However, patient left ___ on ___. She then represented
___ with worsening R flank pain at site of previous chest
tube placement. Imaging with persistent RUL and RLL fluid
collections, though deemed to not be possible to further drain.
Patient was restarted on course of ceftaroline with plan for ___
weeks of antibiotics and reimaging in 3 weeks to re-adjust
course, as needed. Hospital course was complicated by sinus
bradycardia and QT prolongation on EKG. It was thought that the
sinus bradycardia was due to increased vagal tone in the setting
of pain. QT prolonging medications were avoided, and the
interval was closely monitored. Patient was being discharged to
___ for ongoing antibiotic therapy and opioid
taper.
In the interim, she started at ___ outpatient ___
clinic and started on methadone (she reports 80mg daily, not yet
on "take homes"). She is living at ___ My Sister's House.
In the ED, initial vitals: T98.7 92 144/79 20 100% RA, peak flow
240. Ambulatory 02 Sat 87% RA.
She was noted to be very wheezy.
Labs were significant for WBC 17.9, glucose 240 and lactate 2.2
CXR showed: "A vague opacity in the right lung base is new since
prior study, nonspecific and potentially atelectasis, in the
appropriate clinical setting may represent early infectious
process."
In the ED, she received multiple duonebs.
Vitals prior to transfer: T97.8, HR 88, Spo2 128/88, RR 20, SPo2
94% RA.
On arrival to the floor, she was on room air, did not have
audible wheezing and did not appear in distress.
Past Medical History:
- DM, diagnosed ___ with A1C 12.7
- Hepatitis C
- Lung abcess s/p VATS at ___ c/b MRSA bacteremia
- Anxiety
- PTSD
- IV drug abuse, heroin
Social History:
___
Family History:
No cardiac history. Family history of asthma and emphysema.
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
VS:T 98.3, BP 119/77, HR 82, RR 16, SpO2 94% RA. Wt. 73.48 kg
GEN: Alert, lying in bed, no acute distress; conversational and
appropriate
HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI
NECK: no JVD
PULM: no increased work of breathing, decreased breath sounds on
the right lower lung fields with associated dullness to
percussion; no wheezes or rhonchi appreciated
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, +BS, no HSM
EXTREM: Warm, well-perfused, no ___ edema
NEURO: CN II-XII grossly intact, motor function grossly normal,
sensation grossly intact
DERM: multiple tattoos on the back, no rashes, no obvious track
marks
DISCHARGE PHYSICAL EXAM
========================
VS: Tm 98.4, BP 120-140/73-85, HR 69-73, RR 20, SpO2 93-95% RA.
Wt. 73.48 kg on admission.
GEN: Alert, sitting up in bed, no acute distress; conversational
and appropriate
HEENT: Moist MM, anicteric sclerae, NCAT, PERRL, EOMI
NECK: no JVD
PULM: no increased work of breathing, wheezing has significantly
improved in the posterior fields, no crackles or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended, +BS, no HSM
EXTREM: Warm, well-perfused, no ___ edema
NEURO: CN II-XII grossly intact, motor function grossly normal,
sensation grossly intact
DERM: multiple tattoos on the back, no rashes, no obvious track
marks
Pertinent Results:
ADMISSION LABS
===============
___ 05:40PM BLOOD WBC-17.9*# RBC-5.24*# Hgb-14.6# Hct-43.5#
MCV-83# MCH-27.9 MCHC-33.6 RDW-14.8 RDWSD-44.4 Plt ___
___ 05:40PM BLOOD Neuts-73.6* Lymphs-18.5* Monos-6.5
Eos-0.6* Baso-0.4 Im ___ AbsNeut-13.17*# AbsLymp-3.31
AbsMono-1.17* AbsEos-0.11 AbsBaso-0.07
___ 05:40PM BLOOD Glucose-240* UreaN-15 Creat-0.6 Na-136
K-3.8 Cl-97 HCO3-24 AnGap-19
___ 05:40PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Negative
___ 05:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:50PM BLOOD Lactate-2.2*
OTHER PERITNENT LABS
====================
___ 07:00AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.9
___ 07:00AM BLOOD ALT-41* AST-35 AlkPhos-129* TotBili-0.6
___ 07:00AM BLOOD %HbA1c-7.6* eAG-171*
___:17AM BLOOD Lactate-1.7
___ 09:39AM BLOOD ___ PTT-27.2 ___
___ 07:00AM URINE Color-Yellow Appear-Hazy Sp ___
___ 07:00AM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 07:00AM URINE RBC-7* WBC-3 Bacteri-NONE Yeast-NONE
Epi-3
___ 07:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-POS* oxycodn-INTERFEREN mthdone-POS*
DISCHARGE LABS
===============
___ 07:19AM BLOOD WBC-7.7 RBC-4.97 Hgb-13.8 Hct-41.7 MCV-84
MCH-27.8 MCHC-33.1 RDW-14.5 RDWSD-44.1 Plt ___
___ 07:19AM BLOOD Glucose-214* UreaN-11 Creat-0.5 Na-134
K-4.3 Cl-97 HCO3-24 AnGap-17
MICROBIOLOGY
=============
___ BCx - no growth to date
___ UCx - no growth, final
___ 08:36AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
IMAGING
==========
___ CXR
IMPRESSION:
A vague opacity in the right lung base is new since prior study,
nonspecific and potentially atelectasis, in the appropriate
clinical setting may represent early infectious process.
___ CT Chest
IMPRESSION:
Interval resolution of the previously noted pleural
collection/empyema.
Multifocal areas of ground-glass opacity in the upper and mid
lung zones, bronchial wall thickening and retained secretions.
In the differential diagnosis consider infective bronchiolitis
and respiratory bronchiolitis interstitial lung disease (in the
setting of marked centrilobular emphysema).
Solid left adrenal lesion measuring 26 x 21 mm. This lesion is
not a lipid rich adenoma as evidenced by ___ value of 40 on the
previous non contrast study done ___. The lesion
demonstrates avid enhancement to 90 ___. Referral for
biochemical workup and possible tissue sampling advised.
Brief Hospital Course:
___ with history of polysubstance abuse c/b MRSA bacteremia and
lung abscesses in ___ who presented with acute on
subacute worsening of dyspnea and cough.
# Dyspnea, hypoxia: She had initially presented to OSH ED three
days prior and diagnosed with COPD exacberation. Patient with
reported dyspnea for months which was worsening over the past
month to week. She has no history of COPD or asthma, but was
very wheezy, and did not respond to albuterol, prednisone and
azithromycin as an outpatient. She does have history of
significant lung abscesses s/p multiple VATS in the past as a
complication of MRSA bacteremia. She was supposed to have repeat
CT Chest for follow-up but it is unclear if this occurred (not
in BI system). Given the chronicity of her symptoms, it is the
team chose to rule out superimposed bacterial infection, viral
respiratory panel and repeat chest CT to evaluate for recurrent
abscess/effusion. Chest CT imaging was preliminary during her
hospitalization, but suggested respiratory infection
(bronchiolitis), and no evidence of recurrent abscess or
effusion. Flu negative. She was initially treated with
ceftaroline and azithromycin while chest imaging was pending (to
cover for possible recurrent MRSA abscess), and then narrowed to
azithromycin mono therapy to cover for bronchitis. Clinically
she improved in terms of oxygenation, coughing and dyspnea. She
likely does have underlying COPD given imaging findings (see
below), though. Ambulatory O2 saturation was checked prior to
d/c and found to be 91-94% on room air. She was given duonebs,
steroids were held and she was discharged with instructions to
obtain PFTs as outpatient.
# Emphysema: noted to have centrilobular emphysema on Chest CT.
Likely ___ smoking given >30 pack year history. Has currently
cut down to 5 cigarettes/day. She will need PFTs as outpatient.
She was discharged with prn albuterol and spacer. She was
encouraged to stop smoking, as well.
# Leukocytosis: This was likely ___ to prednisone as outpatient
versus infection. Resolved with withdrawal of steroids that she
was prescribed at OSH ED.
# Opioid use disorder: patient with history of IV heroin abuse
now transitioned to methadone maintenance as an outpatient and
___ outpatient methadone. Her outpatient methadone dose
was confirmed to be 80mg PO daily with ___, LPN at ___.
- f/u GCMS opioid testing added by lab due to oxycodone assay
interference
# DMII: patient transitioned to oral agents (metformin and
glipzide) as outpatient. Used ISS as inpatient. A1C was 7.6%.
Increased glipizide to BID dosing as outpatient.
# HCV: patient diagnosed during ___ with viral load
9,210,000 IU/mL at the time. HIV negative. Only had mild
transaminitis. No evidence of infection by Hep B or Hep A. Needs
vaccination as outpatient.
# Insomnia, PTSD: continued home doxepin, abilify and
gabapentin.
TRANSITIONAL ISSUES:
====================
- CT chest final read still pending at discharge (>24hrs)
- Needs hepatitis B and A, pneumococcal vaccinations as
outpatient
- increased glipizide to BID dosing given A1C above goal
- f/u pending OPIATES, GC/MS (___) which was reflexively
checked by lab
- Needs PFTs done as outpatient
- discharged with albuterol inhaler, spacer and azithromycin
(last dose ___
- continue to encourage smoking cessation
- 2.9-cm heterogeneously enhancing left adrenal nodule again
noted; further evaluation with non-emergent adrenal MRI as well
as biochemical workup and possible tissue sampling advised.
Billing: Greater than 30 minutes spent on discharge counseling
and coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 5 mg PO QHS
2. Gabapentin 300 mg PO TID
3. MetFORMIN (Glucophage) 500 mg PO BID
4. nalOXone 4 mg/actuation nasal PRN
5. GlipiZIDE 5 mg PO DAILY
6. Doxepin HCl 50 mg PO HS
7. Methadone 80 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheezing
9. PredniSONE 40 mg PO DAILY
10. Azithromycin 250 mg PO Q24H
Discharge Medications:
1. Azithromycin 250 mg PO Q24H
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
2. GlipiZIDE 5 mg PO BID
RX *glipizide 5 mg 1 tablet(s) by mouth twice daily Disp #*30
Tablet Refills:*0
3. ARIPiprazole 5 mg PO QHS
4. Doxepin HCl 50 mg PO HS
5. Gabapentin 300 mg PO TID
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Methadone 80 mg PO DAILY
8. nalOXone 4 mg/actuation nasal PRN
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: acute bronchiolitis
SECONDARY: diabetes mellitus II, adrenal nodule, likely COPD
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 hospitalization
at ___. You were admitted for shortness of breath and a cough,
and found to have an infection of the lungs called
bronchiolitis. You were given antibiotics which helped improve
your breathing and your cough. We also gave you breathing
treatments with medications that can help if you have COPD. We
are suspicious that you may have COPD but this needs to be
confirmed with testing that you can do after you leave the
hospital. When you leave the hospital, you can continue to use
the albuterol inhaler that was prescribed to you earlier this
week, using it every six hours for wheezing. Albuterol works
best when used with a spacer (and is equivalent to the nebulizer
version when used with a spacer).
We are increasing your glipizide to twice daily to improve your
blood sugar control.
The CT scan that you had showed a small growth on one of your
adrenal glands. This was noted previously during your last
hospitalization. The next steps are to have some additional
blood work and testing, but does not require you to stay in the
hospital.
You should take all of your medications are prescribed and
follow-up with your doctor as below.
We wish you the best!
- Your ___ Team
Followup Instructions:
___
|
19758118-DS-12
| 19,758,118 | 26,769,790 |
DS
| 12 |
2142-05-13 00:00:00
|
2142-05-15 13:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F with history of neurofibromatosis, PVD, HTN, recent
admission for humeral fracture in setting of mechanical fall
treated conservatively (discharged 5 days ago, ___ who
presents with acute SOB. Evening of ___, patient reports dry
cough. 1 hr prior to presentation accutely SOB.
Per EMS, patient was satting mid ___ on non-rebreather. In the
ED, VITALS: T 97.2, HR 94, 220/124, 99% non rebreather. On exam,
negative JVP, no pedal edema, looked dry. Labs notable for:
Bicarb 13, K 6.4 (hemolyzed), AG 22, Phos 6, BNP 17,500, PLT
500, WBC 17, HCT 42, Hb 13, trop 0.02, Lactate 7.0. ABG: 7.42,
CO2 30, O2 130, Bicarb 20. CXR: LLL pna and some pulmonary
edema. For lactate 7, gave 750cc IVF, lactate improved to 2.1, K
4.5. As pt was given fluids, breathing improved.
ABG on non rebreather: pH 7.40, CO2 34, O2 81, HCO3 22,
Temp 100.2 rectally.
Pt was given: zosyn and levofloxacin 750mg.
Vitals on transfer: RR 24, 98.2 axillary, HR 75, 185/93
(150-160s SBP), 100% on non rebreather.
On arrival to the MICU, patient is comfortable on a
non-rebreather at 70%. She denies any chest pressure or
pleuritic component chest pain. She also denies any headache.
She is ___ on Room Air when checked.
Past Medical History:
- HTN
- HLD
- DCIS s/p excision/XRT, on tamoxifen in past but d/c'd due to
side effects
- Osteoporosis
- Neurofibromatosis type II
- Lichen sclerosis
- Left hip fracture s/p hemiarthroplasty
- Carotid stenosis s/p CEA of left ICA in ___. Right ICA with
80% stenosis as of ___
- PVD
- Cataracts s/p removal (___)
Social History:
___
Family History:
Mother: ___, unknown reason.
Father: ___, TB.
Cancer History: Sister with breast cancer in her ___.
Coronary Artery Disease History: None.
Diabetes Mellitus History: None.
Physical Exam:
Admission Exam:
79% on room air.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles at bases, otherwise, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Right leg is tender to palpation in calf
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge exam:
Vitals: T:98.1 BP 118/61 P:72 R:18 97% on 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles at bases, scattered rhonchi, no wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Right leg is tender to palpation in calf
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
___ 03:36PM GLUCOSE-87 UREA N-40* CREAT-1.1 SODIUM-139
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-22 ANION GAP-21*
___ 03:36PM cTropnT-0.03*
___ 03:36PM CALCIUM-8.9 PHOSPHATE-4.7* MAGNESIUM-1.7
___ 04:13AM LACTATE-1.5
___ 02:55AM GLUCOSE-123* UREA N-42* CREAT-1.0 SODIUM-139
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-20* ANION GAP-17
___ 02:55AM cTropnT-0.06*
___ 02:55AM CALCIUM-8.3* PHOSPHATE-4.1# MAGNESIUM-1.7
___ 02:55AM WBC-13.1* RBC-3.99* HGB-11.5* HCT-35.6*
MCV-89 MCH-28.8 MCHC-32.2 RDW-15.3
___ 02:55AM PLT COUNT-396
___ 12:20AM ___ PO2-81* PCO2-34* PH-7.40 TOTAL
CO2-22 BASE XS--2 COMMENTS-GREEN TOP
___ 12:20AM LACTATE-2.1* K+-4.5
___ 11:04PM TYPE-ART TEMP-37.9 PO2-130* PCO2-30* PH-7.42
TOTAL CO2-20* BASE XS--3 INTUBATED-NOT INTUBA COMMENTS-O2
DELIVER
___ 11:04PM K+-4.5
___ 10:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.5
LEUK-NEG
___ 10:50PM URINE RBC-5* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-2
___ 10:50PM URINE HYALINE-17*
___ 10:50PM URINE MUCOUS-RARE
___ 09:40PM GLUCOSE-152* UREA N-36* CREAT-1.0 SODIUM-138
POTASSIUM-6.4* CHLORIDE-103 TOTAL CO2-13* ANION GAP-28*
___ 09:40PM estGFR-Using this
___ 09:40PM ALT(SGPT)-143* AST(SGOT)-272* ALK PHOS-209*
TOT BILI-0.8
___ 09:40PM cTropnT-0.02*
___ 09:40PM ___
___ 09:40PM CALCIUM-9.0 PHOSPHATE-6.0*# MAGNESIUM-2.1
___ 09:40PM WBC-17.4*# RBC-4.46 HGB-13.2 HCT-42.4 MCV-95
MCH-29.7 MCHC-31.2 RDW-15.2
___ 09:40PM NEUTS-82.7* LYMPHS-13.1* MONOS-3.3 EOS-0.3
BASOS-0.5
___ 09:40PM PLT COUNT-500*
___ 09:40PM ___ TO PTT-UNABLE TO ___
TO
___ 09:23PM LACTATE-7.0* K+-5.2*
.
Discharge Labs:
___ 07:05AM BLOOD WBC-7.7 RBC-4.15* Hgb-11.9* Hct-37.4
MCV-90 MCH-28.6 MCHC-31.7 RDW-15.4 Plt ___
___ 07:05AM BLOOD Glucose-102* UreaN-36* Creat-1.0 Na-140
K-3.8 Cl-97 HCO3-33* AnGap-14
___ 07:05AM BLOOD ALT-137* AST-48* LD(LDH)-228 AlkPhos-96
TotBili-0.5
___ 07:05AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.9
CTA Chest ___. No pulmonary embolus.
2. Bilateral pleural effusions with centrilobular emphysema and
ground glass opacities, the appearance may be due to fluid
overload. Focal punctate areas of consolidation are noted in
the right upper lobe only.
3. Multivessel coronary artery calcifications and progression
of extensive ulcerating plaques in the aortic arch.
.
EKG ___: HR 96, PR 104, QTc 390, nl axis, a in III, flat T in
III
Shoulder Films:
Three views of the right humerus show a comminuted fracture of
the neck of the
proximal humerus with displaced associated fractures of the
tuberosities of
the humeral head. No dislocation and the visualized right lung
is grossly
normal. Little position change from previous exam ___.
RUQ ultrasound ___:
IMPRESSION:
1. No liver pathology and no biliary dilatation seen.
2. Cholelithiasis with no sign of cholecystitis.
3. Bilateral pleural effusions.
4. Small non-obstructing stone in the right kidney and small
simple right
renal cyst.
Echo ___
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. with
normal free wall contractility. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion
CXR ___ FINDINGS: In comparison with the study of ___, there
is some continued enlargement of the cardiac silhouette with
little change in the degree of pulmonary vascular congestion.
Continued opacification of the right hemidiaphragm, consistent
with pleural effusion and atelectasis at the left base. Again
supervening pneumonia would be difficult to exclude in the
appropriate clinical setting.
Brief Hospital Course:
___ with history of neurofibromatosis, PVD, HTN, recent
admission for humeral fracture in setting of mechanical fall
treated conservatively (discharged 5 days prior to this
admission) who presented with acute SOB.
.
# Shortness of breath: Pt met 2 SIRS criteria on presentation:
leukocytosis (WBC 17), tachypnea, possible sources include
pulmonary (?LLL opacity) or GI (diarrhea). Given 750cc IVF in
the ED and started on zosyn and levofloxacin empirically for
possible infectious process. Differential for SOB also includes:
PE (considered in pt with recent humeral fracture) and recent
immobility and right calf tenderness. ACS (trop 0.02, but no
chest pain or EKG changes), acute heart failure (BNP 17,500 (no
prior), pulmonary edema on CXR). Aa gradient of 590 assuming
100% FiO2 on non-rebreather. Heparin drip was started
empirically, but was discontinued when the pt's CT chest showed
no PE. The patient was but on empiric PNA coverage with
vanc/Zosyn/levo. Blood cultures were sent (NG at discharge). The
patient was transferred to the MICU for close monitoring. The
patient had a foley placed and was diuresed with good response.
She remained afebrile and abx were stopped. She was downgraded
to NC and transferred to the floor. She continued to have
difficulty acheiving O2 sat >90% on room air and required O2 NC.
A repeat CXR showed persistent pleural effusions and the patient
was diuresed with moderate improvement She was started on 20mg
PO lasix daily. Additionally, she received chest ___ and was
started on inhaled steroids in setting of emphysema and
persistent cough with sputum production. She remained afebrile
following transfer to floor. At discharge, she is saturating
88-90% on RA, 97% on 3L, and 94-95% on 3L with ambulation.
.
# HTN: Hypertensive to 200s in the ED. Pt has history of BP in
200s on prior admissions in setting of med non compliance. She
states she missed several doses prior to this admission.
Patient without evidence of end organ dysfunction, no chest
pain. BP was controlled with hydralazine and amlodipine in the
unit. In the MICU, the patient's BP was controlled with
hydralazine. Her dose of lisinopril was increased from 20mg to
40mg daily. A beta-blocker was held in the setting of possible
bacterial etiology to SOB and elevated lactate. Upon transfer to
the floor, the patient was started on home atenalol for SBP of
180. Atenolol failed to successfully control BP so pt was
transitioned to labetalol BID. BP is now well controlled. She
has also been started on lasix 20mg daily.
# Metabolic Acidosis/Lactate: AG 22, Lactate 7.0-->2.1 after
750cc IVF. AG closed. Lactate normalized on transfer to the
floor. Still uncertain etiology. Most likely ___ to hypertensive
emergency
# Tachycardia: Patient had a run of supraventricular
tachycardia that self-resolves and did not return after
restarting beta-blockers.
# Right humeral fracture s/p fall: s/p comminuted fracture in
setting of mechanical fall.Ortho saw patient and noted fracture
healing well. Shoulder films show proper healing. Follow up in 2
months.
.
Chronic issues:
# HLD. Continued home simvastatin.
.
# Osteoporosis. Continued calcium/vitamin D daily.
.
# Neurofibromatosis type II. Stable no acute issues
.
# Lichen sclerosis. Continued clobetasol cream.
.
# Carotid stenosis s/p CEA of left ICA in ___. Right ICA with
80% stenosis as of ___. No acute issues.
.
# PVD. Not on any medications, no acute issues.
.
# Cataracts. Stable no acute issues.
Transition of Care:
# Follow lytes in in ___ weeks after starting lasix
# Trend blood pressures to ensure goal ___
# Follow up with Ortho in 2 months
# Communication: ___, Relationship: husband. Phone
number: ___
# Code: DNR/DNI confirmed
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Aspirin 81 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral daily
6. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY:PRN
itching
7. Acetaminophen 1000 mg PO Q6H:PRN pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
hold for SBP<100
3. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY:PRN
itching
4. Acetaminophen 1000 mg PO Q6H:PRN pain
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Furosemide 20 mg PO DAILY
hold for sbp<100
7. Guaifenesin 10 mL PO Q6H
8. Labetalol 200 mg PO BID
hold for SBP <100 and HR <60
9. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral daily
10. Docusate Sodium 100 mg PO DAILY:PRN constipation
11. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypertensive Emergency with Secondary Pulmonary Edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You came in due to shortness of breath and were found to have
high blood pressure. We believe your high blood pressure caused
your shortness of breath. We controlled your blood pressure and
gave you medicine to decrease fluid in your lungs. Your
shortness of breath is now improving, but you still require some
oxygen.
Followup Instructions:
___
|
19758118-DS-13
| 19,758,118 | 26,218,114 |
DS
| 13 |
2144-04-29 00:00:00
|
2144-04-29 20:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Central line, Arterial line, Intubation, EGD(Gastroenterology -
Dr. ___ ___, Gastroduodenal artery coil/gelfoam
embolization (Interventional Radiology ___
History of Present Illness:
Per initial H&P, patient had new onset intermittent abdominal
pain on day prior to admission and an episode of black stool at
home, though this is not confirmed. Her family reports GI
illness over the past 2 weeks or so prior to admission,
primarily vomiting with occasional diarrhea, as well as dry
heaving and poor PO intake. In the ED she was reportedly guaiac
+ and in afib with RVR and was given metop 5mg IV and was
started on diltiazem gtt, however pressures dropped with gtt and
couldn't go to floor so received diltiazem 30mg PO. CT abdomen
pelvis bilateral pleural effusions with associated compressive
atelectasis, mildly distended stomach, but no evidence of bowel
obstruction. No dilated loops of bowel. Stool and air seen
throughout the colon. CXR small b/l pleural effusions.
Upon arrival to the floor, she continued to complain of diffuse
___ abdominal pain. On morning of ICU transfer, she received
metoprolol 25mg PO, labetolol 200mg PO, and lisinopril 40mg PO.
Labetolol was written as home medication, however only takes
metoprolol at home. At 11am, she became more somnolent, BPs
80/50s with pediatric cuff. H/H noted to be down from baseline
of ___ last year to 10.___/33.4 on admission, and ___
on morning of transfer. GI called to bedside, NG lavage guaiac
positive but without coffee grounds or frank blood. Rectal exam
was unremarkable and patient had no recent BMs. Review of CT
scan with radiology revealed no obvious evidence of ischemia or
potential source clinical picture, final read notable for
gastroenteritis.
Past Medical History:
- CHF (LVEF 35-40%): basal/mid inferior wall akinesis and
basal/mid inferolateral wall hypokinesis likely representing a
prior MI. Per documented discussion between patient, daughter,
and ___ cards, revascularization not consistent with goals of
care.
- HTN
- HLD
- DCIS s/p excision/XRT, on tamoxifen in past but d/c'd due to
side effects
- Osteoporosis
- Neurofibromatosis type II
- Lichen sclerosis
- Left hip fracture s/p hemiarthroplasty
- Carotid stenosis s/p CEA of left ICA in ___. Right ICA with
80% stenosis as of ___
- PVD
- Cataracts s/p removal (___)
Social History:
___
Family History:
Father with TB, deceased. Sister with breast cancer diagnosed in
her ___.
Physical Exam:
ON ADMISSION:
VS- T: 97.4 BP: 86/50 P: 80 R: 14 O2: 100% 2LNC
GENERAL: Alert, oriented pleasant elderly female, making good
eye contact
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregular rhythm, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present and
slightly hyperactive, no rebound tenderness or guarding, no
organomegaly
EXT: cool, capillary refill <2s, 1+ pulses, no clubbing,
cyanosis or edema
SKIN: innumerable skin-colored neurofibromas
NEURO: AxOx3, PERRL, EOMI, tongue midline, speech clear and
fluent
ON DISCHARGE:
VS- T: 97.4 BP: 131/71 P: 110 R: 20 O2:95-100% 2LNC
GENERAL: Alert and oriented, now extubated pleasant elderly
female in NAD
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: Neck supple, no JVD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregular rhythm, normal S1 S2, no murmurs, rubs, gallops
ABD: BS normoactive, soft, non-tender, non-distended, no masses,
guarding or rebound tenderness.
EXT: warm extremities with good cap refil, no cyanosis, clubbing
or edema
SKIN: skin-colored neurofibromas too numerous to count
NEURO: A&Ox3, Motor strength and sensation grossly intact
Pertinent Results:
ON ADMISSION:
___ 05:00PM PLT COUNT-571*#
___ 05:00PM NEUTS-86* LYMPHS-8* MONOS-6 EOS-0 BASOS-0
___ 05:00PM WBC-11.0 RBC-4.08* HGB-10.7* HCT-33.4*#
MCV-82 MCH-26.2* MCHC-32.0 RDW-17.3*
___ 05:00PM VoidSpec-UNABLE TO
___ 05:29PM LACTATE-1.8
___ 06:05PM TSH-2.3
___ 06:05PM ALBUMIN-3.0*
___ 06:05PM cTropnT-<0.01 proBNP-6745*
___ 06:05PM LIPASE-25
___ 06:05PM ALT(SGPT)-10 AST(SGOT)-13 ALK PHOS-99 TOT
BILI-0.4
___ 06:05PM estGFR-Using this
___ 06:05PM GLUCOSE-109* UREA N-24* CREAT-0.7 SODIUM-139
POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-28 ANION GAP-13
MOST RECENT LABS ON DISCHARGE:
___ 02:04AM BLOOD WBC-9.7 RBC-4.03* Hgb-10.7* Hct-34.0*
MCV-84 MCH-26.6* MCHC-31.5 RDW-18.3* Plt ___
___ 05:55AM BLOOD WBC-9.5 RBC-4.04* Hgb-10.8* Hct-34.0*
MCV-84 MCH-26.8* MCHC-31.8 RDW-18.4* Plt ___
___ 04:15PM BLOOD Hct-33.1*
___ 02:04AM BLOOD Plt ___
___ 05:55AM BLOOD Plt ___
___ 04:15PM BLOOD Glucose-97 UreaN-27* Creat-0.8 Na-139
K-3.7 Cl-106 HCO3-24 AnGap-13
___ 05:55AM BLOOD Glucose-88 UreaN-31* Creat-0.7 Na-143
K-4.0 Cl-113* HCO3-19* AnGap-15
___ 04:15PM BLOOD Calcium-8.1* Phos-3.6 Mg-1.9
___ 05:55AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.2
___ 02:04AM BLOOD CEA-4.5* AFP-3.2
___ 03:08AM BLOOD Type-ART Temp-36.7 Rates-20/ Tidal V-380
PEEP-5 FiO2-40 pO2-87 pCO2-31* pH-7.39 calTCO2-19* Base XS--4
Intubat-INTUBATED
MICRO:
BCx (___): NGTD
BCx (___): NGTD
IMAGING:
CT Abdomen/Pelvis with contrast (___): Hyperenhancing mucosa
in the stomach and bowel with fluid filled loops of small bowel,
likely representing gastroenteritis. Bilateral pleural effusions
with associated compressive atelectasis.
RUQ U/S ___ gallbladder with stones. Cannot
exclude acute cholecystitis but no specific signs are present on
ultrasound. Right pleural effusion. Mild ascites.
EGD (___)
Findings: Duodenum - Exudate overlying an area of thrombus vs
mass seen in D1-D2 duodenum. With light contact, brisk bleeding
occurred limiting visualization of bleeding source. Due to poor
visualization, decision was made to terminate procedure and
intubate for airway protection and to send to ___ for
embolization.
Impression: Tortuous esophagus but mucosa appeared normal
Abnormal mucosa was noted in the stomach with erythema and small
erosions. Biopsies were not taken due to concern for other area
of upper GI bleeding.
Hiatal hernia present.
D1-D2 bleeding thrombus vs mass.
Otherwise normal EGD to second part of the duodenum.
Mesenteric arteriogram (___):
FINDINGS:
1. Extensive multivessel calcified atherosclerotic disease.
2. Normal anatomy of the celiac artery and its branches. No
active
extravasation.
3. Complete occlusion of the gastroduodenal artery and branches
after
embolization.
4. Normal superior mesenteric artery. No active extravasation or
duodenal
supply identified.
IMPRESSION:Technically successful prophylactic embolization of
the gastroduodenal artery
with coils and Gel-Foam.
Echo ___ left atrium is mildly dilated. The right
atrium is moderately dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
an inferobasal left ventricular aneurysm. Overall left
ventricular systolic function is moderately depressed (LVEF = 35
%) secondary to akinesis of the inferior wall and hypokinesis of
the posterior wall. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The right
ventricular free wall thickness is normal. Right ventricular
chamber size is normal. with borderline normal free wall
function. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The aortic regurgitation jet is eccentric, directed
toward the anterior mitral leaflet. The mitral valve leaflets
are mildly thickened. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of ___ LV systolic dysfunction is now present.
Brief Hospital Course:
Ms. ___ is an ___ with neurofibromatosis, ___ presenting
with abdominal pain, afib with RVR now transferred to ICU with
hypotension and acute anemia concerning for GI bleed, now s/p
EGD notable for friable duodenal mass and ___ embolization of GDA
and two branching arteries.
ACTIVE ISSUES:
#GI bleed: On admission pt complained of abdominal pain and was
subsequently found to have a hemoccult-positive nasogastric
lavage. She developed hypotension and was transferred to the
MICU and underwent EGD on ___ which showed bleeding ulcer
vs mass in duodenum. Bleeding could not be controlled
endoscopically and she was intubated and taken to ___ for
emergent embolization of the GDA with coils and gelfoam. They
did not identify active extravasation during ___ procedure. She
was extubated ___ following further hemodynamic
stabilization.
At that time, she requested no further procedures and strict
DNR/DNI in discussion with the medical team and her family. She
declared her wishes not to be rehospitalized, with the ultimate
goal of gaining enough strength at rehab to return home. Despite
concern for malignancy, no further workup is desired by the
patient.
She remained hemodynamically stable and was maintained on IV
then PO PPI.
- H. pylori Ab pending at time of discharge and would initiate
treatment if positive, otherwise continue PPI
- Restarted aspirin upon discharge
# Abdominal pain: Likely in the setting of GI bleed. CT
abdomen/pelvis by GI did not show evidence of mesenteric
ischemia but did show findings consistent with gastroenteritis.
RUQ U/S showed gallstones but no acute process with normal
hepatoechogeneity. Hepatitis panels were concerning for prior
HepB infection given positive HepBcAb. Since arrival to the MICU
patient's abdominal pain improved but has intermittent pain
treated with Maalox and PPI.
- H. pylori Ab pending at time of discharge and would initiate
treatment if positive, otherwise continue PPI
#Hypotension: Pt became hypotensive shortly following admission,
which was thought to be multifactorial in etiology, with
contributions from heavy beta blockade and acute blood loss.
There were no signs or symptoms to suggest infection
(asymptomatic, afebrile, no leukocytosis, BCx NGTD).
Additionally, pt initially started on ciprofloxacin/flagyl, but
discontinued due to low index of suspicion for infection. During
her stay in the MICU, her BP improved back to SBP 130's-140's
and she was restarted on increased metoprolol in setting of new
afib and home furosemide dose. Home lisinopril was held.
- please check BPs daily and if greater than 160/90 please start
lisinopril 10mg daily
# Atrial fibrillation with RVR: Atrial fibrillation was newly
recognized on admission, possibly precipitated by acute blood
loss. Rate control was complicated by acute hypotension and
metoprolol was restarted and advanced. CHADS2 Score is 3,
TTE showed LV systolic dysfunction (EF=35%) w/inferior wall
akinesis but no evidence of thrombus. Anticoagulation was not
started given her GI bleed and goals of care.
- Please monitor HR carefully, would uptitrate metoprolol
succinate slowly if HR persistently above 110bpm
# Respiratory Failure: Patient was intubated in setting of EGD
and ___ angiography. Pt was extubated shortly following the
procedure without any further respiratory issues. She does
require 2LNC and should be weaned as tolerated. She does desat
to low 80's when off supplemental oxygen.
# Transaminitis: Transaminases were initially normal on
admission then found to be newly elevated during her stay in the
MICU. RUQ U/S showed stones in gallbladder but was not
concerning for acute biliary process. Viral serologies showed HB
immune, and HAV immune. Pt denied further work-up for malignancy
as above.
CHRONIC ISSUES:
# Compensated systolic/diastolic heart failure: Pt was restarted
on beta-blockade while in the MICU as above. She was also
restarted on home furosemide 20mg PO. Her home lisinopril was
held. Aspirin held in setting of GI bleed. She should continue
on metoprolol and furosemide at current doses for comfort
following discharge.
Transitional Issues:
- Code: DNR/DNI
- Do Not Hospitalize per patient
- daughter/HCP ___ first (h ___, c ___, w
___, then ___ (___)
- please check BPs daily and if greater than 160/90 please start
lisinopril 10mg daily
- Please monitor HR carefully, would uptitrate metoprolol
succinate slowly if HR persistently above 110bpm
- H. pylori Ab pending at time of discharge and would initiate
treatment if positive, otherwise continue PPI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Furosemide 20 mg PO EVERY OTHER DAY
4. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral twice daily
5. Atorvastatin 40 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Ibuprofen 600 mg PO BID:PRN pain
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN pain, fever
3. Docusate Sodium 100 mg PO BID
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Maalox/Diphenhydramine/Lidocaine 5 mL PO QID:PRN abdominal
pain
6. Pantoprazole 40 mg PO Q12H
7. Atorvastatin 40 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral twice daily
10. Metoprolol Succinate XL 100 mg PO DAILY
please hold for SBP<90, HR<60
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Duodenal bleed (Upper GI bleed, mass vs ulcer)
Atrial fibrillation
Secondary Diagnosis:
- CHF (LVEF 35-40%): basal/mid inferior wall akinesis and
basal/mid inferolateral wall hypokinesis likely representing a
prior MI. Per documented discussion between patient, daughter,
and ___ cards, revascularization not consistent with goals of
care.
- PVD - Carotid artery stenosis - s/p Left CEA in ___ with
residual right sided stenosis (80%)
- HTN
- HLD
- Neurofibromatosis
- Breast cancer s/p right sided lumpectomy with XRT and
tamoxifen
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 ___,
___ was a pleasure caring for you at ___
___. You were admitted to the hospital with new
atrial fibrillation, an irregular and fast heart rhythm. You
developed GI bleeding that caused very low blood pressures and
required blood transfusions. An endoscopy saw bleeding that they
were unable to stop, and you required a procedure to try and
stop the bleeding.
You remained stable and discussed with your medical team and
your family that you did not want further procedures or
hospitalizations.
You are being transferred to rehab to help regain strength
before going home.
We wish you all the best.
Followup Instructions:
___
|
19758118-DS-14
| 19,758,118 | 22,568,780 |
DS
| 14 |
2144-10-30 00:00:00
|
2144-10-30 15:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH CHF EF 35%, atrial fibrillation new in ___ (not
on anticoagulation secondary to GI bleed), history of GI bleed
in ___ requiring ___ embolization, who presents with general
weakness that started earlier today. She was noted to have to
episodes of emesis over the last 2 days. She denies fever,
chills, chest pain, shortness of breath, dizziness, or diarrhea.
ROS also negative for rashes, dysuria, hematuria, or
hematochezia. Postive for decreased PO intake.
Of note patient admitted in ___ for GI bleed found to
have duodenal mass concerning for malignancy. At that time, she
requested no further procedures and strict DNR/DNI in discussion
with the medical team and her family. She declared her wishes
not to be rehospitalized, with the ultimate goal of gaining
enough strength at rehab to return home. Despite concern for
malignancy, no further workup is desired by the patient.
In the ED, initial vitals were: Temp. 98.5, HR 106, BP 140/96,
RR 20, 96% RA
ED course significant for UA obtaiend that was negative for
nitrites, few bacteria, and 65 WBC's. Lactate noted to be 2.7.
Patient given 500 cc IVF. Influenzae negative. Pro-BNP elevated
to 24,234, creatinine 1.5, and WBC of 11.3. CXR concerning RLL
pneumonia and small bilateral pleural effusion. Patient given
one dose levofloxacin 750 mg. Patient noted to develop afib with
RVR in the ED with rates to 140's that improved with IV
metoprolol 5 mg X 3, PO metoprolol 25 mg X 1, and digoxin 0.5
mg. 10 mg IV lasix given X 1.
Vitals prior to transfer significant for oxygen requirement of
6L NC.
On the floor, the patient notes that 2 days ago she began
feeling weak diffusely. She denies any focal weakness at that
time. She notes that she also had 2 episodes of non-bloody,
non-bilious emesis. She also endorses decreased PO intake at
this time. She reports innacurate history regarding her home
medications and the last time they were taken. She notes that
she lives at home with her husband and is usually able to cook,
clean, and take her medications on her own (though this is
somewhat questionable). She notes she ambulates with a walker.
She notes she may have lost some weight recently though is
unsure of the amount. She also endorses fatigue. She denies any
recent changes in her medications or falls. She denies orthopnea
and paroxysmal nocturnal dyspnea.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias.
Past Medical History:
- CHF (LVEF 35-40%): basal/mid inferior wall akinesis and
basal/mid inferolateral wall hypokinesis likely representing a
prior MI. Per documented discussion between patient, daughter,
and ___ cards, revascularization not consistent with goals of
care.
- HTN
- HLD
- DCIS s/p excision/XRT, on tamoxifen in past but d/c'd due to
side effects
- Osteoporosis
- Neurofibromatosis type II
- Lichen sclerosis
- Left hip fracture s/p hemiarthroplasty
- Carotid stenosis s/p CEA of left ICA in ___. Right ICA with
80% stenosis as of ___
- PVD
- Cataracts s/p removal (___)
Social History:
___
Family History:
Father with TB, deceased. Sister with breast cancer diagnosed in
her ___'s.
Physical Exam:
EXAM ON ADMISSION:
==================
Vitals: T: 99.3 BP: 158/80 P: 109 R: 18 O2: 94% 6L NC, wt 74.5
lbs
General: Alert, oriented X 3 (with prompting), occasionally
confused, no acute distress, thin, pleasant
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP +10 sternal angle, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregular rhythm, tachycardic, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, postive
hepatojugular reflex
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Diffuse skin tags along arms, abdomen, and back
Neuro: CN II-XII intact with the exception of vision in the
right eye, ___ strength in upper and lower extremities
EXAM ON DISCHARGE:
===================
Vitals: temp. 98.1, BP 100/53, HR 94 (rates 80-132), RR 18, 100%
3L
Weight: 84.4 lbs.
General: Alert, oriented X 3, occasionally confused, no acute
distress, thin, pleasant
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregular rhythm, tachycardic, no murmurs, rubs, gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Diffuse skin tags along arms, abdomen, and back
Neuro: Moving all extremities, no focal neurologic deficits
noted
Pertinent Results:
LABS ON ADMISSION:
==================
___ 10:00PM BLOOD WBC-11.3* RBC-4.87 Hgb-13.5 Hct-42.2
MCV-87 MCH-27.6 MCHC-31.9 RDW-18.5* Plt ___
___ 10:00PM BLOOD Neuts-83.0* Lymphs-10.6* Monos-5.6
Eos-0.5 Baso-0.2
___ 10:00PM BLOOD Glucose-108* UreaN-50* Creat-1.5* Na-141
K-4.3 Cl-101 HCO3-22 AnGap-22*
___ 10:00PM BLOOD ___
___ 06:57PM BLOOD Calcium-8.6 Phos-3.6 Mg-1.7
___ 10:51PM BLOOD Lactate-2.7*
LABS ON DISCHARGE:
===================
___ 05:00AM BLOOD WBC-8.1 RBC-4.63 Hgb-12.7 Hct-40.1 MCV-87
MCH-27.3 MCHC-31.6 RDW-17.2* Plt ___
___ 05:00AM BLOOD Glucose-98 UreaN-39* Creat-1.2* Na-140
K-5.2* Cl-99 HCO3-31 AnGap-15
___ 05:00AM BLOOD Calcium-8.3* Phos-3.8 Mg-1.8
___ 01:05PM BLOOD Glucose-120* UreaN-37* Creat-1.0 Na-140
K-4.4 Cl-102 HCO3-29 AnGap-13
Micro:
======
___ 10:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
EKG ___:
=============
Atrial fibrillation with a controlled ventricular response.
Delayed R wave progression. Probable left ventricular
hypertrophy. Compared to the previous tracing of earlier same
date, there is slowing of the ventricular response rate.
IMAGING:
=========
CXR ___:
IMPRESSION:
Right lower lobe pneumonia with small bilateral effusions.
ECG ___: Atrial fibrillation with RVR
Echocardiogram ___:
===========================
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with akinesis of
the basal inferior and inferolateral wall and hypokinesis of the
mid and apical inferior and inferolateral wall.. 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 leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular dysfunction and an
inferobasal aneurysm suggestive of inferior ischemia/infarction.
Mild aortic regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
estimated pulmonary pressures are slightly lower. The other
findings are similar.
Brief Hospital Course:
___ w/ PMH CHF (EF 35%), atrial fibrillation new in ___
(not on anticoagulation secondary to GI bleed), history of GI
bleed in ___ requiring ___ embolization who presented with
generalized weakness found to have atrial fibrillation with RVR,
elevated BNP to 24,000, bilateral pleural effusions and right
lower lobe infiltrate on CXR concerning for heart failure
exacerbation and community acquired pneumonia.
#Severe Sepsis likely secondary to Community Acquired Pneumonia:
Patient noted to have tachycardia and leukocytosis on admission
with presumed source of infection thought to be respiratory with
evidence of end organ damage with elevated lactate and ___ on
admission. Patient had significant oxygen requirement (6L NC on
admission) and RLL opacity on CXR concerning for community
acquired pneumonia. Patient started on ceftriaxone 1 gram Q 24
hours + azithromycin 500 mg Q24 hours. She was then transitioned
to PO levofloxacin to complete a full 7 day treatment course for
CAP with last dose of levofloxacin to be given on ___. Her
oxygen was weaned down to 3L NC. She is noted to have a 2L
oxygen requirement at baseline.
#Systolic Congestive Heart Failure (EF 35%) exacerbation:
Patient with elevated BNP to 24,000, hypoxia on admission, and
small bilateral pleural effusions, and JVP elevated to +10 cm
above the sternal angle concerning for heart failure
exacerbation. Etiology of patient's heart failure exacerbation
thought to be underlying pneumonia with some component of
medication non-adherence. Patient also thought to have some
component of flash pulmonary edema in setting of atrial
fibrillation with RVR and loss of atrial kick. Patient was
diuresed with 10 mg IV lasix BID. She was transitioned back to
20 mg PO lasix daily prior to discharge. In addition her
lisinopril was initially held in the setting ___ but
restarted prior to discharge. Echocardiogram obtained and showed
EF 40% with no significant change from prior. Weight on day of
discharge was 84.4 lbs.
#Atrial fibrillation with RVR (CHADS score of 3 secondary to
heart failure, hypertension, age):
Atrial fibrillation first developed in the setting of a GI bleed
during last hospital course in ___ and is thought to be
precipitated by acute blood loss. Anticoagulation was not
started at that time given her GI bleed and overall goals of
care. Patient presented with atrial fibrillation with RVR in ED
that improved with IV metoprolol in the ED. Patient also
developed atrial fibrillation with RVR and rates to 120's on
hospital day 2. She was again given 5 mg IV metoprolol and
continued on increased dose of PO metoprolol 37.5 mg QID and she
was discharged on metoprolol succinate 150 mg daily. She was
continued on telemtry. Patient not anticoagulated as it was
noted to be against her goals of care as discussed during last
hospital course.
#Coronary Artery Disease
Ms. ___ remained without chest pain during her hospital
course. She was noted to have ST segment depressions in leads V4
and V5 on her EKG at the time of her atrial fibrillation with
RVR that resolved with improvement of her rate control. It was
thought that these changes were secondary to demand ischemia in
the setting of rapid ventricular rates. Repeat EKG with rate
controlled showed resolution of ST segment depressions. In
addition interventions were not consistent with patient's goals
of care and furthermore heparinization was concerning given
patient's prior history of significant GI bleed. She was
continued on aspirin 81 mg daily and atorvastatin 40 mg daily.
#Acute on chronic renal injury with baseline creatinine of 0.7:
Patient presented with ___ that was pre-renal in etiology given
BUN/Cr > 20 thought to be secondary to hypoperfusion in the
setting of sepsis as well as heart failure exacerbation.
Creatine improved with diuresis and treatment of underlying
infection. Lisinopril was held in setting ___ though
restarted prior to discharge. Creatinine increased from 1.0 to
1.2 -> 1.0 and potassium was 5.2 -> 4.4 on day of discharge
after receiving IVF. Renal function with chem-7 should be
rechecked on ___.
#Hyperkalemia
Ms. ___ was noted to be hyperkalemic to 5.2 that improved
with gentle 500 cc of IV fluids at 75 cc/hr. EKG did not show
any evidence of hyperkalemic changes. Chem-7 should be checked
on ___ to assess potassium.
#History of GI bleed with likely gastrointestinal malignancy:
Patient with likely underlying GI malignancy given last hospital
course and noted weight loss and fatigue on admission. At this
time, further work up is against patient's goals of care as per
last hospital course and discussion. The patient was continued
on pantoprazole 40 mg Q12 hours. The patient remained
hemodynamically stable throughout her hospital course.
#Hypertension
Discharged with metoprolol succinate 150 mg XL
#Hyperlipidemia
Atorvastatin 40 mg daily continued
TRANSITIONAL ISSUES:
======================
-Medication changes include: metoprolol increased to metoprolol
succinate 150 mg daily
-levofloxacin started during this hospital course for treatment
of community acquired pneumonia, last dose to be given on
___
-please check chem-7 on ___ to ensure that kidney function,
potassium and magnesium are stable
-please weigh patient daily and consider increasing her daily
lasix dose if her weight increases by more than 3lbs. for 2
consecutive days
-weight on day of discharge 84.4 lbs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Furosemide 20 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Aspirin 81 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral twice daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Furosemide 20 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Atorvastatin 40 mg PO QPM
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral twice daily
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Lisinopril 10 mg PO DAILY
10. Levofloxacin 750 mg PO Q48H
Last day ___
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth every
other day Disp #*1 Tablet Refills:*0
11. Metoprolol Succinate XL 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Community Acquired Pneumonia
Heart failure exacerbation
Atrial fibrillation with RVR
Secondary:
Hypertension
Hyperlipidemia
DCIS s/p excision/XRT, on tamoxifen in past but d/c'd due to
side effects
Osteoporosis
Neurofibromatosis type II
Lichen sclerosis
Left hip fracture s/p hemiarthroplasty
Carotid stenosis s/p CEA of left ICA in ___. Right ICA with 80%
stenosis as of ___
Peripheral Vascular Disease
Cataracts s/p removal (___)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure being involved in your care. You were admitted
to the hospital for weakness and were found to have an infection
in your lungs called pneumonia and extra fluid in your lungs.
You were given antibiotics for your infection and improved
before you left the hospital. We gave you a water pill to get
the extra fluid off of your lungs. Please Weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19758118-DS-15
| 19,758,118 | 24,625,652 |
DS
| 15 |
2145-03-26 00:00:00
|
2145-03-27 16:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath, general malaise
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ yo F w/ PMH CHF (EF 35%), afib (dx ___ not
anticoagulated ___ hx of GI bleed), presents w/ lethargy and
weakness. She reports feeling 'lousy' for 'a while.' She is
unable to quantify how much. She also endorses gradually
worsening dyspnea, decreased apettite for the last week. She
denises fevers, coughs, CP, weight change (stable at 80lbs per
patient), n/v/d, hematochezia or abdominal pain.
Of note, she self d/ced her meds for several months (including
Lasix and metoprolol) 'because I don't want to live anymore.'
She presented to ___ for regular followup appointment
and was noted to be in RVR. EMS was called who gave her
diltiazem 10mg + 15mg. She became hypotensive to the 90's.
ED COURSE
-Initial vitals: afebrile, HR 185, 02 sat 86%, in afib w/RVR
-Notable labs: low bicarb 18, BUN/creat ___, Ca ___, Mg 1.5,
Phos 3.10, WBC 7.4l, H/H 16.7/49.9, lactate 2.3, UA positive for
bact/nitrites/protein.
-Notable studies: bedside echocardiogram with mod ___,
IVC with resp variation. CXR showed asymetric edema(R>L) and ?
of infection.
-She got metoprolol 5mg IV x1 without improvement but became
hypotensive to ___'s SBP. Received 500ml NS bolus followed by
another metoprolol 5mg IV x1. Given CXR and UA results, got
Flagyl 500mg IV, Azithro 500mg IV, Cefepime IV 2g, and 20mg IV
of Lasix x1. Also received mag 2g IV. She was tried on BiPAP
briefly but didn't tolerate so went back to 6L NC.
On transfer, vitals were: 97.5, 137, 93/64, 24, 94% 35% fio2
ROS: 10-point ROS negative except as otherwise noted above in
HPI
Past Medical History:
- CHF with EF 40-45% on ECHO ___, Lisinopril, Furosemide 20
mg, Metoprolol 150 mg qday
- A. fib on metop, not anticoagulated ___ to GI bleeds.
- PVD
- Carotid artery stenosis - s/p Left CEA in ___ with residual
right sided stenosis (80%)
- HTN
- HLD
- PreDM
- Neurofibromatosis
- CKD
- LICHEN SCLEROSIS
- monocular blindness L eye, limited vision R eye
- R proximal humerus fx due to FOOSH ___
- Breast cancer (DCIS) s/p right sided lumpectomy with XRT and
tamoxifen
- Cataracts s/p removal ___
Social History:
___
Family History:
Father with TB, deceased. Sister with breast cancer diagnosed in
her ___.
Physical Exam:
PHYSICAL EXAM:
GENERAL: Alert, oriented, no acute distress,
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP elevated, no LAD
LUNGS: decreased on the left and absent on the right lower and
middle lobes.
CV: Irregular rhythm, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present and
slightly hyperactive, no rebound tenderness or guarding, no
organomegaly
EXT: cool, capillary refill <2s, 1+ pulses, trace edmea.
SKIN: innumerable skin-colored neurofibromas
NEURO: oriented to self, place, current president, not time
(___), PERRL, EOMI, tongue midline, speech clear and fluent
DISCHARGE PHYSICAL EXAM
GENERAL: NAD
HEENT: Sclerae anicteric, MMM
LUNGS: No accessory muscle use
CV: Irregular rhythm, normal S1 S2, no murmurs
ABD: soft, non-tender, non-distended,
EXT: cool, capillary refill <2s, 1+ pulses, trace edmea.
SKIN: innumerable skin-colored neurofibromas
Pertinent Results:
Admission labs
___ 09:50AM BLOOD WBC-7.4 RBC-5.96* Hgb-16.7*# Hct-49.9*
MCV-84 MCH-28.0 MCHC-33.4 RDW-17.7* Plt ___
___ 09:50AM BLOOD Neuts-82* Bands-2 Lymphs-8* Monos-8 Eos-0
Baso-0 ___ Myelos-0 NRBC-1*
___ 09:50AM BLOOD ___ PTT-29.4 ___
___ 10:55AM BLOOD Glucose-93 UreaN-29* Creat-1.0 Na-139
K-3.4 Cl-105 HCO3-18* AnGap-19
___ 09:50AM BLOOD cTropnT-<0.01
___ 03:00PM BLOOD ___
___ 03:00PM BLOOD cTropnT-0.03*
___ 10:55AM BLOOD Calcium-7.9* Phos-3.1 Mg-1.5*
___ 03:00PM BLOOD Calcium-8.0* Phos-3.4 Mg-2.7*
___ 09:58AM BLOOD Lactate-2.3*
___ 03:00PM BLOOD TSH-3.1
Discharge labs:
None drawn on day of discharge
Studies:
___ PCXR
IMPRESSION:
1. Interval increase in layering right pleural effusion, now
moderate to large with adjacent consolidation concerning for
pneumonia.
2. New mild pulmonary edema.
.
___ PCXR
IMPRESSION:
Moderate to large right pleural effusion has changed in
distribution but probably not in severity. Severe cardiomegaly
and pulmonary vascular congestion persist. Mild pulmonary edema
has improved. No pneumothorax. The thoracic aorta is heavily
calcified but not focally dilated.
.
___ PCXR
IMPRESSION:
No change.
.
MICROBIOLOGY:
___ C. diff assay: NEGATIVE
___ MRSA screen: NEGATIVE
___ Blood cultures x 2 sets: No Growth (FINAL)
___ Urine culture
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- <=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
.
Brief Hospital Course:
___ w/ ___ ischemic sCHF (EF 40%), atrial fibrillation (not on
anticoagulation secondary to GI bleed and pt preference),
history of GI bleed in ___ requiring ___ embolization who
presents in A. fib with RVR found to be hypoxic with large right
sided effusion.
ED presentation
=================
Ms. ___ presented to the ED with generalized weakness and
lethargy. She was found to be in afib with RVR in the setting of
having self D/Ced her home medications. She was given repeated
doses of both diltiazem and Lopressor in the ED without
resolution of her afib, but did become hypotensive to the ___.
She was given a NS bolus of 500cc with some improvement. CXR
showed a possible infiltrate and she was started on antibiotics
including Flagyl given multiple malodorous BMs in the ED. She
was then transferred to the MICU.
MICU course
==================
# Afib with RVR: In the MICU the patient remained
hemodynamically stable and in NAD. She was started on a
diltiazem gtt with only minimal improvement in her symptoms. She
did not appear to be clinicaly fluid overloaded, however,
bedside ultrasound revealed a full IVC with no respiratory
variation in size and poor systolic function with a chest xray
that showed pulmonary edema. We stopped the dilt gtt and
restarted her home medications with significant improvement in
her heart rate. We elected not to diurese as she's been having
diarrhea for the last month and was dry on exam. We attempted
10mg IV Lasix with a bump in Cr. She had a moderate pleural
effusion on the right that could hide a consolidation and we
started CTX and azithromycin after which she began to improve
and her 02 sats improved from mid ___ on 6L to mid ___. Her 02
requirement was weaned. Per family discussion, they did not want
invasive procedures and overall wanted to treat her PNA,
depression, and build her strength to get her home via any means
possbible - either through hospice care or ___. For her
diarrhea, she was C. diff negative and we started loperimide 4
mg QID PRN.
# Hypoxic respiratory failure: Patient kept having O2 sats to
the high ___ refusing to wear mask. After discussions with
family it was clear it wasn't within her goals of care to be
intubated. Desats were most likely due to pulmonary edema vs
infection. After much discussion patient was kept on a DNR/DNI
status and transferred to the floor with no plans for ICU
readmission. Palliative care was also consulted. Patient
discharge with plan for comfort-focused care, in agreement with
patient and family's wishes. She was discharge on supplemental
O2 for comfort.
# Pneumonia / #UTI: CXR showed likely consolidation. She was
treated for total 5 days with azithromycin/ceftriaxone. Urine
culture grew Klebsiella sensitive to ceftriaxone.
# Right pleural efffusion: Patient received IV Lasix to assist
with this.
TRANSITIONAL ISSUES:
====================
- Patient/family's wish is to have comfort-focused care:
- No agressive measures
- No hospitalizations
- No lab draws
- only daily blood pressures
- DNR/DNI
- HCP: ___ cell ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Metoprolol Succinate XL 150 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Furosemide 20 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Multivitamins 1 TAB PO DAILY
8. Calcium Carbonate 1000 mg PO DAILY
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Metoprolol Succinate XL 200 mg PO DAILY
3. Acetaminophen 650 mg PO TID
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob, wheeze
5. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath
6. LOPERamide 4 mg PO QID:PRN diarrhea
7. Mirtazapine 15 mg PO QHS
8. Ondansetron 4 mg IV Q8H:PRN nausea
9. OxycoDONE (Immediate Release) 2.5 mg PO Q6H
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*20 Tablet Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
11. Simethicone 40 mg PO BID:PRN abdominal pain/gas
12. TraZODone 25 mg PO QHS:PRN insomnia
13. Pantoprazole 40 mg PO Q24H
14. Furosemide 20 mg PO DAILY
Hold if patient not eating/drinking.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
1. atrial fibrillation with rapid ventricular response
2. pleural effusion
3. community-acquired pneumonia
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 ___,
___ was a pleasure taking care of you at ___. You were admitted
with a rapid heart rate (atrial fibrillation with rapid
ventricular response) and shortness of breath. While you were
here, we controlled your heart rate by re-starting your home
medicines.
We also saw that there was a pneumonia and treated you with
antibiotics.
You and your family have now decide to focus your care on
comfort, so you are being discharged to a facility that can
accomodate your needs.
We wish you all the best,
Your ___ team
Followup Instructions:
___
|
19758387-DS-18
| 19,758,387 | 27,830,216 |
DS
| 18 |
2158-07-21 00:00:00
|
2158-07-21 21:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ presenting with left flank pain. Pt reports pain began
yesterday morning around 11am. Came on slowly and gradually got
worse. Radiates to back and left abdomen. Sharp, cramping and
cannot get comfortable. No other associated symptoms. Denies
fevers, nausea/emesis, abdominal pain or hematuria. Pt had URI
about 2 weeks ago but no infectious symptoms since then.
In ED CTU shows left adrenal stranding, concerning for
hemorrhage. Pt given 2Lns, 4mg IV morphine x3, 2.5mg oxycodone
x2.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
-BPH
-Esophagitis/GERD
-Chronic anemia
-Borderline HTN
-R groin hernia s/p repair
-Seasonal allergies
Social History:
___
Family History:
No strokes, cardiac or neurologic diseases
Physical Exam:
Vitals: T:98.3 BP:187/84 P:78 R:18 O2:97%ra
PAIN: 4
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Back: No CVA tenderness ___
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
Admission Labs:
___ 04:45PM BLOOD WBC-19.0*# RBC-4.48* Hgb-12.9* Hct-38.8*
MCV-87 MCH-28.8 MCHC-33.2 RDW-13.7 RDWSD-42.5 Plt ___
___ 04:45PM BLOOD Neuts-92.4* Lymphs-4.2* Monos-2.5*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-17.59* AbsLymp-0.79*
AbsMono-0.47 AbsEos-0.00* AbsBaso-0.04
___ 04:45PM BLOOD Glucose-175* UreaN-15 Creat-0.9 Na-136
K-3.7 Cl-98 HCO3-25 AnGap-17
___ 12:59PM BLOOD ALT-11 AST-15 LD(LDH)-222 AlkPhos-92
TotBili-0.6
___ 12:59PM BLOOD Albumin-4.0 Calcium-8.5 Phos-2.0* Mg-1.8
___ 04:26PM BLOOD Lactate-3.1*
___ 05:52PM BLOOD Lactate-2.9*
___ 12:20AM BLOOD Lactate-3.2*
___ 10:41AM BLOOD Lactate-0.9
___ 12:59PM BLOOD Cortsol-18.3
___ 06:01PM BLOOD Cortsol-11.6
___ 09:00AM BLOOD HIV Ab-Negative
RPR w/check for Prozone (Final ___: NONREACTIVE.
Blood Cx x 3, PENDING, NGTD
___ 04:16PM BLOOD RENIN 0.22 (low)
___ 06:01PM BLOOD ALDOSTERONE-PND
24 HR URINE VOLUME 2350
EPINEPHRINE, 24 HR URINE 7
NOREPINEPHRINE, 24 ___ 65
CALCULATED TOTAL (E+NE) 72
DOPAMINE, 24 HR URINE 204
CREATININE, 24 HOUR URINE 1.71
24 HR URINE VOLUME 2350
METANEPHRINE 144
NORMETANEPHRINE 793 H
METANEPHRINES, TOTAL 937 H
CORTISOL, FREE, URINE 136.5 H
Discharge Labs:
___ 06:39AM BLOOD WBC-9.1 RBC-3.63* Hgb-10.6* Hct-32.1*
MCV-88 MCH-29.2 MCHC-33.0 RDW-13.3 RDWSD-43.6 Plt ___
___ 07:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:00PM URINE RBC-6* WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
ECG - Sinus rhythm. Intraventricular conduction delay. Compared
to the previous tracing of ___ no change.
CT A/P -
1. No nephrolithiasis or ureterolithiasis.
2. Hypoenhancement of the left adrenal gland with surrounding
fat stranding/haziness of the adjacent fat. Findings are
concerning for left adrenal hemorrhage. Consider MRI fur
further assessment. No underlying adrenal mass seen on CT.
3. Mildly prominent bilateral external iliac lymph nodes. Sub
centimeter para-aortic numbers are greater in number than
typically seen. Findings are non-specific.
CXR - IMPRESSION:
Comparison to ___. No relevant change. Normal
lung volumes. Normal size of the cardiac silhouette. Normal
hilar and mediastinal contours. No pneumonia, no pulmonary
edema, no pleural effusions.
MRI Abdomen - IMPRESSION:
1. Interval increase in size of the left adrenal hemorrhage, as
described above. The most likely cause is hemorrhagic
infarction of the gland. No definite mass is identified.
2. Numerous unchanged subcentimeter retroperitoneal lymph
nodes, which are nonspecific. Short term imaging follow-up is
recommended to ensure resolution.
Brief Hospital Course:
___ with chronic mild anemia, BPH, GERD admitted with acute
onset abdominal pain to L flank, leuctyosis w/ left shift,
elevated lactate and idiopathic, unilateral adrenal hemorrhage.
He has a h/o hypertension, and a prior history of vasovagal
episodes ___ years ago. He has no known history of abdominal
trauma.
# Adrenal Hemorrhage: ID evaluated and felt that infectious
etiologies unlikely. MRI showed slight increase in size of
adrenal hemorrhage without any evidence of underlying mass
effect. Surgery consulted early in admission, felt no need for
surgical intervention. Given slight increase in size on MRI, he
was monitored for one additional night for repeat Hct, which was
stable. Ultimately, adrenal hemorrhage attributed to presumed
spontaneous adrenal infarction.
There was no evidence of adrenal insufficiency on exam,
including no hypotension or electrolyte abnormalities. Several
studies of adrenal function were sent and were pending at the
time of discharge. Of note, however, after discharge, urine
studies returned with elevated urinary normetanephrine as well
as elevated urinary cortisol. Lab tests were also notable for
mildly decreased serum renin, with aldosterone still pending.
The patient should likely be referred to endocrine for further
evaluation of these findings.
# HTN: Initially hypertensive on admission, likely related to
pain and anxiety. BP improved on its own, and he was
normotensive at the time of discharge.
# Leukocytosis: ? acute phase reactant, resolved.
# GERD: On home omeprazole.
# BPH: On home doxazosin and finasteride.
TRANSITIONAL ISSUES:
- Please refer patient to endocrine as explained above
- Pt will need follow up imaging given lymphadenopathy on MRI
(see MRI read above)
- Please follow up aldosterone level
- Please follow up blood cultures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxazosin 4 mg PO HS
2. Finasteride 5 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Doxazosin 4 mg PO HS
2. Finasteride 5 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
Do not take more than prescribed. Will cause drowsiness.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours as
needed Disp #*20 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*15 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Idiopathic unilateral (left) adrenal hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with left abdominal pain and found to have
bleeding on the left adrenal gland of unclear etiology. Further
imaging with MRI showed no concerning masses. You were managed
conservatively with pain medicaiton and fluids. You were seen
in consultation by infectious disease and surgerical consult
services. Several blood and urine tests were sent to evaluate
you adrenal function. It is very important that you follow up
with your PCP to go over these test results.
Followup Instructions:
___
|
19758810-DS-11
| 19,758,810 | 23,710,321 |
DS
| 11 |
2166-12-16 00:00:00
|
2166-12-18 11:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aminophylline / Bactrim / Erythromycin Base /
Benadryl Decongestant / Scopolamine / Codeine / Keflex / Tagamet
/ Cytotec / Azmacort / Cipro / Zantac / Pepcid / Celebrex /
Hydrocodone / yellow dye / red dye / Lasix / metformin /
triamcinolone / Quinolones / Cephalosporins / metoprolol /
aspirin / latex / ___ / oxycodone / Milk Containing
Products / Milk Containing Products
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
==============
___ 06:40PM BLOOD WBC-7.7 RBC-4.03 Hgb-10.4* Hct-34.7
MCV-86 MCH-25.8* MCHC-30.0* RDW-18.1* RDWSD-56.1* Plt ___
___ 06:40PM BLOOD Neuts-63.1 ___ Monos-8.1 Eos-0.0*
Baso-0.3 Im ___ AbsNeut-4.88 AbsLymp-2.17 AbsMono-0.63
AbsEos-0.00* AbsBaso-0.02
___ 06:40PM BLOOD ___ PTT-26.9 ___
___ 06:40PM BLOOD Glucose-127* UreaN-11 Creat-1.0 Na-137
K-6.5* Cl-106 HCO3-20* AnGap-11
___ 05:39AM BLOOD ALT-19 AST-19 AlkPhos-96 TotBili-0.3
___ 06:40PM BLOOD cTropnT-<0.01
___ 10:59PM BLOOD cTropnT-<0.01
___ 06:40PM BLOOD proBNP-59
OTHER PERTINENT LABS
====================
___ 01:16AM BLOOD %HbA1c-7.0* eAG-154*
___ 06:40PM BLOOD Triglyc-195* HDL-45 CHOL/HD-3.7
LDLcalc-81
___ 06:40PM BLOOD Cholest-165
DISCHARGE LABS
==============
___ 05:39AM BLOOD WBC-10.1* RBC-3.65* Hgb-9.4* Hct-32.3*
MCV-89 MCH-25.8* MCHC-29.1* RDW-17.8* RDWSD-57.4* Plt ___
___ 05:39AM BLOOD ___ PTT-37.5* ___
___ 05:39AM BLOOD Glucose-159* UreaN-12 Creat-1.0 Na-139
K-4.5 Cl-103 HCO3-24 AnGap-12
___ 05:39AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.3
MICRO
=====
___ 06:40PM URINE Color-Straw Appear-Clear Sp ___
___ 06:40PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0
Leuks-SM*
___ 06:40PM URINE RBC-0 WBC-4 Bacteri-NONE Yeast-NONE Epi-1
___ 6:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP B. 10,000-100,000 CFU/mL.
IMAGING
=======
CXR ___
PA and lateral views of the chest provided. Lungs are clear.
No large
effusion or pneumothorax. Previously noted NG tube has been
removed.
Cardiomediastinal silhouette appears mildly prominent though
unchanged. No
definite signs of congestion or edema. Bony structures are
intact. Partially
visualized spinal hardware is noted in the upper abdomen.
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[ ] A1C 7.0. Patient on Invokana only. Patient would benefit
from additional oral hypoglycemic to lower A1C further as an
outpatient.
[ ] Patient started on atorvastatin 40mg daily for ASCVD score
>10% (12%). Please monitor for tolerance.
[ ] Patient with close cardiology follow-up with Dr ___.
Recommend dobutamine stress test to further evaluate cardiac
function.
BRIEF HOSPITAL COURSE
======================
Ms. ___ is a ___ year old woman with history of AFib,
severe asthma, DM, HLD, and iron deficiency anemia who presented
with chest pain during IV iron infusion found to have possible
ST depressions on EKG, without elevated troponins initially
started on heparin gtt. However, patient then described more GI
symptoms with indigestion, belching, N/V, and acid reflux
relieved with Tums and Zofran. Heparin was discontinued and
patient continued to be chest pain free even with
ambulation/exertion, making GERD more likely and cardiac
pathology less of an acute concern.
ACUTE PROBLEMS:
===============
#Chest pain
#GERD
Patient has multiple cardiac risk factors including diabetes and
obesity. EKG showed mild ST segment depressions in V1-V3
(similar to prior on further review). Troponins were negative.
Initial concern for unstable angina so patient was started on
heparin gtt and nitro gtt for chest pain. Patient was not given
ASA due to angioedema allergy. No beta-blocker was given due to
allergy/severe asthma. After a few hours, patient's chest pain
was completely resolved. She described more of a reflux type
pain and was experiencing belching/nausea and acid taste at the
back of her mouth. This was relieved with Zofran and Tums.
Patient was taken off heparin gtt and nitro gtt due to lower
suspicion for cardiac pathology and more likely GERD. She
continued to be chest pain-free. Patient ambulated with nursing
staff and exerting herself prompted no chest pain, shortness of
breath, or any other symptoms. Her presentation was discussed in
detail with her outpatient cardiologist, Dr. ___ it was
agreed there was very low suspicion for ACS. Patient was
discharged with close cardiology follow-up and likely plan for
outpatient dobutamine echo stress test with Dr. ___.
# Acute hypoxic respiratory failure
Briefly required oxygen in the ED but now weaned off. Likely
required O2 in setting of acute pain and anxiety. Patient
satting well on RA on ambulation and at rest.
# Severe asthma
Patient continued on home fluticasone, Incruse Ellipta
(umeclidinium) 62.5 mcg/actuation
inhalation DAILY, tiotropium, Levalbuterol Neb 0.63 mg NEB
Q6H:PRN dyspnea, Montelukast 10 mg PO DAILY, and budesonide 180
mcg/actuation inhalation BID
# Type II DM
UA with large glucose concerning for uncontrolled diabetes. A1C
elevated at 7, unsure of previous value. Was on insulin sliding
scale during admission, restarted home Invokana on discharge.
Patient would benefit from additional oral hypoglycemic to lower
A1C further as an outpatient.
CHRONIC PROBLEMS:
=================
# Vitamin use
Patient continued on daily vitamin D, Mg, B6, and B12.
# Constipation
Patient continued on home docusate, Miralax
# Allergies
Patient continued on home azelastine 137 mcg (0.1 %) nasal and
home Fexofenadine 180 mg PO DAILY
# A fib
Patient continued on home Plavix. Patient continued on home
Propafenone HCl 225 mg PO BID. Patient continued on home
diltiazem fractionated at 60 mg PO q6h while admitted.
# Depression
Patient continued on home DULoxetine ___ 120 mg PO DAILY
# Nutrition
Patient continued on home FoLIC Acid 1 mg PO DAILY
# Chronic pain
Patient continued on home Gabapentin 300 mg PO BID and home
TraMADol 50 mg PO Q8H:PRN.
# Hypothyroidism
Patient continued on home Levothyroxine Sodium 200 mcg PO DAILY
# GERD
Patient continued on home Pantoprazole 40 mg PO Q24H
# Iron deficiency anemia
Patient to continue outpatient iron infusions
# Insomnia
Patient continued on home TraZODone 200 mg PO QHS
# CODE: Full, presumed
# CONTACT: HCP: Name of health care proxy: ___
Relationship: husband Phone number: ___
___ time 25 min
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Pulmicort Flexhaler (budesonide) 180 mcg/actuation inhalation
BID
3. Breo Ellipta (fluticasone furoate-vilanterol) 200-25 mcg/dose
inhalation DAILY
4. azelastine 137 mcg (0.1 %) nasal DAILY
5. Montelukast 10 mg PO QPM
6. Diltiazem Extended-Release 240 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Propafenone HCl 225 mg PO BID
9. Pantoprazole 40 mg PO Q24H
10. TraZODone 200 mg PO QHS
11. DULoxetine ___ 60 mg PO BID
12. Levothyroxine Sodium 200 mcg PO DAILY
13. Gabapentin 300 mg PO BID
14. TraMADol 50 mg PO BID
15. Potassium Chloride 10 mEq PO BID
16. Vitamin D ___ UNIT PO 1X/WEEK (SA)
17. Invokana (canagliflozin) 100 mg oral DAILY
18. Fexofenadine 180 mg PO DAILY
19. Docusate Sodium 100 mg PO BID
20. Polyethylene Glycol 17 g PO DAILY
21. Magnesium Oxide 500 mg PO DAILY
22. FoLIC Acid ___ mg PO DAILY
23. Vitamin D 1000 UNIT PO DAILY
24. Pyridoxine 100 mg PO DAILY
25. Cyanocobalamin 2500 mcg PO DAILY
26. Acetaminophen 1000 mg PO BID
27. Sodium Chloride Nasal 1 SPRY NU DAILY AND PRN nasal dryness
28. azithromycin 500 mg oral 1X:ASDIR
29. Methylprednisolone 4 mg PO ASDIR taper for asthma attacks
This is dose # of tapered doses
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. Acetaminophen 1000 mg PO BID
3. azelastine 137 mcg (0.1 %) nasal DAILY
4. Azithromycin 500 mg oral 1X:ASDIR
5. Breo Ellipta (fluticasone furoate-vilanterol) 200-25
mcg/dose inhalation DAILY
6. Clopidogrel 75 mg PO DAILY
7. Cyanocobalamin 2500 mcg PO DAILY
8. Diltiazem Extended-Release 240 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. DULoxetine ___ 60 mg PO BID
11. Fexofenadine 180 mg PO DAILY
12. FoLIC Acid ___ mg PO DAILY
13. Gabapentin 300 mg PO BID
14. Invokana (canagliflozin) 100 mg oral DAILY
15. Levothyroxine Sodium 200 mcg PO DAILY
16. Magnesium Oxide 500 mg PO DAILY
17. Methylprednisolone 4 mg PO ASDIR taper for asthma attacks
This is dose # of tapered doses
18. Montelukast 10 mg PO QPM
19. Pantoprazole 40 mg PO Q24H
20. Polyethylene Glycol 17 g PO DAILY
21. Potassium Chloride 10 mEq PO BID
22. Propafenone HCl 225 mg PO BID
23. Pulmicort Flexhaler (budesonide) 180 mcg/actuation
inhalation BID
24. Pyridoxine 100 mg PO DAILY
25. Sodium Chloride Nasal 1 SPRY NU DAILY AND PRN nasal dryness
26. Tiotropium Bromide 1 CAP IH DAILY
27. TraMADol 50 mg PO BID
28. TraZODone 200 mg PO QHS
29. Vitamin D 1000 UNIT PO DAILY
30. Vitamin D ___ UNIT PO 1X/WEEK (SA)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
GERD
Chest Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were having chest pain
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given medications to treat a heart problem however
the origin of the chest pain seemed less likely to be caused by
the heart so those were stopped. You were given medications to
treat you indigestion and nausea which did help. You were chest
pain free on trial off the medications and were doing well with
walking around.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
-Please continue to take all of your medications and follow-up
with your appointments as listed below.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19759059-DS-12
| 19,759,059 | 28,161,037 |
DS
| 12 |
2175-07-29 00:00:00
|
2175-07-30 17:15:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dysphagia
Major Surgical or Invasive Procedure:
EUS/ERCP
Lumbar puncture
History of Present Illness:
===================================================
MEDICINE ADMISSION NOTE
===================================================
PCP: ___
CC: ___, dysphagia
HISTORY OF PRESENT ILLNESS:
___ ___ speaking with history of diabetes mellitus and
hyperlipidemia who presents with symptoms of cough, chills, and
body aches, as well as dysphagia since ___ afternoon.
History was obtained the help of her daughter.
The patient has been in her usual state of health until 3 days
prior to admission when she developed elevated temperatures to
99-100 ___s a dry cough. No chest pain shortness of
breath.
On the same day, she developed worsening dysphagia. She
describes a feeling of food getting stuck in the back of the
throat and inability to clear her throat. She reports
intermittent episodes of the feeling of food getting stuck in
the
esophagus in the past (approximately 3 times last year and
several times since ___. However, it she had the feeling
that her food got stuck in the lower part of esophagus. In
addition, this feeling would usually resolve after approximately
1 hour. In contrast, after swallowing a small bite on ___
associated feeling of food getting stuck in the back of the
throat and this feeling did not resolve after 1 day prior to
presentation. In addition, she started vomiting several times
small amounts of food later the day of symptom onset without
symptom relief. Since her symptoms started she is essentially
not eaten or drunken. She denies coughing spells with
swallowing
or eating.
Patient lives alone but her cleaning lady has been out sick.
She
has 2 daughters who are visiting her regularly. Persistent she
did receive a flu shot this year.
Last EGD in ___ with normal mucosa and no evidence of
esophageal
stricturing.
In the ED, initial VS were:
Tmax 101.9 at 952a on ___, Hr 78-100, BP 116-166/48-100, ___,
96-98% on RA
Exam notable for:
Constitutional: ill appearing
HEENT: Normocephalic, atraumatic
dry MM
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: warm to touch
Psych: Normal mood
ECG: NSR, nonspecific ST changes in avR, left axis deviation
Labs showed:
Trop <.01, CBC, CHEM 10, LFTs unremarkable except for Plt 89,
Glu
275.
FluB PCR positive
UA with small blood, 1000 glucose, 13 WBC, few bacteria, 80
ketone
Lactate 2.1
Imaging showed:
CXR: Right apical consolidation which could certainly represent
pneumonia in the proper clinical setting. Recommend follow-up
after treatment to document resolution.
Patient received:
12:09 IVF NS
___ 12:09 IV Levofloxacin
___ 13:40 IV Levofloxacin 500 mg
___ 14:35 IVF NS 1000 mL
___ 17:49 IV Acetaminophen IV 1000 mg
___ 18:19 IVF ___ ( 1000 mL ordered)
___ 21:52 IVF ___
___ 21:53 PO Acetaminophen
___ 21:53 PO/NG OSELTAMivir
___ 22:55 SC Insulin
On arrival to the floor, patient reports persistent dry cough,
as
well as persistent difficulty swallowing, but currently no
globus
sensation.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
High Cholesterol, HTN, NIDDM
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.1 PO 150 / 74 77 16 93
GENERAL: well-appearing, no acute physical or mental distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, OP clear w/o swelling, exudate, or asymmetry
NECK: supple, no LAD, no JVD, trachea midline
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: normal effort, CTAB
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, CN II-XII intact, UE and ___ strength ___
throughout, no pronator drift, no asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Temp: 100.7 (Tm 100.7), BP: 114/63 (99-121/58-71), HR: 91
(88-101), RR: 17 (___), O2 sat: 93% (93-96), O2 delivery: Ra,
Wt: 119.27 lb/54.1 kg
GENERAL: Awake answering questions appropriately, comfortable,
voice seems stronger, strong non-productive cough intermittently
HEENT: normocephalic, pupils equal, anicteric sclera, pink
conjunctiva, ++mucous membranes very dry with significant food
material/crusting + erythema hard palette, OP w/mucus, dophoff
in
place
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: normal effort, CTAB
ABDOMEN: soft, non-tender today, Neg Murphys, no
rebound/guarding, +BS
EXTREMITIES: warm, no ___ swelling
NEURO: more alert today, speech normal
SKIN: Miliaria crystalline improved. No other new lesions or
rashes.
Pertinent Results:
ADMISSION LABS:
==============
___ 10:31AM BLOOD WBC-6.8 RBC-3.96 Hgb-13.6 Hct-40.2
MCV-102* MCH-34.3* MCHC-33.8 RDW-12.9 RDWSD-48.5* Plt Ct-89*
___ 10:31AM BLOOD Neuts-88.0* Lymphs-5.1* Monos-6.3
Eos-0.1* Baso-0.1 Im ___ AbsNeut-6.00 AbsLymp-0.35*
AbsMono-0.43 AbsEos-0.01* AbsBaso-0.01
___ 09:35AM BLOOD ___ PTT-23.4* ___
___ 10:31AM BLOOD Glucose-275* UreaN-16 Creat-0.7 Na-142
K-4.2 Cl-101 HCO3-20* AnGap-21*
___ 10:31AM BLOOD ALT-35 AST-38 AlkPhos-50 TotBili-1.0
___ 10:31AM BLOOD Lipase-27
___ 10:31AM BLOOD cTropnT-<0.01
___ 10:31AM BLOOD Albumin-4.1 Calcium-8.6 Phos-3.0 Mg-2.3
NOTABLE HOSPITAL COURSE LABS:
=============================
___ 06:45AM BLOOD Hapto-36
___ 06:00AM BLOOD Ret Aut-5.1* Abs Ret-0.13*
___ 06:50AM BLOOD Ret Aut-8.0* Abs Ret-0.19*
___ 10:31AM BLOOD Lipase-27
___ 06:45AM BLOOD Lipase-169*
___ 06:50AM BLOOD Lipase-38
___ 06:50AM BLOOD ___ Folate-9 Hapto-61
___ 02:39AM BLOOD %HbA1c-9.9* eAG-237*
___ 06:10AM BLOOD TSH-0.34
___ 06:20AM BLOOD 25VitD-57
___ 06:10AM BLOOD CRP-15.4*
___ 06:20AM BLOOD CRP-4.1
___ 05:05PM BLOOD PEP-NO SPECIFI ___ FreeLam-17.3
Fr K/L-0.74
___ 01:21PM BLOOD HIV Ab-NEG
___ 11:18AM BLOOD Lactate-2.1* K-3.5
___ 03:24AM BLOOD Lactate-2.5*
___ 08:39AM BLOOD Lactate-2.0
___ 08:21AM BLOOD freeCa-1.03*
ACETYLCHOLINE RECEPTOR ANTIBODY negativve
ACETYLCHOLINE RECEPTOR MODULATING ANTIBODY negativve
ALDOSTERONE MUSK negativve
ANTIBODY RENIN - FROZEN SED RATE negativve
___ 21:15
CORTISOL
Test Result Reference
Range/Units
TOTAL VOLUME 3700 mL
CORTISOL, FREE, URINE 1510.3 H 4.0-50.0
mcg/24 h
Analysis performed by Tandem Mass Spectrometry
This test was developed and its analytical performance
characteristics have been determined by ___. It has not been
cleared or approved by FDA. This assay has been validated
pursuant to the ___ regulations and is used for clinical
purposes.
Test Result Reference
Range/Units
CREATININE, URINE 0.95 0.63-2.50 g/24
h
DISCHARGE LABS:
==============
___ 06:15AM BLOOD WBC-5.8 RBC-2.39* Hgb-8.4* Hct-25.2*
MCV-105* MCH-35.1* MCHC-33.3 RDW-16.1* RDWSD-52.1* Plt ___
___ 06:00AM BLOOD Neuts-83.3* Lymphs-9.4* Monos-5.4
Eos-0.5* Baso-0.1 NRBC-1.0* Im ___ AbsNeut-6.80*
AbsLymp-0.77* AbsMono-0.44 AbsEos-0.04 AbsBaso-0.01
___ 06:45AM BLOOD Hypochr-NORMAL Anisocy-1+*
Poiklo-OCCASIONAL Macrocy-1+* Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL
___ 06:15AM BLOOD ___ PTT-25.8 ___
___ 06:50AM BLOOD Ret Aut-8.0* Abs Ret-0.19*
___ 06:15AM BLOOD ALT-83* AST-80* LD(LDH)-395* AlkPhos-60
TotBili-0.5 DirBili-<0.2 IndBili-0.5
___ 06:50AM BLOOD Lipase-38
___ 06:45AM BLOOD Lipase-169*
___ 10:31AM BLOOD Lipase-27
___ 04:30PM BLOOD Calcium-8.1* Phos-1.7* Mg-2.3
___ 06:50AM BLOOD ___ Folate-9 Hapto-61
___ 04:30PM BLOOD Osmolal-278
___ Imaging GALLBLADDER SCAN
___ Gastroenterology ERCP Scanned
___ Gastroenterology Endoscopic Ultrasound- Upper
___ Imaging LIVER OR GALLBLADDER US
___ Imaging LIVER OR GALLBLADDER US
___ Pathology Herpes Simplex Virus PCR CSF
___ Imaging LUMBAR PUNCTURE (W/ FLU
___ Imaging MR HEAD W/O CONTRAST
___ Imaging BILAT LOWER EXT VEINS
___ Cardiovascular ECHO
___HEST W/CONTRAST
___ Imaging CT HEAD W/O CONTRAST
___BD & PELVIS WITH CO Approved
___ Imaging DX CHEST PORT LINE/TUBE
___ Imaging VIDEO OROPHARYNGEAL SWA
___ Imaging PORTABLE ABDOMEN
___ Imaging CHEST (PA & LAT)
Brief Hospital Course:
___ ___ speaking with history of diabetes mellitus and
hyperlipidemia who presented with worsening dysphagia, found to
have influenza, hospital course complicated by worsening fatigue
and persistent fevers.
#GOC: Multiple goals of care conversations took place with case
management, primary team and family. Ultimately, family decided
that they like the idea of 'more monitoring' at ___ including
labs and daily VS monitoring. However, they do not wish for her
to return to the hospital, and if patient deteriorates further,
they would prefer hospice care. They do not want to pursue any
aggressive measures including further workup for current imaging
and lab abnormalities. For example, family was hesitant to
pursue HIDA scan for work up of cholecystitis and were hesitant
to accept heme/onc consult for work up of malignancy. In terms
of patient's severe dysphagia, family understands that even
small drops of food/liquids will put the patient at risk for
pneumonia and death, but they would like to pursue intake as
tolerated per quality of life goals. As such, she was discharged
with TF. She is DNR/DNI/DNH, ok for artificial nutrition and
hydration; noninvasive ventilation and HD are not within GOC.
# Influenza:
Symptoms started 3 days prior to admission. Initially briefly
treated with Tamiflu, but discontinued given concern for
aspiration in the setting of severe dysphagia as below. Further
treatment deferred given time from symptom onset. Her
respiratory symptoms improved during her hospital stay.
# Oropharyngeal dysphagia:
The exact etiology remained unclear. There appeared to be an
acute on chronic component of what appears to be largely
oropharyngeal dysphagia as objectively demonstrated by video
swallowing study obtained during this admission. Neurology was
consulted and concerned for isolated bulbar myasthenia, which
though rare, does fit patient's presentation quite well. Less
likely central cause given negative MRI brain. Further possible
causes included paraneoplastic syndrome, possibly in the setting
of lung nodule. While serological tests returned negative for
myasthenia, per neurology this could still be myasthenia ___
if the clinical suspicion is high enough. The only definitive
way to diagnose it would have been an EMG. This was discussed
with patient's daughter who very clearly stated that this would
not be within the patient's goals of care. Therefore, EMG was
deferred. There is a suspicion of paraneoplastic syndrome as
well given that malignancy is high on DDx due to fevers, lung
nodule, and blood count abnormalities (see details below). The
patient underwent dobhoff placement ___. Tube feeds were
initiated and well tolerated at goal. G tube was not within GOC
given family's preference to avoid invasive procedures.
#Toxic Metabolic Encephalopathy: Patient was profoundly
somnolent over hospital course and was seen by neurology. EEG
was declined by family, but subclinical seizures unlikely
based on improving mental status. MRI ___ showed a T1
hyperintense, T2 hyperintense
lesion which demonstrates restricted diffusion with its
epicenter in the left parietal bone with an exophytic component
extending inferiorly into the left frontoparietal subarachnoid
space, progressed from prior imaging. A contrast enhanced MRI
was recommended, but declined by family. This finding, however,
is unlikely to explain her overall somnolence. Patient underwent
LP which which revealed prot 56, normal gluc, normal wbc/rbc
ratio. She remained persistently somnolent throughout hospital
course.
#?Malignancy of unknown origin
Patient suffered from fevers and severely high levels of
cortisol that were never explained by influenza and
choledocholithiasis. There was concern for underlying malignancy
with possible paraneoplastic syndrome. There were multiple
lesions found on imaging that were concerning for malignancy,
including lung nodule and brain MRI findings as above as well as
nucleated cells concerning for bone marrow process. However,
family did not want to pursue any workup or heme/onc consult.
# Fevers
# ___ course complicated by persistent high-grade fevers up
to 104. Given prolonged time course, this was though to be
unlikely secondary to influenza. However, additional work up
including pan-CT scan, MRI brain, and LP remained largely
unremarkable. An initial antibiotic treatment with vancomycin /
cefepime was stopped given normal WBC, ESR, CRP, and lack of
improvement. Additional work-up for fever of unknown origin
including TTE and LENIs was negative. In the setting of
worsening abdominal tenderness and LFT abnormalities, imaging
was obtained that demonstrated gall stones in the CBD, the
cystic duct, as well as signs of worsening biliary dilatation
and a thick walled gall bladder. Overall, imaging concerning for
biliary source of an infection despite inflammatory parameters
within normal limits. The patient was started on empiric
antibiotics (ceftriaxone, Flagyl, day 1= ___ and referred for
EUS which demonstrated a stone in the CBD without pus. Patient
underwent ERCP (on ___ with successful removal of stone and
resolution of RUQ pain. She continued to have low grade fevers
(of note, fevers measured tactile at temples did not correlate
with oral temperatures). HIDA scan after EGD showed delayed
gallbladder visualization although no cholecystitis. Still, CCY
or perc chole was considered to prevent recurrence of
choledocholithiasis. However, this was not within ___ even if
offered. Per general surgery recommendations, she remained on a
3 day course of antiobitiocs ending ___.
# Hypercortisuria
# Hypokalemia
# Hypophosphatemia
# Glycosuria:
___ hospital course was complicated by severe hypokalemia
and hypophosphatemia, concerning for renal losses, possibly in
the setting of underlying osmotic diuresis from considerable
glycosuria. However, glycosuria seemed to be out of proportion
for serum glucose values. Notably, 24 hour urine cortisol level
was 30x the upper limit of normal, which may explain the
wasting.
# Hyperglycemia:
Likely poorly controlled at baseline given high recent A1c. Held
home glipizide and started on long acting insulin plus regular
insulin sliding scale on admission. Course was complicated by
persistently high serum glucose levels in 200s-300s. Long acting
insulin and SSI were adjusted accordingly with sugars controlled
(below regimen).
# Hyperlipidemia: Continued home atorvastatin although this was
discontinued over hospital course due to elevated LFTs and given
overall GOC.
TRANSITIONAL ISSUES
===================
#GOC: Please continue ongoing ___ discussions with family. They
had decided on hospice on the day of discharge but then felt
they wanted to wait for possible recovery before fully
transitioning to CMO. However, throughout admission, labs,
imaging, consults have been not within ___. As above she is
DNR/DNI/DNH but not CMO
#INSULIN REGIMEN:
Continue insulin regimen while on current tube feed regimen:
Glargine 15U Breakfast
Regular insulin sliding scale (Give 2U for BG 150; Increment by
4U every 50 above 150)
- Sugars need to be closely monitored on tube feeds.
#ORAL HYGIENE
[] Please continue Chlorhexidine Gluconate 0.12% Oral Rinse 15
mL ORAL QID with green swab given poor oral hygiene
#Anemia
[] Hemoglobin has been slowing trending down from 11 (___) to
8.4 ___ or day of discharge). Please check weekly if within
___ to trend and manage this.
#Low Sodium
[] Patient's sodium slowly down before discharge. Please recheck
on ___ if within ___ to manage this.
#Lesions not worked up per patient preference/concern for
malignancy:
- LUNG
[] Follow up CT is recommended for 1.6 x 1.4 cm mass in the
posterior segment the right upper lobe abutting the posterior
subsegmental bronchus of the right upper lobe, which is
indeterminate but concerning for malignancy.
- BRAIN
[] There is an incompletely evaluated T1 hyperintense, T2
hyperintense lesion which demonstrates restricted diffusion with
its epicenter in the left parietal bone with an exophytic
component extending inferiorly into the left frontoparietal
subarachnoid space. The lesion measures 22 x 16 mm on sagittal
T1 imaging. There is no adjacent edema in the left perirolandic
cortex. Post-contrast MP rage imaging is advised to better
assess this lesion.
***Patient's family declined MRI with contrast to further
categorize lesion.
-THYROID
[] There is a is approximately 16 x 14 mm hypodense lesion in
the left lobe of thyroid. The superior extent of the lesion has
not been imaged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 10 mg PO QPM
2. GlipiZIDE 2.5 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID
2. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
3. LOPERamide 2 mg PO QID:PRN diarrhea
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Oropharyngeal dysphagia
Cholangitis and choledocholithiasis
Hypercortisuria
Encephalopathy
Leukocytosis
Hypokalemia
Hyponatremia
Protein calorie malnutrition requiring tube feeds
Fever
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic and not arousable.
Mental Status: Confused - always.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you!
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
You were admitted because you were having trouble swallowing.
WHAT HAPPENED WHILE I WAS HERE?
==============================
You were diagnosed with the flu. You were seen by our swallowing
specialists and neurologist teams who ordered an extensive
workup for your swallowing difficulties. Per discussions with
you and your family, it was decided to limit some of these tests
given your goals of care. You were also found to have a stone in
your biliary system that was causing an infection. You were
taken for a procedure to remove the stone, which was successful.
WHAT SHOULD YOU DO WHEN YOU LEAVE?
==================================
Take your medications as below. As you know, there is a high
risk of you aspirating or choking on your food and getting a
Pneumonia. However, if you're willing to take that risk, please
eat as tolerated!
We wish you the very best!
Kind wishes,
Your ___ Care Team
Followup Instructions:
___
|
19759059-DS-13
| 19,759,059 | 23,986,645 |
DS
| 13 |
2175-08-17 00:00:00
|
2175-08-17 18:27:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
clogged NGT
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with recent
hospitalization for influenza, cholangitis and dysphagia and
concern for malignancy. The patient's family declined additional
work up and she was discharged to rehab with dobhoff for
nutrition. Since transfer to rehab, per the patient's family,
she
has improved significantly. She is much stronger and has been
working with physical therapy although still requires two people
for transfers. Since transfer, the patient's doboff clogged last
week. She was evaluated at ___ where an NGT was placed. This NGT
was noted to be clogged yesterday evening therefore the patient
was transferred to ___ for consideration of PEG placement.
Since discharge, the patient has had intermittent low fevers.
She
was recently treated for a urinary tract infection with cipro.
She has a chronic indwelling foley, it is unclear if she had
urinary retention or if this was placed for comfort. The family
reports intermittent cough, but patient denies. She also denies
shortness of breath. Denies abdominal pain. No nausea or
vomiting. The family notes the patient had diarrhea before last
hospitalization which has since resolved. Per family, mental
status is at recent baseline and waxes and wanes.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Hyperlipidemia
Diabetes- Type 2
?Mild cognitive impairment
Choledocolithasis
Concern for lung malignancy
Social History:
___
Family History:
No family history of neurologic problems or diabetes
Physical Exam:
VITALS: ___ 0744 Temp: 97.6 PO BP: 116/72 HR: 97 RR: 18 O2
sat: 93% O2 delivery: RA
GENERAL: Alert and in no apparent distress, thin.
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. NGT in
in
nare.
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs scattered wheeze, ronchi, crackle- Poor effort.
GI: Abdomen soft, non-distended, slightly tender to palpation.
Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent although speaks only a little, thinks she is at
home, moves all limbs
PSYCH: pleasant, appropriate affect
Exam on discharge:
___ 0709 Temp: 98.5 PO BP: 139/83 R Lying HR: 108
RR:
16 O2 sat: 93% O2 delivery: Ra
GENERAL: Alert and in no apparent distress, opens eyes to voice,
smiles
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 +tachycardic, no murmur, no S3, no S4. No
JVD.
RESP: Breathing is non-labored
GI: non-tender
GU: foley draining amber urine
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:
___ 03:53AM GLUCOSE-191* UREA N-15 CREAT-0.5 SODIUM-136
POTASSIUM-3.9 CHLORIDE-91* TOTAL CO2-32 ANION GAP-13
___ 03:53AM estGFR-Using this
___ 03:53AM ALT(SGPT)-81* AST(SGOT)-91* LD(LDH)-532* ALK
PHOS-112* TOT BILI-0.6
___ 03:53AM WBC-6.0 RBC-2.40* HGB-8.1* HCT-25.3* MCV-105*
MCH-33.8* MCHC-32.0 RDW-16.5* RDWSD-63.2*
___ 03:53AM NEUTS-79.0* LYMPHS-12.6* MONOS-6.2 EOS-0.2*
BASOS-0.2 NUC RBCS-0.5* IM ___ AbsNeut-4.75 AbsLymp-0.76*
AbsMono-0.37 AbsEos-0.01* AbsBaso-0.01
___ 03:53AM PLT COUNT-216
___ 03:51AM LACTATE-1.2
Chest X Ray:
IMPRESSION:
1. New enteric tube ends in the proximal stomach. Similar right
upper lobe mass.
2. New bibasilar airspace disease may represent aspiration
pneumonia
Brief Hospital Course:
___ with history of diabetes, and recent hospitalization for
influenza, cholangitis and dysphagia presented with clogged NGT.
After discussion with the patient's family, the decision was
made to focus on comfort.
#Oropharyngeal dysphagia
Patient with recent history of dysphagia. Evaluated by neurology
during recent admission with some concern for MG, although
antibodies are negative. During most recent hospitalization,
family declined additional evaluation for dysphagia such as EMG.
After discussion with family, decision was made to allow the
patient to eat for comfort and not place PEG tube.
#Lung mass, concern for malignancy
#Brain mass
#?Aspiration pneumonia
Patient without signs of systemic infection. WBC count not
elevated and on room air. Antibiotics were not given during
hospitalization.
#Recent Choledocolithasis
Some abdominal pain on exam, LFTs slightly elevated although
hemolyzed. No additional labs.
#Urinary Retention
Leave foley in place for comfort
#Diabetes, ___
D/W family, will stop FSBS and insulin.
#Goals of care:
Confirmed with the patient's daughters ___ and ___. They want
their mother to be
comfortable at all costs and do not want her to suffer. They
also confirm that they do not want to place PEG tube. The
patient has a MOLST form from most recent hospitalization
DNR/DNI/DNH. The patient will be discharged to Care One in
___ with ___ providing hospice services.
# Contacts/HCP/Surrogate and Communication: ___
>30 minutes on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 15 Units Breakfast
Insulin SC Sliding Scale using Novolog Insulin
2. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL QID
3. LOPERamide 2 mg PO QID:PRN diarrhea
4. Acetaminophen 650 mg NG Q6H:PRN Pain - Mild
5. Senna 8.6 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Haloperidol 0.5 mg PO TID:PRN agitation/discomfort
RX *haloperidol 0.5 mg 1 tablet(s) by mouth TID PRN Disp #*15
Tablet Refills:*0
2. LORazepam 0.5 mg PO Q6H:PRN discomfort/anxiety/agitation
RX *lorazepam 0.5 mg 1 tablet(s) by mouth Q6hrs as needed Disp
#*20 Tablet Refills:*0
3. Morphine Sulfate (Oral Solution) 2 mg/mL 2 mg PO Q4H:PRN
discomfort/dyspnea
RX *morphine 10 mg/5 mL 2 mg by mouth Q4hrs as needed Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Dysphagia, concern for neuromuscular disorder
Lung mass, concerning for malignancy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
___,
It was a pleasure taking care of you during your admission to
___. You were admitted with a
clogged NG tube. We discussed your care moving forward with your
family and decided to focus your care on comfort.
You will be discharged to your skilled nursing facility with
hospice care.
We wish you the best,
Your ___ Care team
Followup Instructions:
___
|
19759225-DS-35
| 19,759,225 | 22,038,858 |
DS
| 35 |
2143-08-01 00:00:00
|
2143-08-02 17:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Phenergan Plain / Reglan / Vancomycin / Prochlorperazine Maleate
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year-old with history of chronic pancreatitis
___ EtOH, alcohol abuse, presenting with alcohol intoxication
and epigastric pain, which he says is consistent with his
chronic epigastric pain. Patient reports that he has had
worsening epigastric pain over the past several days. He has
constant pain in his epigastric region, which does not radiate.
Also endorses nausea, and non-bloody, non-bilious emesis over
the past two days. He has non-bloody diarrhea, which is at his
current baseline. Pt complains of chills. He has been drinking
excessively over the past several days because of the worsening
abdominal pain. Patient drinks vodka, last drink was today.
In the ED, initial vitals were: 97.2 100 114/77 15 99%. Labs
were significant for AST of 60, lipase of 85, serum EtOH of 479.
He received morphine 10 mg IV, 1 L NS, 1 L NS with 40 mEq of K.
Vitals on transfer are 98.8 94 20 125/69 96%.
On the floor, patient continues to complain of epigastric
abdominal pain. He requests dilaudid or percocet for pain and
would like to drink carbonated beverages as this helps with his
symptoms.
ROS: Denies fever, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria. The ten point review of systems is otherwise
negative.
Past Medical History:
- Pancreatitis: lipase has ranged from normal level to 433. CT
abd/pelvis x 2 has shown no evidence of acute or chronic
pancreatitis, but has shown diffuse fatty infiltration of the
liver.
- Chronic pain secondary to pancreatitis, narcotics use
- Alcohol abuse, starting at age ___ multiple attempts at detox
w/ h/o DT's (no h/o withdrawal seizures)
- Gastritis
- Hepatitis C (not documented in this system)
- Iron-deficiency Anemia
- Prosthetic left eye
- Positive H. pylori serology, ___
- Panic disorder
Social History:
___
Family History:
Father and mother w/history of alcoholism.
Physical Exam:
Admission Exam
VS: 98, 144/99, 71, 20, 99% on RA
GENERAL: Intoxicated, appears comfortable, in no acute distress
A&Ox3.
HEENT: NC/AT, prosthetic left eye. Right eye pupil reactive.
NECK: Supple, no thyromegaly, no JVD.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: + Bowel sounds, soft, voluntary guarding, diffuse
tenderness to palpation
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact.
Discharge Exam
VS: 98.9 98.4 ___ ___ 18 97-100%RA
GENERAL: Comfortable appearing, A&Ox3.
HEENT: NC/AT, prosthetic left eye. Right eye pupil reactive.
NECK: Supple, no thyromegaly, no JVD.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement,
resp unlabored.
ABDOMEN: + Bowel sounds, soft, no guarding, Mild diffuse
tenderness to palpation
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact.
Pertinent Results:
___ 07:50PM SODIUM-137 POTASSIUM-4.1 CHLORIDE-101
___ 07:50PM MAGNESIUM-2.5
___ 01:13PM LIPASE-387*
___ 07:10AM GLUCOSE-115* UREA N-5* CREAT-0.6 SODIUM-145
POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-29 ANION GAP-10
___ 07:10AM ALT(SGPT)-22 AST(SGOT)-45* ALK PHOS-62 TOT
BILI-0.3
___ 07:10AM LIPASE-924*
___ 07:10AM ALBUMIN-3.6 CALCIUM-7.4* PHOSPHATE-3.2
MAGNESIUM-1.6
___ 07:10AM WBC-5.9 RBC-3.13* HGB-8.5* HCT-27.5* MCV-88
MCH-27.1 MCHC-30.8* RDW-18.7*
___ 07:10AM PLT COUNT-101*
___ 11:11PM GLUCOSE-97 UREA N-6 CREAT-0.7 SODIUM-149*
POTASSIUM-2.9* CHLORIDE-105 TOTAL CO2-31 ANION GAP-16
___ 11:11PM estGFR-Using this
___ 11:11PM ALT(SGPT)-28 AST(SGOT)-60* ALK PHOS-83 TOT
BILI-0.3
___ 11:11PM LIPASE-85*
___ 11:11PM ALBUMIN-5.0
___ 11:11PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:11PM WBC-4.4 RBC-4.12* HGB-11.1* HCT-35.9* MCV-87
MCH-26.8* MCHC-30.8* RDW-19.3*
___ 11:11PM NEUTS-50.1 ___ MONOS-4.8 EOS-3.3
BASOS-1.3
___ 11:11PM PLT COUNT-120*
.
CT Abd/Pelv
Fatty liver.
hyperenhancing focus in segment II of the liver (2, 7) that was
not seen on prior examination but was seen on examination from
___ (2, 9). The lesion measures 9 mm, grossly
unchanged from prior examination. This lesion cannot be fully
characterized on single phase CT examination. The gallbladder is
within normal limits. No signs of gallbladder stones. No signs
of cholecystitis. There is no intra- or extra-hepatic biliary
duct dilation.
The spleen is unremarkable. The pancreas is within normal limits
except for tiny calcification in the uncinate process (2, 25)
that was seen on CT examination from ___.
The pancreatic duct is not dilated and the pancreas parenchyma
is within
normal limits. Both adrenals are unremarkable.
The kidneys enhance and excrete symmetrically. Note is made of
subcentimeter hypoattenuating cortical focus in the interpolar
region of the right kidney (2, 31), too small to characterize.
No mesenteric lymphadenopathy is seen. A few prominent lymph
nodes are seen in the retroperitoneum. The small and large
bowels are within normal limits.
PELVIS: The urinary bladder is distended. The prostate gland is
within
normal limits. There is no lymphadenopathy or free fluid in the
pelvis.
The aorta and its branches are of normal caliber and patent.
The portal vein branches, the splenic vein and SMV are of normal
caliber and patent.
Normal appearance of the hepatic vein and the vena cava.
OSSEOUS STRUCTURES: No concerning lytic or osteoblastic lesions
are seen.
Note is made of a subcutaneous soft tissue nodule in the
anterior aspect of
the right thigh (2, 85) that measures on current examination
14-mm in
comparison to 11 mm on examination from ___.
IMPRESSION:
1. No signs of cholecystitis or pancreatitis.
2. Small hyperenhancing focus in segment II of the liver,
grossly unchanged
from prior examination might represent small hemangioma but
cannot be fully
characterized. Further characterization with MR or ultrasound is
recommended.
3. Fatty liver.
4. Subcutaneous soft tissue nodule is seen in the anterior right
thigh.
Correlation with physical examination is recommended.
Brief Hospital Course:
ASSESSMENT & PLAN: Patient is a ___ year-old with history of EtOH
abuse, chronic pancreatitis presenting with abdominal pain.
.
# Abdominal Pain: Most likely from his chronic pancreatitis
based on elevated lipase. may also have component of gastritis.
Abd CT did not show any acute abnormalities or changes of the
pancreas. Fatty liver was demonstrated. He was managed with IV
dilaudid, NPO, and inititiation of a PPI. His abd pain improved
and he was transitioned to PO percocet and a regular diet. He
tolerated the diet and was discharged on a short course of
percocet and PPI.
.
# EtOH Intoxication/Abuse: He was initially manged with valium
per CIWA scale. On Hospital day three he reported no longer
needing the valium and this was discontinued. He was encouraged
not to drink ETOH.
.
# Hypernatremia: From dehydration in setting of heavy ETOH uses
and lack of PO fluids. This resolved with resolved with IVF.
.
TRANSITIONAL ISSUES
-Liver lesion: Small hyperenhancing focus in segment II of the
liver, grossly unchanged from prior examination might represent
small hemangioma but cannot be fully characterized. Further
characterization with MR or ultrasound is recommended.
-CT also showed s subcutaneous soft tissue nodule in the
anterior
right thigh, which can be correlated with physical exam and
followed for any growth.
-Notable labs on last check: WBC 3.8, Hct 32.5, Platelets 101.
Medications on Admission:
None
Discharge Medications:
1. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for Pain for 3 days.
Disp:*15 Tablet(s)* Refills:*0*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
5. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea for
3 days.
Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Chronic pancreatitis
Secondary dignosis:
Alcohol abuse and dependence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for coming to ___
___. You were admitted to the hospital because of abdominal
pain likely caused by your chronic pancreatitis. We are glad
that you are feeling better now. You should continue to take
percocet for pain and ondansetron (zofran) for nausea. Please
follow up with your primary care doctor as instructed.
Medication Recommendations:
Please start:
-Percocet one tab every 6 hours as needed for pain
-Ondansetron (zofran) 4 mg every 8 hours as needed for nausea
-Pantoprazole 40 mg daily
-Thiamine HCl 100 mg daily
-Folic acid 1 mg daily
Followup Instructions:
___
|
19759225-DS-36
| 19,759,225 | 22,567,464 |
DS
| 36 |
2144-08-12 00:00:00
|
2144-08-12 15:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Phenergan Plain / Reglan / Vancomycin / Prochlorperazine Maleate
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient reviewed with night float admitting resident. In brief,
this is a ___ with extensive alcohol abuse history, chronic
abdominal pain, who presents with epigastric discomfort and
anxiety as well as nausea and vomiting. The patient has an
established history of alcohol abuse with prior issues with
withdrawal. He also has a history of chronic pancreatitis.
Reports that this feels like his classic pancreatitis but more
severe. Reports last drinking earlier this morning. He describes
abdominal pain for "years", worse today from increased drinking.
He is now drinking 3pints of vodka per day, last drink 13hrs
prior to admission. Denies other coingestions or illicits.
Describes abdominal pain as ___ abdomen with ___ pain,
"feels as though someone is grabbing my stomach and pulling." He
also had nausea with gagging earlier. Denies diarrhea. Reports a
black stool 3 days prior, but afterwards became brown. He had no
coffee grinds or BRB in his emesis. He said he was admitted a
month ago to somewhere in JP for DT's he reports, cannot recall
the name of the hospital. He denies hallucinations but states
"everything is distorted." He also has chills, denies fevers,
chest pain, SOB, cough.
Of note, patient reports getting out of Detox program 2 months
previously. He was given Suboxone for 14 days and told to find a
new PCP. He was not able to, and when he ran out of Suboxone he
began drinking heavily again.
Initial VS in the ED: 10 100.0 140 127/89 16 96% ra
Labs notable for EtOH 419, lactate 3.1, WBC 3.9, AST 244, ALT
74, lipase 73, tbili 0.2. Na 153, K 3.2.
RUQ u/s was negative for cholecystitis. Blood cultures were
sent.
Patient was given potassium, lorazepam, dilaudid, and zofran, in
addition to 1 L of fluid,
VS prior to transfer: 10 97.8 102 ___ 98%
Overnight, patient was seen gagging himself and had bloody
emesisx2. His vitals remainded stable. He continued to score on
CIWA (>20) and receive Diazepam x 3.
Past Medical History:
- Pancreatitis: lipase has ranged from normal level to 433. CT
abd/pelvis x 2 has shown no evidence of acute or chronic
pancreatitis, but has shown diffuse fatty infiltration of the
liver.
- Chronic pain secondary to pancreatitis, narcotics use
- Alcohol abuse, starting at age ___ multiple attempts at detox
w/ h/o DT's (no h/o withdrawal seizures)
- Gastritis
- Hepatitis C (not documented in this system)
- Iron-deficiency Anemia
- Prosthetic left eye
- Positive H. pylori serology, ___
- Panic disorder
Social History:
___
Family History:
Father and mother w/history of alcoholism.
Physical Exam:
ADMISSION Physical Exam:
Vitals: T: 96.6 BP: 145-156/96-106 P: 95-101 R: 20 O2: 98%RA
General: disshelved gentleman, appears older than stated age,
smells of alcohol, NAD, appears in pain
HEENT: PERRL on R, prosthetic eye on left, no nystagmus on R,
dry MM
Neck: supple, no JVD
CV: RRR, no murmurs, +S1, S2
Lungs: CTAB
Abdomen: +BS, TTP diffusely, greatest in epigastric area. No
rebound/guarding.
Ext: warm, dry, no edema, 2+ DP pulses
Neuro: oriented x3, CN2-12 grossly intact, moving all
extremities, refuses to participate in strength, finger to nose
testing, slight tremor to outstretched hands
DISCHARGE Physical Exam:
Vitals:97.2 ___ ___ 18 99%RA
General: disshelved gentleman, appears older than stated age
HEENT: PERRL on R, prosthetic eye on left, no nystagmus on R,
dry MM
Neck: supple, no JVD
CV: RRR, no murmurs, +S1, S2
Lungs: CTAB
Abdomen: +BS, TTP diffusely, greatest in epigastric area but
improving. No rebound
Ext: warm, dry, no edema, 2+ DP pulses
Neuro: oriented x3, CN2-12 grossly intact
Pertinent Results:
ADMISSION:
___ 08:30PM BLOOD WBC-3.9* RBC-4.42* Hgb-10.5* Hct-34.8*
MCV-79* MCH-23.7* MCHC-30.1* RDW-19.2* Plt ___
___ 08:30PM BLOOD Neuts-51.6 ___ Monos-5.3 Eos-6.5*
Baso-0.8
___ 08:30PM BLOOD ___ PTT-28.9 ___
___ 08:30PM BLOOD Glucose-96 UreaN-3* Creat-0.8 Na-153*
K-3.2* Cl-108 HCO3-27 AnGap-21*
___ 08:30PM BLOOD ALT-74* AST-244* AlkPhos-73 TotBili-0.2
___ 08:30PM BLOOD Lipase-73*
___ 05:40AM BLOOD Calcium-7.8* Phos-3.9 Mg-1.4* Iron-18*
___ 05:40AM BLOOD calTIBC-386 Ferritn-28* TRF-297
___ 08:30PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:30PM BLOOD Lactate-3.1*
DISCHARGE:
___ 06:35AM BLOOD WBC-3.8* RBC-4.00* Hgb-10.0* Hct-32.4*
MCV-81* MCH-25.1* MCHC-30.9* RDW-19.3* Plt ___
___ 06:35AM BLOOD Glucose-101* UreaN-4* Creat-0.8 Na-143
K-3.7 Cl-105 HCO3-31 AnGap-11
___ 06:35AM BLOOD Calcium-8.9 Phos-4.9* Mg-1.7
RUQ u/s:
Gallbladder partly distended without stones, wall thickening, or
pericholecystic fluid. Negative sonographic ___.
EKG: ___, RAD, normal intervals, no STE
CT abd: IMPRESSION:
1. No CT evidence of pancreatitis or other acute intra-abdominal
pathology. Please correlate with laboratory tests if there is
clinical suspicion for pancreatitis as normal CT does not
exclude this diagnosis.
2. Hepatic steatosis.
3. Small enhancing lesion in segment 2 of the liver, and a
probable additional tiny focus in segment III, not significantly
changed from prior CT from ___ may represent hemangiomas or
tiny FNH and are of doubtful significance given stability.
Brief Hospital Course:
Mr. ___ is a ___ with extensive alcohol abuse history,
chronic abdominal pain, who presents with epigastric discomfort
and anxiety as well as nausea and vomiting.
ACTIVE ISSUES:
# Hematemesis: Patient with 2 episodes of hematemesis o/n after
retching on ___. None at home. EGD at ___ 2 weeks prior without
varices but with gastritis. Likely ___ tear but
patients hx makes more significant bleed a possiblility (ulcer
vs gastritis). Patient with blood tinged on further episodes.
HCT stable. GI was consulted who also felt it was likely
___ tear. Patient was put on standing Zofran to
prevent vomitting and patient also given IV Pantoprazole BID.
Hct was stable. Patient was not having any hematemesis after the
first day.
# Abdominal pain: DDx includes acute on chronic pancreatitis vs.
drug seeking vs. gastritis vs. hepatitis. Patient without
surgical abdomen at this time but very tender in epigastric
area. Labs notable for AST/ALT, likely ___ alcohol. Lipase
mildly elevated, which may indicate acute on chronic
pancreatitis. Gastritis from drinking also possible as well as
previously seen H pylori positivity. CT abdomen does not show
any evidence of acute pancreatitis. Patient started treatment
with triple therapy for H pylori eradication on ___. Diet
advance to regular upon discharge.
# Microcytic Anemia: Patient with new microcytic anemia. In
setting of possible GI bleed, most concerned about iron
deficiency. Iron studies showed iron deficiency and patient
started on iron supplementation on discharge.
CHRONIC ISSUES:
# Alcohol abuse: Frequently visits ED, intoxicated with
abdominal pain. Reports history of DT's. ETOH level elevated in
ED. Initially was scoring on CIWA consistently but no longer
scoring on discharge. Given MVI, folate, and IV thiamine.
# Lice: Previously dx with Lice at ___. Found to have knits in
hair. Lice precautions and Lindane Shampoo x 1
# Leukopenia: ANC ___. Possibly from alcoholism with bone
marrow suppression.
TRANSITIONAL ISSUES:
- Patient would like to pursue help with sobriety
- Triple therapy for h pylori eradication
- F/u with PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
___ #*30 Tablet Refills:*0
2. Amoxicillin 1000 mg PO Q12H
RX *amoxicillin 500 mg 2 tablet(s) by mouth twice a day ___
#*22 Capsule Refills:*0
3. Clarithromycin 500 mg PO Q12H
RX *clarithromycin 500 mg 1 tablet(s) by mouth twice a day ___
#*6 Tablet Refills:*0
RX *clarithromycin 500 mg 1 tablet(s) by mouth twice a day ___
#*11 Tablet Refills:*0
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily ___ #*30 Tablet
Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
daily ___ #*30 Capsule Refills:*0
6. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth twice a day ___ #*11 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic pancreatitis
Gastritis
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 came to ___ due to abdominal
pain. CT of your abdomen was normal. Your diet was advanced
while you were here. You were started on treatment for bacteria
in your stomach that can cause inflammation in. You should
continue to take this medication. You should also stop drinking
alcohol as your heavy consumption is likely the reason for these
problems.
Followup Instructions:
___
|
19759225-DS-39
| 19,759,225 | 25,092,935 |
DS
| 39 |
2148-02-24 00:00:00
|
2148-02-24 23:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Phenergan Plain / Reglan / Prochlorperazine Maleate / Tigan
Attending: ___.
Chief Complaint:
Knee pain
Major Surgical or Invasive Procedure:
Left Knee arthrocentesis ___
Left Shoulder Arthrocentesis ___
Chest Port Line Placement ___
Open arthrotomy, left shoulder, with irrigation and debridement
of shoulder joint ___
Open arthrotomy, left knee, with anterior synovectomy,
irrigation and debridement, and placement of deep drains ___
Fluoro-guided left hip joint aspiration ___
History of Present Illness:
___ w/ anemia, also s/p ORIF L hip at ___ on ___ who
presents from rehab with reported acute on chronic anemia. Per
patient, he was brought to ___ from Rehab
due to anemia. His only complaints are pain in his hip, shoulder
and knee. He denies fatigue, CP, SOB, N/V/D. He specifically
denies BRBPR, melena or hematemesis. Last BM per patient was 4
days ago. Per transfer data, he was found to have anemia with Hb
of 6.5. He also may have had fever and tachycardia while at
rehab facility per these records, although this is not clear.
Per the patient, he reports that he has had a difficult stay at
the rehab, reporting that he fell a few days ago and hurt his L
collarbone. He also reports persistent pain in his L hip and
knee, with increased swelling surrounding his L knee recently.
In the ED, initial vitals: 98.4 112 114/67 20 97% RA ->> BP
88/66
- Exam notable for: negative guiac (little stool in vault)
- Labs notable for: H/H ___ (down from hgb 6.5 at ___,
sodium 129,
- Imaging notable for: CXR normal
- Patient given: 1 unit of blood and IL IVF
-Patient was seen by ortho who did an exam which was not
concerning, so decision was made to admit to medicine for
further anemia workup. Ortho decided to not do any further
imaging.
- Vitals prior to transfer: 98.9 89 100/55 16 99% RA
On arrival to the floor, pt reports persistent L shoulder, knee,
and hip pain. of note, he has a documented history of chronic
abdominal pain and has a safety alert in our system warning
against using high dose IV narcotics due to opiate-seeking
behavior. Currently he appears comfortable but is complaining of
___ pain in multiple areas. Otherwise denying abdominal pain,
chest pain, shortness of breath. Denies adamantly recent melena,
hematochezia.
Past Medical History:
- Pancreatitis: lipase has ranged from normal level to 433. CT
abd/pelvis x 2 has shown no evidence of acute or chronic
pancreatitis, but has shown diffuse fatty infiltration of the
liver.
- Chronic pain secondary to pancreatitis, narcotics use
- Alcohol abuse, starting at age ___ multiple attempts at detox
w/ h/o DT's (no h/o withdrawal seizures)
- Gastritis
- Hepatitis C (not documented in this system)
- Iron-deficiency Anemia
- Prosthetic left eye
- Positive H. pylori serology, ___
- Panic disorder
Social History:
___
Family History:
Father and mother w/history of alcoholism.
Physical Exam:
ADMISSION PHYSICAL EXAM
=================
Vitals: 99 ___ 97%RA
___: Alert, oriented, no acute distress. Appears dishelved,
lice in hair, multiple excoriations over skin.
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple,
JVP not elevated, no LAD. L eye with persistent ptosis.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender to palpation in epigastrium per baseline
otherwise nontender along flanks, lower abdomen, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm, well perfused, no cyanosis or edema. B/l feet tender
to palpation. Unable to move L knee at all, moving hip with
2-3/strength. Tender to palpation over hip/femoral neck, TTP
over surgical site. L knee with large tense overlying effusion,
severely decreased ROM (pt states close to baseline).
Skin: Multiple dry, pink areas with significant excoriations
over neck, torso. No obvious bites or evidence of scabies. Also
scalp with definite head lice noted.
Neuro: A&Ox3. Grossly intact.
DISCHARGE PHYSICAL EXAM
==================
VS: Temp 98.7 (Tmax 99 in last 24 hours) BP ___ HR 98 RR 18 Sa
96% RA
___: ___ yo man in NAD, with shaved head. Alert,
conversational, orient to self, place and dat.
HEENT: NC/AT, Sclera anicteric, prosthetic in L eye
Lungs: Clear to auscultation bilaterally; no wheezes, rales,
rhonchi appreciated
CV: Regular rate and rhythm, normal S1 + S2, no ejection murmur,
rubs, gallops
Abdomen: soft, tender to palpation in epigastrium. No rebound no
guarding.
Skin and extremities: L shoulder with surgical incision,
staples in place. Clean margins, no erythema. Ace bandage L leg.
Surgical incision with some ecchymoses, moderate edemea over
left knee, very tender to palpation. Edema and erythema over
left dorsum of foot, with mild overlying skin breakdown. Still
moving L toes on command without pain; no tenderness to
palpation, foot appears warm and well perfused. Swelling over
left knee improved from exam but still very painful on
palpation.
MSK: in bed with L hip slightly externally rotated, but pain in
knee limits exam of L hip. ROM at left shoulder stable at 45
degrees, limited by pain.
Skin: Shaved head, no lice seen
Neuro: Alert and responding to questions appropriately. CN
II-XII grossly intact.
Pertinent Results:
LABS ON ADMISSION
=============
___ 08:44PM BLOOD WBC-12.8* RBC-2.14* Hgb-5.5*# Hct-18.0*#
MCV-84# MCH-25.7*# MCHC-30.6* RDW-17.3* RDWSD-53.6* Plt ___
___ 08:44PM BLOOD Neuts-68.3 Lymphs-13.1* Monos-11.5
Eos-5.5 Baso-0.3 NRBC-0.1* Im ___ AbsNeut-8.73*#
AbsLymp-1.68 AbsMono-1.47* AbsEos-0.70* AbsBaso-0.04
___ 08:44PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Schisto-1+
___ 08:44PM BLOOD Plt ___
___ 08:44PM BLOOD Ret Aut-2.1* Abs Ret-0.05
___ 08:44PM BLOOD Glucose-122* UreaN-6 Creat-0.5 Na-129*
K-4.5 Cl-94* HCO3-24 AnGap-16
___ 08:44PM BLOOD ALT-23 AST-37 LD(LDH)-178 AlkPhos-276*
TotBili-0.6 DirBili-0.3 IndBili-0.3
___ 08:44PM BLOOD Albumin-2.6* Iron-16*
___ 08:44PM BLOOD calTIBC-189* Hapto-430* Ferritn-358
TRF-145*
___ 08:49PM BLOOD Lactate-1.2
NOTABLE LABS
=========
___ 08:44PM BLOOD WBC-12.8* RBC-2.14* Hgb-5.5*# Hct-18.0*#
MCV-84# MCH-25.7*# MCHC-30.6* RDW-17.3* RDWSD-53.6* Plt ___
___ 04:50AM BLOOD WBC-10.7* RBC-2.90*# Hgb-7.7*# Hct-25.0*#
MCV-86 MCH-26.6 MCHC-30.8* RDW-16.5* RDWSD-52.1* Plt ___
___ 12:50PM BLOOD WBC-13.1* RBC-2.87* Hgb-8.1* Hct-24.5*
MCV-85 MCH-28.2 MCHC-33.1 RDW-16.2* RDWSD-50.4* Plt ___
___ 06:35AM BLOOD WBC-11.4* RBC-3.00* Hgb-8.0* Hct-25.7*
MCV-86 MCH-26.7 MCHC-31.1* RDW-16.5* RDWSD-51.4* Plt ___
___ 10:30AM BLOOD WBC-8.8 RBC-2.66* Hgb-7.0* Hct-23.2*
MCV-87 MCH-26.3 MCHC-30.2* RDW-16.5* RDWSD-52.7* Plt ___
___ 03:00PM BLOOD WBC-8.9 RBC-2.84* Hgb-7.6* Hct-24.2*
MCV-85 MCH-26.8 MCHC-31.4* RDW-15.9* RDWSD-49.6* Plt ___
___ 04:17AM BLOOD WBC-9.8 RBC-2.69* Hgb-7.3* Hct-23.3*
MCV-87 MCH-27.1 MCHC-31.3* RDW-16.0* RDWSD-50.9* Plt ___
___ 04:07AM BLOOD WBC-9.5 RBC-2.51* Hgb-6.6* Hct-21.6*
MCV-86 MCH-26.3 MCHC-30.6* RDW-16.2* RDWSD-51.7* Plt ___
___ 07:18PM BLOOD WBC-6.7 RBC-2.71* Hgb-7.7* Hct-23.3*
MCV-86 MCH-28.4 MCHC-33.0 RDW-15.9* RDWSD-49.3* Plt ___
___ 06:08AM BLOOD WBC-7.1 RBC-2.98* Hgb-7.9* Hct-25.2*
MCV-85 MCH-26.5 MCHC-31.3* RDW-15.9* RDWSD-49.2* Plt ___
___ 04:46AM BLOOD WBC-6.1 RBC-2.78* Hgb-7.7* Hct-23.8*
MCV-86 MCH-27.7 MCHC-32.4 RDW-15.9* RDWSD-50.1* Plt ___
___ 05:00AM BLOOD WBC-6.9 RBC-2.94* Hgb-7.8* Hct-25.2*
MCV-86 MCH-26.5 MCHC-31.0* RDW-15.8* RDWSD-49.6* Plt ___
___ 03:58AM BLOOD WBC-6.5 RBC-2.62* Hgb-7.2* Hct-22.7*
MCV-87 MCH-27.5 MCHC-31.7* RDW-16.1* RDWSD-51.1* Plt ___
___ 04:57AM BLOOD WBC-5.6 RBC-2.79* Hgb-7.5* Hct-24.6*
MCV-88 MCH-26.9 MCHC-30.5* RDW-16.0* RDWSD-51.3* Plt ___
___ 04:50AM BLOOD ___ PTT-24.7* ___
___ 06:35AM BLOOD ___ PTT-33.0 ___
___ 10:30AM BLOOD ___ PTT-46.3* ___
___ 03:00PM BLOOD ___ PTT-32.1 ___
___ 04:17AM BLOOD ___ PTT-33.2 ___
___ 04:20PM BLOOD ___ PTT-32.9 ___
___ 04:07AM BLOOD ___ PTT-35.2 ___
___ 06:08AM BLOOD ___ PTT-34.7 ___
___ 06:10AM BLOOD ___ PTT-32.9 ___
___ 05:00AM BLOOD ___ PTT-37.3* ___
___ 03:58AM BLOOD ___ PTT-34.5 ___
___ 04:57AM BLOOD ___ PTT-36.1 ___
___ 06:10AM BLOOD ___
___ 08:44PM BLOOD Ret Aut-2.1* Abs Ret-0.05
___ 06:35AM BLOOD Ret Aut-2.0 Abs Ret-0.06
___ 07:18PM BLOOD Ret Aut-1.3 Abs Ret-0.03
___ 06:08AM BLOOD Glucose-116* UreaN-8 Creat-0.5 Na-136
K-3.8 Cl-99 HCO3-25 AnGap-16
___ 08:44PM BLOOD ALT-23 AST-37 LD(LDH)-178 AlkPhos-276*
TotBili-0.6 DirBili-0.3 IndBili-0.3
___ 04:50AM BLOOD ALT-23 AST-35 LD(___)-220 AlkPhos-283*
TotBili-0.7
___ 06:35AM BLOOD Calcium-9.2 Phos-5.9* Mg-1.7
___ 03:00PM BLOOD Calcium-9.0 Phos-4.7* Mg-1.9
___ 04:07AM BLOOD Calcium-8.2* Phos-5.1* Mg-1.7
___ 06:08AM BLOOD Calcium-8.2* Phos-4.3 Mg-1.6
___ 04:46AM BLOOD Calcium-8.3* Phos-4.8* Mg-1.9
___ 05:00AM BLOOD Calcium-8.6 Phos-4.7* Mg-1.7
___ 08:44PM BLOOD Albumin-2.6* Iron-16*
___ 08:44PM BLOOD calTIBC-189* Hapto-430* Ferritn-358
TRF-145*
___ 04:50AM BLOOD VitB12-852 Folate->20
___ 07:18PM BLOOD PTH-25
___ 04:50AM BLOOD CRP-146.6*
___ 05:00AM BLOOD HIV Ab-Negative
___ 12:50AM BLOOD Vanco-21.0*
___ 05:08PM BLOOD ___ pO2-185* pCO2-33* pH-7.52*
calTCO2-28 Base XS-4
___ 08:49PM BLOOD Lactate-1.2
___ 05:08PM BLOOD Lactate-1.3
___ 02:10AM URINE Color-Straw Appear-Clear Sp ___
___ 02:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
SYNOVIAL FLUID:
=================
___ 01:30PM JOINT FLUID WBC-261* RBC-2950* Polys-3
___ Macro-32
___ 04:15PM JOINT FLUID ___ Polys-89*
___ Macro-8
___ 08:00PM JOINT FLUID ___ RBC-2333* Polys-98*
___ Monos-1
LABS ON DISCHARGE
=============
___ 04:57AM BLOOD WBC-5.6 RBC-2.79* Hgb-7.5* Hct-24.6*
MCV-88 MCH-26.9 MCHC-30.5* RDW-16.0* RDWSD-51.3* Plt ___
___ 04:57AM BLOOD Plt ___
___ 04:57AM BLOOD Glucose-114* UreaN-6 Creat-0.4* Na-140
K-4.3 Cl-103 HCO3-28 AnGap-13
___ 04:57AM BLOOD Calcium-8.3* Phos-4.6* Mg-1.8
MICROBIOLOGY
===========
_________________________________________________________
___ 1:30 pm JOINT FLUID Source: hip.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 3:42 pm TISSUE LEFT KNEE CULTURE #2.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
__________________________________________________________
___ 3:59 pm SWAB LEFT SHOULDER CULTURE X2.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
.
NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(___).
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
__________________________________________________________
___ 3:42 pm SWAB LEFT KNEE CULTURE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___-___
___.
__________________________________________________________
___ 3:55 pm TISSUE LEFT SHOULDER SOFT TISSUE.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
Reported to and read back by ___. ___
(___)
___ @ 11:29 AM.
STAPH AUREUS COAG +. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
__________________________________________________________
___ 4:02 pm TISSUE LEFT SHOULDER TISSUE .
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___-___
___.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
__________________________________________________________
___ 4:15 pm JOINT FLUID Source: shoulder left.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
SENSITIVITIES PERFORMED ON CULTURE # ___
___.
__________________________________________________________
___ 10:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 6:35 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:44 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
======
Abdominal US ___. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded
on the basis of this examination.
2. Mild splenomegaly.
TTE ___
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF = 65%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (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
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. No obvious vegetations
seen (best excluded by TEE)
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
CXR PICC Reposition ___
Repositioned right-sided PICC line, now terminating in the low
SVC. No
pneumothorax.
SHOULDER ___ VIEWS NON TRAUMA LEFT PORT ___
Chronic appearing left distal clavicular fracture. No acute
fracture or
dislocation identified. No radiographic evidence of
osteomyelitis. If there
is however clinical concern for septic arthritis, direct fluid
sampling is
advised.
CTA LOWER EXT W/&W/O C & RECONS LEFT ___. No evidence of hematoma or active extravasation around the
upper left
thigh.
2. Large left knee joint effusion.
EKG ___
Clinical indication for ECG: I38 - Endocarditis, valve
unspecified
Localized baseline artifact. Sinus tachycardia. Right axis
deviation.
Compared to the previous tracing of the same day the rate is
slightly faster
and now tachycardic. Frontal plane QRS axis is now rightwardly
deviated,
likely appropriate for age.
TRACING #2
Read ___
Intervals Axes
RatePRQRSQTQTc (___) ___
Brief Hospital Course:
Mr. ___ is a ___ year old man with history of anemia and
recent left hip ORIF on ___ who presented from rehab with
reported acute on chronic anemia. During the course of his
hospital stay, the following issues were addressed:
# Anemia. Mr. ___ presented on transfer with a hemoglobin
reportedly of 6.5 at ___ (from 8.2 in our
system on ___ but on arrival hemoglobin was found to be 5.5.
Initially corrected appropriately to 8.1 after transfusion of 2
units of blood on ___ but then slowly drifted downward
during the course of the next few days. He required one more
unit of pRBCs on ___ after acute drop from 7.3-6.6 associated
with a surgical joint wash-out described below. No signs of
overt bleeding on presentation, stool occult blood was negative.
CTA of b/l LEs showed no hematoma or active extravasation.
Hematology team was consulted to aid in work-up. Hemolysis
workup showed normal LDH, high haptoglobin, and relatively low
reticulocyte count. Iron studies consistent with anemia of
chronic disease, with ferritin of 358 and low TIB of 189.
Vitamin B12 and folate were wnl. Kinetics of hemoglobin drop,
with initial increase and then slow downward drift suggests that
he is not actively bleeding (likely has exaggerated consumption
of RBCs due to sepsis and splenomegaly, though could not rule
out an oozing bleed). An abdominal ultrasound obtained on ___
showed splenomegaly and echogenic steatosis of the liver. On
discharge hemoglobin was 7.5, and was consistent for 3 days. His
anemia will likely improve as his marrow recovers; he will
follow up with hematology for follow up and possible bone marrow
biopsy after he stabilizes and is finished with his antibiotic
course.
# Septic Arthritis. On presentation Mr. ___ also complained
of significant left knee and shoulder pain as well as some
increased pain in his left hip. Also endorsed subjective fevers
and chills and was found to have a leukocytosis of 13.4. On
exam, he was noted to have a very large knee effusion and
decreased range of motion. Also with decreased range of motion
in shoulder. Arthrocentesis of his knee was performed on ___
and showed ___ wbcs and 98% Neutrophils and eventually grew
MSSA. He was initially placed on vancomycin and ceftazidime fro
___, vancomycin from ___ and finally cefazolin
from ___ one, once final cultures speciated with coag negative
staph, sensitive to oxacillin. He has a history of red-man's
syndrome but tolerated vancomycin with slow infusion. Left
shoulder was tapped and showed ___ WBCs, 89% neutrophils and
also grew MSSA. Patient went for surgical washout of knee and
shoulder on ___ without issue. He complained of continued left
hip pain felt to be out of proportion to expected post-operative
pain after his ORIF at the end of ___. Underwent an
additional arthrocentesis of left hip on ___, with fluid
studies showing WBC 261 3% PMNS and 65% lymphocytes, not
suggestive of infection, with no growth on cultures (though on 6
days on antibiotics at this point, so of limited utility).
Patient did well on cefazolin 2g q8hrs, with plans to continue
for 6 total weeks of antibiotic therapy (Start Date: ___
| Projected End Date: ___, with infectious disease
follow-up.
# Coagulopathy and possible cirrhosis. Mr. ___ presented
with an INR of 1.7, though second to malnutrition. INR improved
to 1.2 with good nutrition supplementation, including 2 Ensure
enlive supplements three times a day with meals, magic cup and
vitamin supplementation (thiamine, MVI), as well as with
phytonadione 5 mg for 3 days from ___ and again from
___. He has a questionable history of hepatitis C (tells
providers that sometimes he has "tested positive" in past and
sometimes has not. Abdominal ultrasound on ___ showed a
diffusely echogenic liver with smooth contours and portal
hepatic vein. LFTs were normal. He will need hepatology follow
up for further cirrhosis work-up. HCV viral load pending at time
of discharge.
# Pain control. Mr. ___ had a significant pain requirement
throughout his hospital stay. He has a history of heavy alcohol
abuse as well as sporadic IV drug use. He came to us on Dilaudid
4 mg PO Q4 hours PRN. Per patient, prior to this medication he
has taken 10 mg oxycodone TID (somewhat effective) and
gabapentin 800 mg (not effective, no regular use) in the past
for pancreatitis. ___ he was placed on dilaudid PCA for 3
days ___. He was then transitioned to a regimen of
PO and IV dilaudid with minimal reported relief before an opiate
cycling was attempted in conjunction with our chronic pain team,
with OxyCODONE (Immediate Release) 10 mg PO/NG Q3H:PRN Pain -
Moderate, OxyCODONE (Immediate Release) 5 mg PO/NG Q6H:PRN
BREAKTHROUGH PAIN and a low-dose fentanyl patch at 12 mcg. He
was aso treated with gabapentin (started at 300 mg TID and
uptitrated to 900 mg TID), Ibuprofen 600 mg Q 8, and Lidocaine
patch. This gave patient a similar relief to the dilaudid PCA.
Plan is to uptitrate fentanyl patch and decrease oxycodone needs
slowly. DO NOT GIVEN FREQUENT PRNS, DO NOT GIVE IV PAIN
MEDICATIONS.
# Head lice. Presented with head lice and was placed on contact
precautions. He was treated with permethrin permethrin 1 %
topical ONCE on ___. He was still noted to have active lice
in his hair on ___ and was treated with Lindane Shampoo 30 mL
once on ___. His hair was also shaved at this time with his
permission.
# Hyperphosphatemia. Patient had persistently elevated
phosphorous, between 4.6 and 5 for most of stay. PTH was normal
at 25.
# Thrombocytosis: Peaked at 617 on___, likely reactive in
setting of infection. Came downto 385 on discharge, with
treatment of infection.
# S/P ORIF. Recently done at ___, ___. Patient was follow by
orthopedic team here who had low suspicion for infection of
joint space or screw. Tap above was reassuring but interpreted
in setting of antibitiotic use.
# H/o chronic pancreatitis, multiple pain admission. Did not
flair this stay.
# GERD. Continued pantoprazole
TRANSITIONAL ISSUES
===============
- Antibiotics: Cefazolin IV 2g q8hrs (Start Date: ___ |
Projected End Date: ___,
- Will need weekly monitoring labs would be CBC with
differential, BUN, Cr, ESR/CRP while on cefazolin. Results
should be faxed to ATTN: ___ CLINIC - FAX: ___.
- Mr. ___ had a persistently elevated INR despite 3 days of
vitamin K administration as well as abdominal ultrasound showing
hepatic steatosis. He has a questionable history of HCV (per
patient has tested both positive and negative in past; HCV viral
load this hospital stay was drawn and is pending on discharge).
He will need follow-up in our liver clinic.
- Pain regimen: Current discharge regimen- PLEASE TITRATE UP
FENTANYL PATCH AND DECREASE OXYCODONE DOSES. SHOULD FOLLOW UP
WITH CHRONIC PAIN CLINIC:
-- OxyCODONE (Immediate Release) 10 mg PO/NG Q3H:PRN for
moderate-severe pain
-- OxyCODONE (Immediate Release) 5 mg PO/NG Q6H:PRN BREAKTHROUGH
PAIN
-- Fentanyl Patch at 12 mcg
-- Gabapentin 900 mg TID
-- Ibuprofen 600 mg Q 8 (continue for 3 weeks after discharge as
noted below)
-- Lidocaine patch
- Patient has constipation and frequently refuses bowel regimen.
PLEASE ENCOURAGE SUPPOSITORY FOR FREQUENT BOWEL MOVEMENTS.
- Lice: Mr ___ came to us with a live infection. He was
initially treated with permethrin on ___ but was noted to have
continued live lice in his hair. His hair was shaved with his
approval and he was given one dose of lindane shampoo. This
should be definitive therapy and nothing else needs to be done.
- Please continue ibuprofen 400 mg Q6H for 3 more weeks from
___ and then discontinue
- Please continue Pantoprazole 40 mg Daily for 1 more week from
___ then discontinue
- Anemia: His anemia will likely improve as his marrow recovers;
he will follow up with hematology and possible bone marrow
biopsy after he stabilizes and is finished with his antibiotic
course (around 6 weeks from discharge)
- Pending: HCV viral load
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. FoLIC Acid 1 mg PO DAILY
3. Miconazole 2% Cream 1 Appl TP BID l foot rash
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Senna 8.6 mg PO BID:PRN constipation
7. Docusate Sodium 100 mg PO BID
8. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Bisacodyl 10 mg PR QHS:PRN constipation
2. CeFAZolin 2 g IV Q8H
3. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
4. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl [Duragesic] 12 mcg/hour One patch every 72 hours
Q72H Disp #*2 Patch Refills:*0
5. Gabapentin 900 mg PO TID
RX *gabapentin 300 mg 3 capsule(s) by mouth three times a day
Disp #*27 Capsule Refills:*0
6. Ibuprofen 400 mg PO Q6H
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
9. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 10 mg 1 tablet(s) by mouth Q3H Disp #*24 Tablet
Refills:*0
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN BREAKTHROUGH
PAIN
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*12 Tablet Refills:*0
11. Polyethylene Glycol 17 g PO ONCE MR1:PRN constipation
12. Sarna Lotion 1 Appl TP QID:PRN as needed for pruritic rash
13. Acetaminophen 1000 mg PO Q8H
14. Docusate Sodium 100 mg PO BID
15. FoLIC Acid 1 mg PO DAILY
16. Miconazole 2% Cream 1 Appl TP BID l foot rash
17. Multivitamins 1 TAB PO DAILY
18. Pantoprazole 40 mg PO Q24H
19. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
=====
Septic arthritis, Left knee and left shoulder
Acute on chronic anemia
Pain
Lice
Malnutrition
Secondary
=======
Gastroesophageal reflux
Chronic Pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you here at the ___
___. You came to us on transfer from
___ with anemia. During your stay here you
also complained of significant shoulder, hip and knee pain. We
performed a fluid collection procedure (arthrocentesis) of your
knee, which grew a bacteria known as Staphylococcus aureus. This
same bug grew in your shoulder but not your hip (though you were
on antibiotics at the time of your hip sampling, so this may
have caused a false negative result). You were placed on
appropriate antibiotics and you were taken to the operating room
to wash out your knee and shoulder. You tolerated these
procedures well but had very bad pain throughout your stay. We
tried to balance your pain needs without giving you too much and
making you dependent on opiate medication in the future. You
were discharged in good condition but still with significant
pain, which you will need managed further at rehab.
Please take all of your medications as detailed in this
discharge summary. If you experience any of the danger signs
listed below, please contact your primary care provider or come
to the emergency department immediately.
Best Wishes,
Your ___ Care Team
Followup Instructions:
___
|
19759233-DS-20
| 19,759,233 | 26,894,276 |
DS
| 20 |
2170-10-27 00:00:00
|
2170-10-29 08:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Latex / Reglan / Sulfa (Sulfonamide Antibiotics) /
metoprolol
Attending: ___.
Chief Complaint:
chest pain, shortness of breath, atrial fibrillation, sinus
bradycardia
Major Surgical or Invasive Procedure:
___ Left cardiac catheterization without intervention
___ Permanent pacemaker placement
History of Present Illness:
___ yr old woman with complex PMH including symptomatic pAF on
amio and dabigatran, failed flecainide and propafenone, multiple
cardioversions and AVRNT ablation, with recent admission for
afib s/p PVI ablation and 3 subsequent cardioversions on ___
as patient's afib remained eaily inducible, who is now
presenting with chest pain. After ___ discharge, patient
noted shortness of breath, chest pain and increased abdominal
girth. She called her outpatient cardiologigist and was given a
dose of lasix on ___ with good UOP and a weight loss
of 5 pounds. She presented to ___ on ___ with CXR showed
trace b/l pleural effusions, troponin 0.18. She was monitored
overnight and then discharged. She again called her outpatient
cardiologist yesterday and was started on diltiazem ER 120mg
daily yesterday afternoon. At 11pm yesterday evening, patient
reported sharp chest pain radiating to both shoulders, dizziness
and dyspnea. She reports the pain was rather intense and has
since improved. EMS was called and she was given ASA 325 and 2
SL nitro and then taken to ___ where she was noted
to have an elevated d-dimer, be in afib with a rate of 60, and
have a trop of 0.04. At ___ she was given dilaudid which
relieved the pain and she was transferred to ___ at the
patient's request.
In the ED, initial vitals were 97 48 124/62 16 99% ra. Labs were
signficant for trop 0.04, proBNP: 1483, hct 26.1, BUN 26, Cr
1.1, glucose 169, electrolytes/WBC and diff/plts/coags
unremarkable. ECG showed sinus bradycardia, rate 46, nonspecific
T wave changes. Tele noted in the ED to have intermittent a-fib
with rates up to 110s only for several seconds which then
resolves without intervention. Noncontrast CT chest showed 1. No
acute aortic abnormality or pulmonary embolus. 2. 3 mm right
lung base nodule which does not require further surveillance in
the absence of high risk factors. 3. Hiatal hernia. Of note,
Chest CT did not visualize amiodarone pulmonary disease. EP
evaluated the patient in the ED and recommended admission to
___ for pacemaker placement given her difficult to control afib
and symptoms which could potentially be related to bradycardia.
VS prior to transfer were 49 109/65 16 100% RA.
On the floor, patient notes mild shortness of breath, no chest
pain, no palps, no lightheadedness/dizziness.
Past Medical History:
Cardiac risk factors: +Hypertension
Cardiac issues:
No significant CAD on cath ___
PAF s/p prior cardioversions, currently on
amiodarone/dabigatran. S/p PVI ___ with cardiversion x3. s/p
PPM ___: AVNRT ablation
Other PMH:
Anemia, baseline hct ___
Roux-en-y gastric bypass surgery
Colon cancer s/p radiation and surgical resection
Spinal stenosis with multiple prior back surgeries, cervical
fusions. Most recent surgery C1-C2 ___ at ___ (C1-C2)
Hysterectomy
Cholecystectomy
Vitamin D deficiency with secondary hyperparathyroidism
Osteoporosis
Hypothyroidism
Hx of falls
Osteoarthritis
Kidney stones, s/p stenting and lithotripsy
Hypoglycermia/insulinoma s/p subtotal pancreatectomy/splenectomy
___
s/p bilateral knee replacements
s/p left hip replacement
Social History:
___
Family History:
Mother heart attack and bone cancer
Father liver cancer
Brother colon cancer, ___
Brother esophageal cancer, ___
Uncle colon cancer, ___
Aunt stomach cancer
x2 children colon polyps in ___
No other early cardiac deaths, known arrthymias.
Physical Exam:
Admission Exam:
VS: 98.4 116/67 50 18, 98%RA Wt 159lbs
GENERAL: NAD, awake and alert, lying comfortably in bed speaking
full sentences
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender and supple, no LAD, no JVD
CARDIAC: sinus, reg rate, nl S1 S2, no MRG
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN grossly intact, strength ___ throughout, sensation
grossly normal
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Exam:
VS: 97.8 ___ 99 ra
GENERAL: NAD, awake and alert, lying comfortably in bed speaking
full sentences
HEENT: EOMI, MMM
NECK: nontender and supple, no LAD, no JVD
CARDIAC: sinus, reg rate, nl S1 S2, no MRG, ppm placed, no signs
of infection
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle
use.
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN grossly intact, strength ___ throughout, sensation
grossly normal
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs:
___ 05:01AM BLOOD WBC-7.3 RBC-2.74* Hgb-8.1* Hct-26.1*
MCV-95 MCH-29.7 MCHC-31.2 RDW-14.5 Plt ___
___ 05:01AM BLOOD Neuts-61.6 ___ Monos-7.6 Eos-1.2
Baso-0.7
___ 05:01AM BLOOD ___ PTT-42.6* ___
___ 05:01AM BLOOD Glucose-169* UreaN-26* Creat-1.1 Na-137
K-5.0 Cl-104 HCO3-24 AnGap-14
___ 05:01AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.0
BNP:
___ 05:01AM proBNP-1483*
First set of CEs:
___ 05:01AM BLOOD CK(CPK)-69
___ 05:01AM BLOOD CK-MB-3
___ 05:01AM BLOOD cTropnT-0.04*
Second set of CEs:
___ 03:27PM BLOOD CK(CPK)-55
___ 03:27PM BLOOD CK-MB-2 cTropnT-0.04*
Hgb A1c:
___ 05:01PM BLOOD %HbA1c-6.7* eAG-146*
Admission Urine
___ 08:45AM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:45AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 08:45AM URINE RBC-119* WBC-11* Bacteri-FEW Yeast-NONE
Epi-5
Discharge Labs:
___ 06:30AM BLOOD WBC-6.6 RBC-2.88* Hgb-8.5* Hct-27.4*
MCV-95 MCH-29.4 MCHC-30.9* RDW-14.4 Plt ___
___ 06:30AM BLOOD ___ PTT-37.2* ___
___ 06:30AM BLOOD Glucose-137* UreaN-17 Creat-0.9 Na-136
K-4.7 Cl-102 HCO3-26 AnGap-13
___ 06:30AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.0
Imaging:
___ ___ CXR: TRACE BILATERAL PLEURAL EFFUSIONS, WHICH MAY
BE RELATED TO EARLY INTERSTITIAL EDEMA. NO FOCAL CONSOLIDATION.
___ Admission ECG: sinus bradycardia, rate 46, nonspecific T
wave changes.
___ Left Cardiac Catheterization:
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: No angiographically apparent disease
LAD: Mild plaquing
LCX: 50% distal OM3
RCA: 30% mid
Assessment & Recommendations
1. No significant coronary disease
2. Medical management
3. Continue EP evaluation
___hest:
1. No acute aortic abnormality or pulmonary embolus.
2. Right heart failure.
3. 3-mm nodule at the right lung base in a background of mild
paraseptal emphysema.
___ Echo:
The left atrium is mildly dilated. The left atrial volume is
mildly increased. The estimated right atrial pressure is at
least 15 mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF = 65%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. There is a trivial/physiologic pericardial effusion. There
are no echocardiographic signs of tamponade.
___ CXR: IMPRESSION: PA and lateral chest compared to ___: Previous external pacer leads have been removed. New
transvenous right atrial and ventricular leads follow their
expected courses from the new left axillary generator. Small
bilateral pleural effusions, unchanged since ___. Heart
size top normal, given mild hyperinflation of the lungs. No
evidence of cardiac decompensation. Lungs are grossly clear.
Previous Imaging:
___ Cardiac MR: Normal size and orientation of the pulmonary
veins without evidence of anomalous pulmonary venous return.
Mildly dilated left ventricular cavity with normal
regional/global systolic function. Moderate mitral
regurgitation.
2D-ECHOCARDIOGRAM: ___ No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque
to 40 cm from the incisors. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion. IMPRESSION: No intracardiac thrombus seen.
Normal biventricular systolic function.
ETT: ___ Stress test: Anginal chest pain without ischemic EKG
changes or ventricular arrhythmia. Nuclear report sent
seperately.
___ Cardiac persantine perfusion: 1. Normal myocardial
perfusion study. 2. Normal left ventricular cavity size and
global systolic function. When compared to prior study dated
___, there is no significant change.
___ Holter monitor: Long-term event monitoring was performed
in this patient with history of A.Fib, S/P cardioversion ___,
on a drug trial of Amiodarone 200 mg daily, to assess rhythm and
rates. Other reported medications include Calcitrol, Dabigatran,
Levothyroxine, Lisinopril and Pantoprazole. On ___ the
baseline recording showed sinus rhythm at rates 49 to 76 BPM
with 1 APB. The baseline intervals were as follows: rate 76 BPM:
QT .40, QRS .09, PR .18. On ___ the final transmission (4
recordings) showed sinus rhythm at rates 66 to 90 BPM. The final
intervals were as follows: rate 83 BPM: QT .38, QRS .09, PR .17.
From ___ to ___ ___ recordings were transmitted. Thirty
recordings showed sinus rhythm alternating with ectopic atrial
rhythm at rates 45 to 103 BPM with 1 APB. One recording showed
A.Fib with average ventricular response rates over 6 seconds of
100 to 120 BPM. On ___ to ___ eight recordings showed atrial
fibrillation with average ventricular response rates over 6
seconds of 90 to 110 BPM. From ___ to ___ ___
recordings were transmitted. ___ recordings showed sinus
rhythm alternating with ectopic atrial rhythm at rates 45 to 97
BPM with APBs, VPBs, and a blocked APB. Five recordings showed
atrial fibrillation with average ventricular response rates over
6 seconds of 80 to 100 BPM.
Brief Hospital Course:
___ yr old woman with complex PMH no sig CAD, symptomatic pAF on
amio and dabigatran, failed flecainide and propafenone, multiple
cardioversions and AVRNT ablation, with recent admission for
afib s/p PVI ablation and 3 subsequent cardioversion on ___,
who was admitted with continued poorly controlled atrial
fibrillation with concern over symptomatic bradycardia, now s/p
permanent pacemaker placement.
# Tachy-brady, sick sinus: Patient's symptomatic paroxysmal afib
has been exceedingly difficult to control. She is currently on
amiodarone (CT chest without evidence of amio toxicity,
reassuringly) and dabigatran. She has failed flecainide and
propafenone, as well as multiple cardioversions and an AVRNT
ablation. Her most recent admission was just over a week ago,
when she had a PVI ablation and 3 subsequent cardioversions on
___ as patient's afib remained eaily inducible. This
admission she presented with persistent symptoms (shortness of
breath) in the context of now sinus bradycardia, concerning for
difficult to control afib with subsequent symptomatic sinus
bradycardia. She continued in sinus bradycardia, rates ___,
despite being off nodal agents. On ___ a permanent pacemaker
was placed without complication. She was given vancomycin for
antibiotic prophylaxis while in the hospital and then
transitioned to keflex for a total of a 3 day course. She was
continued on dabigatran and amiodarone 200mg daily with close
cardiology follow up. If atrial fibrillation remains an issue,
can consider AV nodal ablation and pacemaker dependency in the
future.
# Chest pain: Chest pain was substernal and associated with
dizziness the night prior to admission. CKMB 3,2 and trops flat
(0.04), story concerning for ACS though ECG reassuring. No
previous cath. Given multiple admissions for various above
symptoms and no prior cath, left heart catheterization was
pursued on ___ and reassuringly did not show any significant
CAD. She has remained chest pain free throughout the admission.
# PUMP: No prior history of CHF. Cardiac MR from ___ showed
mildly dilated left ventricular cavity with normal
regional/global systolic function, moderate mitral
regurgitation. Given several recent cardioversions, patient may
have developed some recent myocardial stunning and resultant
mild CHF exacerbation, requiring 1 dose of lasix 20mg once on
___ (prior to admission), which she reported excellent
urinary output to. During this admission, clinical imaging
suggested decompensated CHF, however the patient was clinically
euvolemic and on CXR the day of discharge she had no evidence of
pulmonary edema. Echo this admission showed EF 65%, moderate
pulm artery systolic hypertension,and significant pulmonic
regurgitation.
# Anemia: Baseline hct ___, admitted with hct of 26 which
steadily increased each day without any evidence of bleeding on
exam. Discharge hct 27.4. Iron levels not recently checked but
Ferritin borderline low and TIBC elevated. B12 last month in
500s.
# HTN: Continued home lisinopril with good control of BPs. Of
note, patient should be on asa 81mg for primary stroke
prevention, which can be started in the outpatient setting
(given PPM was placed this admission and medication is for
primary prevention).
# VitD and secondary hyperparathyroidism: Continued home
Calcitriol 0.5 mcg PO DAILY.
# Dyspepsia: Continued home Pantoprazole 40 mg PO Q12H.
# Hypothyroidism: Continued home Levothyroxine.
# s/p subtotal pancreatectomy with secondary diabetes: Continued
home pramlintide and creon. Gets octreotide injection monthly.
Was noted to have mild hyperglycemia this admission and on
recent labs with A1c this admission on 6.7%. Given complicated
endocrine regimen s/p subtotal pancreatectomy, we continued her
home regimen of octreotide/pramlintide combination. This should
be followed up with PCP/endocrine in outpatient setting.
# OA s/p spinal surgery: Continued home Vicodin HS PRN for neck
pain.
Transitional Issues:
# CODE: Full code
# CONTACT: Patient, Husband ___ ___
- device clinic follow up and outpatient cardiologist follow up
for PPM checks and continued management of atrial fibrillation.
If atrial fibrillation is still an issue despite medical
management, can consider AV nodal ablation and pacemaker
dependency in the future.
- prophylactic antibiotics through ___ in AM
- hyperglycemia (glucose high 100s this admisison) with A1c 6.7%
on octreotide and pramlintide. Management deferred to outpatient
providers.
- should be started on ASA 81mg for stroke prevention (given dx
HTN)
- recommend work up for iron deficiency anemia given high TIBC
and borderline low ferritin. B12 normal. ___ need repeat
colonoscopy if low.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Calcitriol 0.5 mcg PO DAILY
3. Creon 12 5 CAP PO TID W/MEALS
4. Dabigatran Etexilate 150 mg PO BID
5. Levothyroxine Sodium 125 mcg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. pramlintide 2,700 mcg/2.7 mL subcutaneous TID QAC
10. bifidobacterium infantis 4 mg oral daily
11. Cyanocobalamin 1000 mcg IM/SC QMON
12. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO HS:PRN pain
13. Octreotide Acetate 20 mcg SC Q1MO
14. Diltiazem Extended-Release 120 mg PO DAILY
Discharge Medications:
1. Calcitriol 0.5 mcg PO DAILY
2. Creon 12 5 CAP PO TID W/MEALS
3. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO HS:PRN pain
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. pramlintide 120 mcg subcutaneous TID w/Meals
9. bifidobacterium infantis 4 mg oral daily
10. Cyanocobalamin 1000 mcg IM/SC QMON
11. Dabigatran Etexilate 150 mg PO BID
12. Octreotide Acetate 20 mcg SC Q1MO
13. Cephalexin 500 mg PO Q12H Duration: 2 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every 12 hours Disp
#*4 Capsule Refills:*0
14. Amiodarone 200 mg PO DAILY
15. Sarna Lotion 1 Appl TP QID:PRN itching
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % four times a
day Disp #*1 Tube Refills:*0
16. Acetaminophen 1000 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth q6 Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Sick sinus syndrome, atrial fibrillation
Secondary diagnosis:
Hypertension
Anemia
hypothyroidism
vitamin D deficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you at ___
___. You were admitted for difficult to control
atrial fibrillation and resultant slow heart rate that was
causing chest pain and shortness of breath. We performed a
cardiac catheterization and your coronary arteries (the arteries
that supply the heart muscle) did not have any significant
blockages that could be causing the chest pain you had. Your
symptoms were thought to be due to your slow heart rate and so a
pacemaker was placed. You should have close follow up in device
clinic, as mentioned below.
Please rest your right arm and do not over extend if for at
least a week while the pacemaker site is healing to prevent bed
bruising or bleeding in the area.
Followup Instructions:
___
|
19759432-DS-21
| 19,759,432 | 26,266,243 |
DS
| 21 |
2182-08-27 00:00:00
|
2182-08-28 03:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal distension
Major Surgical or Invasive Procedure:
Therapeutic paracentesis: ___
History of Present Illness:
___ w/ hx heavy alcohol abuse ___ years ago and newly diagnosed
cirrhosis and renal failure p/w increasing abdominal girth.
Patient is new to our system but was admitted over the past
month for approx 1 weeks at ___ where he had 27
liters total of ascites drained. He plans to establish care with
our hepatology service but has yet to formally be evaluated
here. He was advised by Dr. ___ to whom he was referred by Dr.
___ GI) to come to ED tonight for admission after
routine labs drawn 2 days ago showed continued renal failure. He
also notes his abdomen has increased in size over the past 2
weeks and he is experiencing mild dyspnea at times.
.
On review of his ___ records and discussion with the patient
it appears as if he was admitted for several days in early
___ for tense ascites. He initially had 4L of fluid removed
and continued to lead an additional 6L into an ostomy bag from
the tap site over the next several days. He then had a 17 L
paracentesis prior to discharge and reports that on day of
discharge his abdomen was completely flat. He does not recall
ever receiving any albumin following the procedures. He was
never started on diuretics secondary to his renal failure with
Cr at ___ reported to range from 4.5-4.9 during his stay. He
says that he was told that his ascites was secondary to
alcoholic cirrhosis. Although no biopsy was done he says he had
a "number of scans." He reports a ___ year period of heavy alcohol
use ___ years ago where he was drinking "liters" of alcohol as
well as 30 beers a day. He reports his last drink was ___ years
ago in ___ detox. He denies any history of
IVDU or travel outside the ___. He reports that all of his
hepatitis serologies were checked and are normal. He reports
having HBV and HAV vaccines in ___.
.
No access to his discharge summary at this time but he was seen
by ___ GI who reports that:
"Review of his hospital record showed that he has no Hep B
immunity with neg HBV S Ag/Ab, negative HCV antibody. His
ascitic fluid analysis showed WBC of 200, and t.protein of 3.8.
There was no serum/ascitic fluid albumin levels nor gradient.
His CT scan at the time of his hospitalization showed cirrhosis
and splenomegaly suggestive of portal venous hypertension,
massive ascites and GBS. He also had abd sonogram with doppler
that demonstrated patent portal vein."
.
Currently he denies any skin changes or changes in his bowel
habits/color/consistency. He denies any N/V hematemsis, melena
or hematochezia.
.
He is currently in no distress except for abdominal discomfort.
He reports that he never experienced jaundice, confusion,
fevers.
.
In the ED, initial VS were: 98.0 92 132/79 18 100%
.
DX para was completed in the ED and shows no evidence of SBP,
SAAG 1.9 showing evidence of portal hypertension.
.
REVIEW OF SYSTEMS:
Per HPI
Denies CP, SOB, N/V/D, dysuria or abdominal pain.
Past Medical History:
Hypothyroidism-newly diagnosed ___
Ascites ___
Gout
Social History:
___
Family History:
He is adopted, unknown family history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 97.8 128/81 93 20 100%RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD,
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
BACK: 2cm pylonidal cyst, dressings over right superior buttock.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - Tense ascites with +fluid wave, non-tender, faint
bowel sounds. No spider agiomata. No gynecomastia. No caput
medusa. +splenomegaly.
EXTREMITIES - WWP 2+ pitting edema to the knees ___. No palmar
erythema
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, no asterixis
DISCHARGE PHYSICAL EXAM
VS - 97.9 166/60 62 18 96% RA
I/O Yest: 1260/750 + 18L paracentesis
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - Markedly smaller ascites, non-tender, + bowel sounds.
No spider agiomata. No gynecomastia. No caput medusa.
+splenomegaly
BACK: 2cm pylonidal cyst, dressings over right superior buttock.
EXTREMITIES - WWP 2+ pitting edema to the knees ___. No palmar
erythema
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, no asterixis
Pertinent Results:
ADMISSION LABS
___ 01:00AM BLOOD WBC-8.6 RBC-3.88* Hgb-10.9* Hct-33.8*
MCV-87 MCH-28.1 MCHC-32.2 RDW-14.2 Plt ___
___ 01:00AM BLOOD Neuts-72.1* ___ Monos-6.5 Eos-1.4
Baso-0.6
___ 01:00AM BLOOD ___ PTT-43.4* ___
___:00AM BLOOD Glucose-114* UreaN-47* Creat-4.7* Na-135
K-4.2 Cl-100 HCO3-20* AnGap-19
___ 01:00AM BLOOD ALT-11 AST-20 AlkPhos-196* TotBili-0.7
___ 07:25AM BLOOD Albumin-4.0 Calcium-8.5 Phos-4.4 Mg-2.5
Iron-30*
___ 01:17AM BLOOD Lactate-1.6
RELEVANT LABS
___ 01:00AM BLOOD Lipase-24
___ 07:25AM BLOOD calTIBC-138* Ferritn-195 TRF-106*
___ 05:25AM BLOOD %HbA1c-5.4 eAG-108
___ 06:20AM BLOOD TSH-6.7*
___ 06:20AM BLOOD Free T4-1.1
___ 07:17AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
___ 05:25AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 05:25AM BLOOD ___ * Titer-1:40
___ 05:55AM BLOOD IgG-753 IgA-184 IgM-87
___ 05:25AM BLOOD HIV Ab-NEGATIVE
___ 07:17AM BLOOD HCV Ab-NEGATIVE
___ 06:02AM BLOOD CERULOPLASMIN-PND
___ 06:02AM BLOOD ALPHA-1-ANTITRYPSIN-PND
DISCHARGE LABS
___ 06:02AM BLOOD WBC-6.6 RBC-3.64* Hgb-10.5* Hct-32.1*
MCV-88 MCH-28.9 MCHC-32.7 RDW-14.3 Plt ___
___ 06:02AM BLOOD ___ PTT-37.1* ___
___ 06:02AM BLOOD Glucose-129* UreaN-59* Creat-5.5* Na-134
K-4.0 Cl-100 HCO3-20* AnGap-18
___ 06:02AM BLOOD ALT-5 AST-11 LD(LDH)-103 AlkPhos-91
TotBili-1.1
___ 06:02AM BLOOD Calcium-9.1 Phos-6.3* Mg-2.5
URINE
___ 12:11PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 12:11PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 11:07AM URINE Eos-NEGATIVE
___ 11:07AM URINE Hours-RANDOM UreaN-486 Creat-132 Na-<10
K-39 Cl-12
___ 11:07AM URINE Osmolal-330
MICRO
___ 1:40 am PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
IMAGING
___ CXR
FINDINGS: There is a small left pleural effusion, best
identified on the
lateral view. No right effusion is identified. There is no
consolidation,
pulmonary edema, or pneumothorax. The cardiomediastinal
silhouette is normal.
IMPRESSION: Small unilateral left pleural effusion.
___ ABDOMINAL ULTRASOUND
IMPRESSION:
1. Patent portal vein with hepatopetal flow.
2. Cirrhotic appearance to liver. No concerning focal lesions.
3. Splenomegaly and large volume ascites, consistent with
chronic portal
hypertension.
4. Cholelithiasis.
___ ECHO
The left atrium is elongated. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). 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.
There is no mitral valve prolapse. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Normal study. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
No structural heart disease or pathologic flow identified.
___ PARACENTESIS
IMPRESSION: Technically successful paracentesis with 19 liters
of clear
yellow-green fluid removed.
___ EGD
Impression:Food in the whole stomach
No esophageal varices
Due to food in the stomach could not adequately assess for
gastric mucosal abnormalities or gastric varices
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ M with reportedly newly diagnosed cirrhosis s/p LV
paracentesis in early ___ presenting to the ED for renal
failure and tense ascites.
# Ascites: presumed to be from newly diagnosed cirrhosis given
cirrhotic appearance of liver on ultrasound with evidence of
portal hypertension and splenomegaly. Etiology of cirrhosis
likely secondary to alcohol abuse, however has been sober for
about a decade. SAAG was 1.9 c/w cirrhosis. ECHO with no signs
of heart failure. Normal serum albumin and UA without large
amount of protein argues against nephrotic syndrome. Of note, he
has relatively normal platelet, albumin, INR, and LFTs.
Workup for cirrhosis negative for hepatitis, iron studies, HIV,
AMA, anti-smooth. IgG, IgA, IgM normal. ___ positive, but titer
is 1:40. Pending alpha1-antitrypsin and ceruloplasmin.
Diagnostic paracentesis negative for SBP and peritoneal fluid
with no growth. Therapeutic paracentesis was performed on ___
with removal of 19 liters of clear yellow-green fluid, repleted
with albumin. Patient was kept in a low sodium diet and
instructed to continue once discharged. Scheduled for
therapeutic paracentesis every 2 weeks as outpatient.
# ___: Pt presented with creatinine of 4.7 without a documented
baseline. Presentation could be compatible with HRS type 2 given
ascites + ARF, pre-renal etiology with FeNa<1, and no response
to albumin challenge. It is however unusual that he developed
HRS without a long standing history of decompensated liver
failure. Also, Cr was already elevated to 4.5 upon presentation
to OSH and patient reported that no albumin was given after LVP
at OSH. Abdominal US without signs of obstruction or structural
lesion of the collecting system. Per renal, there are some
granular casts on urine sediment analysis but overall sediment
is not active. Patient was started on octreotide and midodrine
on ___ without much improvement and was discontinued upon
discharge. Creatinine trended up to 5.7 and day of discharge,
creatinine was 5.5. He was started on sodium bicarb for acidosis
and calcium acetate for high phosphate. Patient discharged with
close renal follow up.
# newly diagnosed cirrhosis: presumed to be secondary to heavy
alcohol use in the past. Per patient, has been sober for about a
decade. Workup for cirrhosis negative so far, pending
alpha1-antitrypsin and ceruloplasmin. MELD 24 (driven by
creatinine).
No other sequelae of cirrhosis other than ascites - denies
history of jaundice, GI bleed, confusion. EGD performed during
this admission with no signs of esophageal varices (although
food in stomach prevented from adequately assessing for gastric
varices). Due to patient's insurance, requires workup for
possible liver and kidney transplant at ___, so will refer to
physician at ___ for biopsy and transplant evaluation in the
future.
# Anemia: Hct downtrending since admission 33.8 --> 30.6, but
then remained stable in the high ___. He has received
large amounts of albumin and no esophageal varices per EGD. No
stigmata of bleeding, has not had bloody BM this admission.
# Hypothyroidism: TSH was 6.7, but free T4 normal at 1.1. He was
continued on levothyroxine
# Pylonidal cyst: no evidence of infection, but with some
discomfort due to pressure. Patient had daily dressing changes.
# TRANSITIONAL ISSUES
-patient needs hep B vaccine
-please follow up with pending ceruloplasmin and
alpha-1-antitrypsin results
-patient scheduled for therapeutic paracentesis every 2 weeks
-will have outpatient lab draw on ___, please follow up with
results and ensure creatinine remains stable/downtrending
-patient's insurance requires workup for possible liver and
kidney transplant at ___, thus will refer to physician at ___
for biopsy and transplant evaluation in the future. In the
interim, will f/u with hepatologist and nephrologist at ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
4. FoLIC Acid 5 mg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
4. FoLIC Acid 1 mg PO DAILY
5. Calcium Acetate 667 mg PO TID W/MEALS
RX *calcium acetate 667 mg 1 tablet(s) by mouth three times a
day with meals Disp #*90 Tablet Refills:*0
6. melatonin *NF* 1 mg Oral HS
take 30 minutes prior to bedtime
RX *melatonin 1 mg 1 tablet(s) by mouth at night 30 minutes
prior to bed as needed Disp #*30 Tablet Refills:*0
7. Simethicone 40-80 mg PO QID:PRN bloating, flatus
RX *simethicone [Gas Relief] 80 mg 1 tablet by mouth up to four
times a day as needed Disp #*60 Tablet Refills:*0
8. Sodium Bicarbonate 650 mg PO BID
RX *sodium bicarbonate 650 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
9. Outpatient Lab Work
Please draw chem10 on ___ and fax results to:
___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: cirrhosis, renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted for evaluation and treatment of your ascites, liver and
renal disease. You had renal failure which remained stable at
the time of discharge. You had chronic liver disease as well
that probably led to the ascites (fluid in your abdomen). You
had multiple paracenteses which removed fluid from your abdomen.
You will require paracentesis every 2 weeks after discharge to
help make you more comfortable and remove extra fluid. Because
of your insurance situation, we felt that it is in your interest
to refer you to ___ for further workup. In
the interim, you will see our hepatologist and nephrologist at
___ for followup.
Followup Instructions:
___
|
19759447-DS-11
| 19,759,447 | 21,796,017 |
DS
| 11 |
2161-05-01 00:00:00
|
2161-04-30 15:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
MD-___ R / Morphine / Iodine-Iodine Containing
Attending: ___.
Chief Complaint:
Lethargy and hypoactive delirium
Major Surgical or Invasive Procedure:
Bedside irrigation of wound
Wound vac placement
History of Present Illness:
___ years-old female with history of dementia (limited ability to
communicate, but can speak in simple sentences), HTN, HLD, T2DM,
CAD s/p MI ___, 2x stent), hypothyroidism, CVA s/p right
temporal lobe ischemia (___), anemia, and anxiety presented
with worsening weakness and encephalopathy. Patient was noted to
have a more rapid decline in the setting of a few weeks of
progressive weakness and decreased interaction with primary
caregivers. ___ arrival, patient was found to have a
severe/large gluteal abscess complicated by hypotension,
requiring ICU placement for vasopressors.
Past Medical History:
- CAD s/p inferior MI ___ treated with PTCA complicated by
embolization to the PLV. Subsequent Velocity stent to the
mid-RCA in ___. Also had several catheterizations for atypical
symptoms that did not reveal significant coronary obstruction.
Last stress MIBI with EF 47%, moderate partially reversible
inferolateral perfusion defect.
- Hypertension
- Hypercholesterolemia
- Anemia, iron deficiency?
- Diabetes mellitus, Type II
- GERD/PUD
- Osteoarthritis
- Apocrine bromhidrosis
- Hypothyroidism
- Anxiety
- s/p hysterostomy and bilateral tubal ligations
- S/P Right total knee replacement ___
Social History:
___
Family History:
Mother died of cancer at ___. Father died of emphysema at ___
after working in ___. Grandmother with diabetes. 3
brothers and 4 sisters, no H/O heart disease in family
Physical Exam:
DISCHARGE EXAMINATION:
Pertinent Results:
___ 05:43AM BLOOD WBC-30.6* RBC-2.48* Hgb-7.7* Hct-23.1*
MCV-93 MCH-31.0 MCHC-33.3 RDW-15.6* RDWSD-51.9* Plt ___
___ 01:43PM BLOOD WBC-27.5* RBC-3.90 Hgb-11.8 Hct-40.0
MCV-103* MCH-30.3 MCHC-29.5* RDW-13.6 RDWSD-51.4* Plt ___
___ 05:06AM BLOOD Neuts-77* Bands-4 Lymphs-5* Monos-9 Eos-0
Baso-0 ___ Metas-2* Myelos-3* NRBC-1* AbsNeut-20.01*
AbsLymp-1.24 AbsMono-2.22* AbsEos-0.00* AbsBaso-0.00*
___ 05:43AM BLOOD ___
___ 05:06AM BLOOD ___ 05:43AM BLOOD Glucose-133* UreaN-32* Creat-1.2* Na-141
K-3.2* Cl-103 HCO3-27 AnGap-11
___ 01:43PM BLOOD Glucose-240* UreaN-63* Creat-4.1*#
Na-154* K-4.8 Cl-113* HCO3-19* AnGap-22*
___ 05:06AM BLOOD Albumin-1.6* Calcium-7.0* Phos-2.3*
Mg-1.3*
___ 01:43PM BLOOD Albumin-2.7*
___ 12:05AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.8
___ 05:43AM BLOOD ALT-17 AST-28 TotBili-2.6*
___ 01:43PM BLOOD ALT-36 AST-92* CK(CPK)-1591* AlkPhos-131*
TotBili-1.1
___ 01:43PM BLOOD Lipase-35
___ 08:03AM BLOOD CK-MB-5 cTropnT-0.12*
___ 12:05AM BLOOD TSH-0.65
___ 03:21PM BLOOD ___ pO2-43* pCO2-23* pH-7.36
calTCO2-14* Base XS--10
___ 09:12AM BLOOD Lactate-2.2*
___ 01:49PM BLOOD Lactate-5.7*
CT head without acute hemorrhage, mass, territorial infarct.
MRI pelvis 7.2 cm right gluteal abscess with visible skin track
contains internal foci of air and appears to communicate with
the rectum. No evidence of osteomyelitis.
ECHOCARDIOGRAM: LEFT VENTRICLE (LV): Normal wall thicknesses.
Normal cavity size. Cannot exclude regional systolic
dysfunction. The visually estimated left ventricular ejection
fraction is >=60%. Normal overall systolic function (greater
than 55%). Normal cardiac index (>2.5 L/min/m2). No resting
outflow tract gradient.
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of dementia
(limited ability to communicate, but can speak in simple
sentences), HTN, HLD, T2DM, CAD s/p MI ___, 2x stent),
hypothyroidism, CVA s/p right temporal lobe ischemia (___),
anemia, and anxiety presented with worsening weakness and
encephalopathy. She was found found to have a large gluteal
abscess complicated by hypotension, requiring ICU admission for
vasopressors for septic shock. She was seen by wound care and
colorectal surgery who recommend antibiotics and local wound
care/draining (as surgery would likely require need for
temporary diverting colostomy).
#Septic shock secondary to right gluteal abscess:
MRI pelvis on ___ showed 7.2 cm right gluteal abscess with
visible skin track containing internal foci of air and appeared
to communicate with the rectum. Colorectal surgery performed
I&D of the abscess on ___ and felt the rectum was intact
despite MRI report. They recommended local wound care and
placed wound vac on ___, rather than surgery since it would
likely require temporary diverting colostomy. Gluteal abscess
swab grew E. coli and Corynebacterium and B. fragilis, for which
she was started on Zosyn and Clindamycin on ___, after a short
course of vancomycin, cefepime, and flagyl. She had no evidence
of necrotizing infection. Wound vac was changed every 3 days and
she will need follow up with Dr. ___ in ___ weeks.
Blood cultures were negative. ID was consulted and she was
changed to Ceftriaxone and Flagyl on ___. Given concern for
fistula between abscess and rectum the patient underwent a
repeat MRI which she could not complete. She thus underwent an
exam under anesthesia which did not show a fistula. They
recommended continued wound care. Per ID recommendations she
was transitioned to Levo/Flagyl to complete a 14 day course
through ___.
#Altered mental status/acute encephalopathy with hypoactive
delirium and decompensated dementia, triggered by infection: CT
head showed no acute hemorrhage, mass, territorial infarct but
was notable for global cortical atrophy with sequela of chronic
microvascular ischemic disease. Mental status improved slightly
with treatment of underlying infection, but has definite waxing
and waning course. Patient was started on Zyprexa which is not
a home medication. At home the patient is on trazodone which
was resumed prior to discharge
#Dysphagia/poor nutrition:
Hospitalization was complicated by poor oral intake and
nutrition. Speech therapy evaluated the patient given concern
for risk of aspiration with encephalopathy and she was strictly
NPO for days. Feeding tube was considered given poor oral
intake, but her mental status improved enough that she performed
better during repeat swallow evaluation and was advanced to
nectar thick liquids. She was not able to take oral medications
safely due to pocketing of the medications and had coughing with
thin liquids. She also had hypokalemia, hypomagnesemia, and
hypophosphatemia, which resolved with repletion. The patient
was evaluated by speech and swallow and noted to not swallow
solid food. She was advanced to liquids only with NO purée.
Nutritional status and dysphasia will need ongoing evaluation.
As she improved she was advanced to pureed solids thin liquids.
#Anemia:
She had initial anemia and thrombocytopenia., without lab
evidence of DIC. She received 1 unit PRBCs on ___. Her
hemoglobin dropped to 6.9 and she required a second unit of
PRBCs on ___. She had one guaiac positive stool.
#Elevated CK and Elevated AST:
These lab abnormalities were likely secondary to increased
demand in the setting of sepsis. They normalized with
supplemental IV fluids. Similarly, patient was noted to have
acute renal failure likely prerenal azotemia in the setting of
volume depletion. This improved with IV fluids.
Ms. ___ was seen and examined on the day of discharge and
is clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
2. TraZODone 37.5 mg PO BID
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
4. Acetaminophen 500 mg PO BID:PRN Pain - Mild
5. Metoprolol Tartrate 12.5 mg PO BID
6. Memantine 10 mg PO BID
7. Losartan Potassium 50 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Clopidogrel 75 mg PO DAILY
12. Atorvastatin 40 mg PO QPM
13. Aspirin 81 mg PO DAILY
14. amLODIPine 5 mg PO DAILY
15. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Second
Line
16. NIFEdipine (Extended Release) 90 mg PO DAILY
17. OLANZapine 2.5 mg PO BID
18. Omeprazole 20 mg PO BID
19. Valsartan 80 mg PO DAILY
Discharge Medications:
1. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
2. Levofloxacin 500 mg PO Q48H
through ___. MetroNIDAZOLE 500 mg PO Q8H
through ___. Acetaminophen 500 mg PO BID:PRN Pain - Mild
5. amLODIPine 5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Clopidogrel 75 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
11. Levothyroxine Sodium 100 mcg PO DAILY
12. Losartan Potassium 50 mg PO DAILY
13. Memantine 10 mg PO BID
14. Metoprolol Tartrate 12.5 mg PO BID
15. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Second
Line
16. Senna 17.2 mg PO QHS
17. TraZODone 25 mg PO BID:PRN agitation
18. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Septic shock
Leukocytosis
Gluteal Abscess
Anemia and thrombocytopenia
Coagulopathy
Poor oral intake/nutrition
Hypokalemia
Hypomagnesemia
Hypophosphatemia
___
AMS: Acute encephalopathy with hypoactive delirium superimposed
on decompensated dementia
Mixed AG Metabolic acidosis and Respiratory Alkalosis
CAD with prior PCI & stents
Hypernatremia
Volume depletion
Type 2 Diabetes
Essential HTN
Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___ were admitted with weakness and altered mental status. ___
were found to have a buttock abscess. This was a serious
infection that caused low blood pressure treated in the ICU. ___
were treated with antibiotics and debridement by colorectal
surgery who also placed a wound vac temporarily. We hope these
measures allow the wound to heal completely, so to avoid a major
surgery. ___ will need to follow up with the surgeons as an
outpatient to make sure your wound is healing.
It was a pleasure taking care of ___,
Your ___ Team
Followup Instructions:
___
|
19759491-DS-28
| 19,759,491 | 20,320,276 |
DS
| 28 |
2192-08-18 00:00:00
|
2192-08-18 17:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Percodan / Adhesive / Dilaudid
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female wirh history of ESRD secondary to FSGS, s/p
pancreas/kidney transplant x 2 (___), HTN/HL, t1DM,
chronic systolic heart failure (EF 30% in ___ ischemic
cardiomyopathy s/p CABG and MVR, on warfarin, pleural effusions
s/p VATS/pleurectomy, presenting with 2 weeks of diffuse
abdominal pain and nausea. She has been in touch with ___
Gastroenterology, who informed here to get a CT abdomen at her
local hospital, which showed bilateral pleural effusions,
fecalization of the large bowel, and small amount of pneumatosis
in the small bowel (cystoides variant). Given that she only had
mild abdominal pain, she was subsequently started on outpatient
levofloxacin (500mg q48h) and flagyl 250mg TID for a 14-day
course, starting on ___, and she was instructed to report to
the ED with any worsening pain. Two days ago, she notes that she
had worsening pain, described as diffuse, nonradiating, and
"gnawing" causing significant nausea. This pain generally only
occurs during the night and wakes her from sleep. She is so
tired the next day that she just is not hungry until just prior
she goes to bed, when she has a snack. She has never tried NOT
eating before bed over these past 2 weeks. She started vomiting
this AM (nonbloody, nonbilious). Her last BM this AM was normal
or nonbloody and she has not been having any diarrhea. She has
also had a low grade temp to 100 ___s chills. She does
not have much of an appetite during the day and has lost ~5 lbs
over the past few weeks. She states that this pain is exactly
the same as her earlier bout of pneumatosis intestinalis this
year when she was hospitalized. Of note, she did not complete
hyperbaric therapy as an outpatient, as was prescribed.
She was recently evaluated on ___ in the ___ Transplant
Center with Dr. ___ noted that while her pancreas
transplant is working well, she continues to have marginal
kidney graft function with CKD stage V. She is continuing on
immunosuppression with prednisone 5 mg daily, Rapamune 1 mg
daily (target ___, and Prograf 0.5 mg (target level ___. She
is active on the kidney transplant list, with numerous anti-HLA
antibodies and overall PRA 97% without any current compatible
potential donors. She has been pursuing listing in ___ as
well. Since she is a difficult match, it was suggested to her
that she consider accepting a kidney from almost any donor
against whom she has no anti-HLA antibodies, except for an older
donor kidney with significant damage. This information was also
communicated to the physicians at ___, where
she is also listed.
In the ED, initial VS were: 98.3 82 133/60 16 95%. Exam was
notable for TTP around the umbilicus without guarding or
rebound, soft, and non-distended, with hyperactive BS. She was
guaiac negative. Her RLE is swollen, per her baseline since her
graft placement for PVD). EKG shows LBBB, c/w prior. She was
started on IV antibiotics, ciprofloxacin and Flagyl, after blood
cultures were drawn. Labs were notable for baseline creatinine
of 3.0 and elevated INR to 4.0. Her CT was repeated here and
showed no evidence of pneumotosis intestinalis, colitis, or
acute surgical process, but did show some fecal loading in the
colon, without obstruction or evidence of severe constipation.
As a result, she was offered stool softeners/laxatives, but she
was unwilling to take anything PO and is sure that this is not
constipation. Prior to transfer, she continued to have abdominal
pain and nausea. She was given 1L of fluid total due to her
pleural effusions and pulmonary edema on CXR as well as
ondansetron and morphine for nausea/pain control.
On arrival to the floor, she is not in very much pain and is
actually hungry, consistent with her increased appetite before
bed at home. We discussed that we might try NOT eating tonight
and see if she still has pain overnight. She reluctantly agreed
to this.
Past Medical History:
-End stage renal disease secondary to FSGS, s/p pancreas/kidney
transplant x 2 ___ currently under evaluation at both
___ and ___ for re-transplantation, actively
looking to list herself in ___ no current HD access
-Pleural effusion s/p VATS/pleurectomy ___
-Chronic systolic heart failure (EF 30% in ___
-Coronary artery disease s/p MI and CABG and MVR ___, on
warfarin
-Dyslipidemia
-Hypertension
-Diabetes mellitus type 1, which looks to be cured s/p
transplant with A1c 4.9-6.3 dating back to ___
-PVD s/p R femoral-anterior tib bypass graft
-chronic anemia
-menorrhagia s/p vaginal hysterectomy ___
-charcot R foot
Surgical:
- s/p simultaneous pancreas-kidney transplant in the mid ___
followed by a repeat renal transplant (___) and repeat
pancreas transplant (___)
- s/p retinal detachment and enucleation of left eye
- s/p D & C (___)
- s/p Hysterectomy (___)
- s/p TMJ surgery
- s/p CABG/MVR ___
- s/p R femoral-anterior tib bypass graft ___
Social History:
___
Family History:
No family Hx of CAD or DM. MGM had HTN but lived to be ___. MGF
had a CVA in his ___. Her father had RA that was complicated by
restrictive lung disease. PGF had renal disease. PGM had small
bowel CA in her ___.
Physical Exam:
admission exam:
VS - Temp 97.8F, BP 150/81, HR 89, RR 18, O2-sat 97% RA
GENERAL - female appearing older than stated age, NAD,
comfortable, appropriate
HEENT - NC/AT, PERRL on right, artifical eye on left, sclerae
anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - decreased BSs to bases with crackles just above these
areas, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, loud V/VI systolic, mechanical
murmur heard throughout chest, nl S1-S2
ABDOMEN - hyperactive bowel sounds, soft/NT/ND, no masses or
HSM, no rebound/guarding
EXTREMITIES - WWP, chronic RLE edema to ankle with visible
pulsation of her fem-ant tib graft through the skin, 1+
peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, gait not
assessed
Pertinent Results:
admission labs:
___ 02:45PM BLOOD WBC-3.3* RBC-3.56* Hgb-10.7* Hct-34.3*
MCV-96 MCH-30.1 MCHC-31.2 RDW-17.0* Plt ___
___ 02:45PM BLOOD ___ PTT-43.5* ___
___ 02:45PM BLOOD Glucose-115* UreaN-104* Creat-3.0* Na-141
K-3.6 Cl-101 HCO3-26 AnGap-18
___ 02:45PM BLOOD ALT-13 AST-25 AlkPhos-54 TotBili-0.6
___ 02:45PM BLOOD Albumin-3.5
___ 02:50PM BLOOD Lactate-1.2
CXR ___
The patient is status post median sternotomy, CABG, and mitral
valve
replacement. The heart is mildly enlarged. The mediastinal
contours are
unchanged with calcification of the aortic knob again noted.
Mild pulmonary
edema appears progressed compared to the prior exam with small
bilateral
pleural effusions, also minimally increased compared to the
prior exam. Left
basilar opacification likely reflects atelectasis. There is no
pneumothorax.
No acute osseous abnormalities are identified.
IMPRESSION:
Slight interval worsening of mild pulmonary edema with small
bilateral pleural effusions. Left basilar opacity likely
reflects atelectasis.
CT abdomen with oral contrast ___
Evaluation of abdominal structures is limited due to lack of IV
contrast.
There is a new small nonhemorrhagic right pleural effusion. A
small partially
loculated left pleural effusion is stable. There is mild
bibasilar smooth
septal thickening with associated ground glass opacities
compatible with mild
pulmonary edema.
Extensive vascular calcifications are noted involving the
coronary arteries,
the abdominal aorta, the mesenteric branches, and the iliac
arteries. No
abdominal aortic aneurysm is seen.
Bilateral native kidneys appear atrophic. The native pancreas
appears
atrophic. The stomach and visualized small large bowel are
within normal
limits with moderate fecal loading noted throughout the colon.
Bilateral
adrenal glands, liver, gallbladder, spleen are within normal
limits. There is
no free fluid or free air in abdomen. There is no mesenteric or
retroperitoneal lymphadenopathy by CT size criteria.
CT pelvis with oral contrast:
Assessment of the pelvic structures is limited due to lack of IV
contrast.
Transplant kidney in the right lower quadrant appears
unremarkable without
hydronephrosis or calculi. Transplant pancreas in the left
lower quadrant is
not well assessed on this study, though no fluid collections or
adjacent fat
stranding is seen. The patient is status post hysterectomy.
Again noted is a
stable multilobulated cystic structure in the right adnexa
measuring 5.2 x 2.7
cm (2: 68). Also again visualized inferior to this cystic
structure is a 1.9
cm hyperdense round structure measuring 1.6 x 1.4 cm (2: 72),
possibly
reflecting a fibroid arising from the cuff of the hysterectomy.
There is no
free fluid or free air. There is no pelvic or inguinal
lymphadenopathy.
Rectum, bladder, and distal ureters are within normal limits.
Osseous structures: There are no lytic or sclerotic osseous
lesions
suspicious for malignancy. Mild multilevel degenerative changes
are
visualized throughout the thoracolumbar spine.
IMPRESSION:
1. No evidence of acute abdominal or pelvic processes.
2. Unchanged partially loculated small left pleural effusion
and new small
right pleural effusion. Mild pulmonary edema noted at the lung
bases.
3. Stable appearance of multilobulated cystic structure in the
right adnexa.
This can be further assessed with pelvic ultrasound. Adjacent
hyperdense round
structure in the right hemipelvis may reflect a fibroid arising
from the
hysterectomy cuff.
4. Unremarkable appearance of the transplant kidney in the
right lower
quadrant and transplant pancreas in the left lower quadrant,
though assessment
is limited on this non-contrast study.
5. Moderate fecal loading throughout the colon.
6. Extensive vasculopathy.
discharge labs:
Brief Hospital Course:
___ year old female with history of ESRD s/p pancreas and kidney
transplant x2 with stage V CKD on active transplant list,
chronic systolic heart failure ___ ischemic cardiomyopathy s/p
CABG and MVR, chronic pleural effusions s/p VATS and
pleurectomy, hx of chronic abdominal pain with hx of pneumatosis
intestinalis, presented with new onset abdominal pain, resolved
with bowel regimen and subsequent bowel movement.
# Abdominal pain: Patient described pain to be subjectively
similar to her pneumatosis intestinalis pain from her prior
admission in ___. However, final read of CT scan here did not
show any evidence of it; instead, it showed fecal loading
suggesting constipation. Levofloxacin and flagyl were
discontinued because of benign abdominal exam. Gastroenterology
service was consulted because of history of pneumatosis. Celiac
serologies were sent, which were negative. H pylori serologies
were sent, which were pending on discharge. Patient was
initiated on aggressive bowel regimen and had large bowel
movement during hospital day 2. Her nausea as well as abdominal
pain resolved. Patient was discharged with close follow up.
# End stage renal disease secondary to FSGS, s/p pancreas/kidney
transplant x 2 (___): Patient's creatinine was at
baseline. She was noted to be on triple immunosuppression with
Bactrim, Prograf, and rapamune. These were continued with
goals, per Dr. ___ sirolimus ___ and tacro < 5.
Patient was within target during the admission. Bactrim and
ranitidine were continued.
# Pleural effusion s/p VATS/pleurectomy: She has chronic
bilateral pleural effusions, noted on exam and imaging. Patient
did not have any oxygen requirement or shortness of breath, and
did not require further workup during the admission.
# Chronic systolic heart failure with MVR: EF 30% in ___. Likely secondary to ischemic cardiomyopathy s/p MI with
subsequent CABG and MVR. No evidence on admission for a heart
failure exacerbation at this point. However, patient was noted
to have a supratherapeutic INR on admission (to 4.0; patient's
goal is ___, likely because of fluoroquinolone use. Warfarin
was held. One dose of 2 mg was administered on ___ because of
an INR drifting down towards therapeutic range. Patient was
discharged with instructions to HOLD further coumadin dosing and
to follow up with her PCP shortly after discharge for further
management. Continued ASA.
# Hypertension: Continued carvedilol
# Hyperlipidemia: Continued rosuvastatin
PENDING LABS:
- h. pylori serologies
TRANSITIONAL ISSUES:
- Patient is on tacrolimus and rapamycin, and these should be
titrated to goal levels
- Patient is on warfarin, and plan (per discussion with PCP) is
for patient to hold warfarin until being called by PCP ___ ___
- Long standing adnexal mass should be followed
- H. pylori serology pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Senna 2 TAB PO DAILY
4. Warfarin 5 mg PO 2X/WEEK (MO,FR)
5. Epoetin Alfa 40,000 units/ml SC QWEEK Start: HS
6. Ranitidine 150 mg PO BID
7. Rosuvastatin Calcium 10 mg PO DAILY
8. Sirolimus 1 mg PO DAILY
Daily dose to be administered at 6am
9. Tacrolimus 0.5 mg PO Q12H
10. Torsemide 100 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Aspirin 81 mg PO DAILY
13. Warfarin 2.5 mg PO 2X/WEEK (WE,TH)
14. Warfarin 6 mg PO 3X/WEEK (___)
15. paricalcitol *NF* 1 mcg Oral daily
16. Vitamin D 50,000 UNIT PO QMONTH
17. Sulfameth/Trimethoprim SS 1 TAB PO MWF
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Epoetin Alfa 40,000 units/ml SC QWEEK
4. Multivitamins 1 TAB PO DAILY
5. PredniSONE 5 mg PO DAILY
6. Rosuvastatin Calcium 10 mg PO DAILY
7. Senna 2 TAB PO DAILY
8. Sirolimus 1 mg PO DAILY
Daily dose to be administered at 6am
9. Sulfameth/Trimethoprim SS 1 TAB PO MWF
10. Tacrolimus 0.5 mg PO Q12H
11. Torsemide 150 mg PO BID
12. paricalcitol *NF* 1 mcg Oral daily
13. Vitamin D 50,000 UNIT PO QMONTH
14. Polyethylene Glycol 17 g PO QHS Duration: 10 Days
RX *polyethylene glycol 3350 17 gram 17 grams by mouth Daily
Disp #*1 Bottle Refills:*0
15. Ranitidine 150 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, NOS
ESRD ___ kidney and pancreas transplant
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
___ because of acute on chronic abdominal pain and discomfort
accompanied by nausea. You had been on antibiotics as an
outpatient for a potential intra-abdominal process.
In house, we managed you conservatively by discontinuing your
antibiotics, encouraging oral intake, start a bowel regimen, and
following your clinical status. We performed a CT scan which did
not show evidence for an acute process and there was no evidence
of pneumatosis, which has been an issue in the past for you. We
also asked our gastroenterology specialists to see you as well,
who recommended that you start taking miralax every day for 10
days to ensure that your constipation has completely resolved.
Since you usualy have 4 small bowel movements daily, we
recommend that if you have more than 4 large bowel movements in
one day, stop taking this medication for one day. 7 days from
now (___) you may start taking this medication only as
needed for constipation.
Your INR was high (4.0) and warfarin (coumadin) was stopped. We
discussed with your ___ care provider Dr ___ will
call you tomorrow (___) and discuss your warfarin dosing.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please resume your home medications as prescribed with the
following exceptions:
- DISCONTINUE Levofloxacin
- DISCONTINUE Metronidazole
- DISCONTINUE Warfarin
Followup Instructions:
___
|
19759491-DS-34
| 19,759,491 | 27,958,855 |
DS
| 34 |
2193-04-10 00:00:00
|
2193-04-18 19:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Adhesive / percocet percodan dilaudid
Attending: ___
Chief Complaint:
low-grade temp, whole body pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with ESRD on HD (s/p kidney panc tx ___, DDRT ___ with ___
panc tx, now with failure of renal tx) and recent admission with
fever and malaise presents with fever of 99.6F and whole body
pain. Pt reports onset of pain all over, including legs, hands,
neck, head and back starting today after returning from HD this
AM. She reports no particular area more painful than others. She
reports she has had body aches all over in the past when having
flu-like illness, but milder in the past. She reports diffuse
abdominal pain, same as that during recent admission started 2
nights ago. She reports it would occur when lying down to go to
sleep at night and would keep her awake overnight. She reports
the pain would improve in the AM and was not present during the
day. She reports today the pain was all day associated with her
whole body pain. She reports Tmax of 99.6 today after returning
home from HD. She reports chills today. She makes minimal urine
(~1cup daily) and has no associated dysuria. She reports nausea
this AM with emesis x1. She denies diarrhea, reports last BM
this afternoon was normal. No cough, CP, SOB, photophobia,
confusion, rashes, pain at HD or PD cath site. No sore throat,
congestion or sick contracts.
She reports she restarted her Coumadin on ___ at 6mg, then 5mg
on ___, then 4mg on ___. She was using lovenox 30mg daily on
___ and ___ because of an INR of 1.9 on ___.
On interview in ED, pt has elevated BP and HR secondary to pain,
which responded to 5 mg IV morphine. Prior to morphine pain was
in her head, neck (although able to touch chin to chest), arms,
abdomen and legs. Describes upper abdominal pain that cannot be
further localized. Denies specific chest tightness, SOB. Pt says
that 51.8 down to 50.8, base wt 51.
Pt recently admitted ___ for fever. Tm to 100.6 during adm.
No localizing symptoms of infection though report of abd pain.
Pt has no evidence of SBP based on peritoneal fluid cell count.
CXR neg. Pancreatic U/S normal. Ucx no growth. Treated with vanc
and cefepime and narrowed to cephalexin 500mg po q12 (HD dosing)
for possible superficial peritoneal catheter site infection,
plan total 7d course. Pt with periumbilical abd pain during
admission. Pain improved with increased bowel reg. Pt does not
have mesenteric ischemia per formal vascular studies in ___, although the celiac, hepatic, and splenic arteries and SMV
were not visualized due to extensive overlaying bowel gas.
Lactate and LDH were all normal.
In the ED, initial vs were: 98.7 97 153/73 18 98% ra. On exam no
tenderness to palpation around HD or PD catheter. Per transplant
surgery, PD cath site does not appear infected. Unable to
appreciate any ascites on exam. Left leg is swollen relative to
right, pt states this is chronic since saphenous vein graft
harvest. Labs were remarkable for WBC count of3.9, Hct 27.7,
plt217, BUN/Cr ___, K4.3, lactate 1.4, INR 6.7. Patient was
given 2.5 PO vit K and 5mg IV morphine. DDx included concern for
catheter infection, transplant rejection, low flow state post
fluid removal with HD causing ? transient mesenteric ischemia.
Renal transplant and transplant surg consulted. Vitals on
Transfer: 78 130/73 18 100%.
Renal transplant consult:
___ with ESRD on HD (s/p kidney panc tx ___, DDRT ___ with ___
panc tx, now with failure of renal tx) and recent admission with
fever and malaise presents with low grade temps and abdominal
pain- these were not well explained during last admission which
involved elaborate workup. Agree with infectious workup for now,
particularly if becomes febrile. Pain control as needed. Labs
reassuring, no acute HD need. Will see in AM.
Transplant surg consult:
Pt is s/p pancreas/kidney transplant 10+ years ago, recent lap
PD catheter; no e/o infection, abdomen remains soft. Labwork
notable for INR >6, but no leukocytosis. Admit to medicine, f/u
blood cx, can send peritoneal cx but likely low yield.
On the floor, pt is without complaints. Reports no pain after IV
morphine in the ED. No nausea, no abd pain. Overnight, she
received one dose of morphine 2mg iv x 1 at 3am. She states that
she feels very well and has no pain but is frustrated at why she
keeps having "fevers" (Tmax 99.6), and
Review of sytems:
(+) Per HPI
Past Medical History:
- End stage renal disease secondary to FSGS, s/p pancreas/kidney
transplant (___), then a DDRT in ___ followed by a separate
pancreas transplant that year; currently listed at ___ and
___ for re-transplantation
- Systolic heart failure (EF 25% in ___, s/p BiV ICD
placement ___
- Coronary artery disease s/p CABG ___ (LIMA to LAD, rSVG
to pLVCA, rSVG to PDA)
- Mitral Regurgitation s/p mechanical MVR (On-X Conform-X)
___
- NSTEMI in ___ s/p PDA stenting (___) and DES x2 to RCA
(___).
- Possible Mesenteric Ischemia
- Pleural effusion s/p VATS/pleurectomy ___
- Dyslipidemia
- Hypertension
- Diabetes mellitus type 1 (prior to pancreas transplant)
- PVD s/p R femoral-anterior tib bypass graft
- Chronic Anemia
- menorrhagia s/p vaginal hysterectomy ___
- Charcot R foot
PAST SURGICAL HISTORY
- s/p simultaneous pancreas-kidney transplant in the ___
followed by a repeat renal transplant (___) and repeat
pancreas transplant (___)
- s/p retinal detachment and enucleation of left eye
- s/p D & C (___)
- s/p Hysterectomy (___)
- s/p TMJ surgery
- s/p CABG/MVR ___
- s/p R femoral-anterior tib bypass graft ___
Social History:
___
Family History:
Mother has history of CAD. No family Hx of DM. MGM had HTN but
lived to be ___. MGF had a CVA in his ___. Her father had RA that
was complicated by restrictive lung disease. PGF had renal
disease. PGM had small bowel CA in her ___.
Physical Exam:
PHYSICAL EXAM on admission:
Vitals: 98, 88, 146/70, 20, 100% 3L NC
General: thin, middle-aged woman, lying in bed, in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, full ROM without meningismus; R IJ HD line
nontender
CV: RRR with rate in ___, systolic murmur, mechanical S1
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi; breathing comfortably without accessory muscles
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound/guarding, PD catheter under sterile dressing
Ext: Warm, well perfused, ___ > LLE, no edema, ___ with medial
longitudinal scar
Skin: no rashes
Neuro: grossly intact
Physical exam on discharge:
Vitals: Tm 99.6F, 120-146/68-76, 91-98, 18, 95% RA
No BMs
General: thin, middle-aged woman, lying in bed, in NAD
Lungs: reduced breath sounds on R
Abd: soft, non-tender, normal bowel sounds
Ext: R > L pedal edema, normal pulses
Pertinent Results:
Labs on admission:
___ 06:05PM BLOOD WBC-3.9* RBC-3.17* Hgb-8.1* Hct-27.7*
MCV-88 MCH-25.6* MCHC-29.2* RDW-17.6* Plt ___
___ 06:05PM BLOOD Neuts-77.6* Lymphs-15.1* Monos-5.5
Eos-1.1 Baso-0.7
___ 07:52PM BLOOD ___ PTT-49.0* ___
___ 06:05PM BLOOD Glucose-102* UreaN-16 Creat-2.0*# Na-140
K-4.3 Cl-102 HCO3-23 AnGap-19
___ 06:05PM BLOOD CK(CPK)-34
___ 05:45AM BLOOD CRP-43.5*
___ 05:45AM BLOOD ESR-20
___ 05:45AM BLOOD Lipase-62*
OTHER BODY FLUID ANALYSIS WBC RBC Polys Lymphs Monos Macro
___ 17:30 31* 905* 10* 72* 0 18*
PERITONEAL DIALYSATE
Micro:
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ Immunology (CMV) CMV Viral Load-FINAL not
detected
___ DIALYSIS FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL
___ URINE URINE CULTURE-FINAL - MIXED BACTERIAL
FLORA
Radiology:
___ Imaging ABDOMEN (SUPINE & ERECT
2 supine abdominal radiographs were obtained. There are no
abnormally dilated loops of small or large bowel. There is no
free air. A peritoneal dialysis catheter is in the right lower
quadrant. Ascities outlines the liver contour. There is
moderate femoral acetabular degenerative disease. There is no
concerning lytic or sclerotic bone lesion. Pacing leads, aortic
valve replacement, and sternal wires are in appropriate
positions. IMPRESSION: Nonobstructive bowel gas pattern.
___ Imaging CHEST (PA & LAT)
New left lower lobe infiltrate and effusion.
___ Imaging CTA ABD & PELVIS
CT ABDOMEN: A 5 mm hypodensity is visualized in hepatic segment
VIII, which is too small to fully characterize by CT but likely
represents a biliary hamartoma or cyst. A region of peripheral
wedge-shaped hyperattenuation in hepatic segment VIII does not
persist into the delayed phases and is likely perfusion anomaly.
The liver otherwise enhances homogeneously without worrisome
focal lesion or intra- or extra-hepatic biliary duct
dilatations. The gallbladder is thin-walled and unremarkable.
The spleen and adrenal glands are unremarkable in appearance.
The pancreas is significantly atrophied but otherwise
unremarkable. Bilateral native kidneys are again severely
atrophied with dense vascular calcifications within. The
stomach, duodenum and small bowel are unremarkable in appearance
without focal wall thickening or evidence of obstruction. The
large bowel has a moderate amount of fecal load, but is
otherwise unremarkable. Both, small and large bowel wall
enhances homogeneously without evidence of ischemia. An
enteroenteric anastomosis is seen in the left hemiabdomen
without evidence of obstruction at this point. The abdominal
aorta is of normal caliber with prominent dense mural
atherosclerotic calcifications along its entire length and
extending to all branch vasculature. Despite significant
vascular calcifications, on post-contrast images there does not
appear to be significant flow-limiting stenosis, with preserved
distal opacification and blood flow. There is no mesenteric or
retroperitoneal lymphadenopathy. There is no ascites,
pneumoperitoneum or frank herniation. CT PELVIS: A
transplanted kidney is noted in the right lower quadrant, which
enhances homogeneously without focal lesion or hydronephrosis.
Transplanted pancreas is noted in the upper pelvis and enhances
homogeneously without focal lesion or ductal dilatation. A
peritoneal dialysis catheter inserts in the left lower quadrant
abdominal wall with the tip extending and ending within the
lower pelvis. The bladder and rectum are unremarkable in
appearance. The uterus is surgically absent. There is a 3.7 x
2.9 cm cystic structure in the right adnexa. There is no free
pelvic fluid or air. There is no inguinal or pelvic wall
lymphadenopathy by CT size criteria. OSSEOUS STRUCTURES:
There is no focal blastic or lytic lesions in the visualized
osseous structures concerning for malignancy. IMPRESSION: 1.
Dense atherosclerotic calcification of the abdominal aorta and
branch vasculature which remain patent on post-contrast phases.
No flow-limiting stenosis. 2. No evidence of enteric pathology,
without evidence of bowel ischemia. 3. Right adnexal cystic
lesion which should be further evaluated by ultrasound. 4.
Right greater than left pleural effusion. 5. Prominently
atrophied native kidneys. Normal-appearing transplant kidney
and pancreas. 3D reconstructions were not available at time of
dictation. These will be reviewed, and if there are changes in
interpretation, these will be reflected on a further addendum.
Discharge labs:
___ 07:10AM BLOOD WBC-4.6 RBC-3.18* Hgb-8.3* Hct-27.7*
MCV-87 MCH-26.3* MCHC-30.1* RDW-18.1* Plt ___
___ 07:30AM BLOOD ___ PTT-72.3* ___
___ 07:10AM BLOOD Glucose-81 UreaN-34* Creat-4.0*# Na-135
K-4.5 Cl-95* HCO3-27 AnGap-18
___ 07:10AM BLOOD Calcium-9.8 Phos-3.7 Mg-2.7*
___ 07:30AM BLOOD tacroFK-5.0 rapmycn-4.7*
Brief Hospital Course:
___ year old female with a history of T1DM and ESRD ___ FSGS s/p
failed transplant in ___ and separate DDRT and DDPT in ___,
CHF s/p resynchronization with BiV ICD on ___, s/p R IJ
tunneled HD cath on ___ and lap PD catheter on ___ who
presents w/ chronic abdominal pain.
# Diffuse abd pain: pt with similar pain last admission with
workup unrevealing other than possible constipation. Pain mostly
nocturnal and during day today after HD. Etiology remains
unclear. Pt without pain on admission after morphine in the ED.
DDx includes constipation, ischemia after HD, transplant
rejection. No signs currently of PD line infection. Repeat
peritoneal dialysate cell count showed 31 WBCs, 905 RBCs, 10
PMNs, cultures negative. CMV viral load not detectable. Pt was
seen by GI service, who felt that Pt may have some element of
ischemia when hypotensive given extensive calcifications. GI
recommended increased bowel regimen, metoclopromide for nausea /
vomiting, and outpatient EGD if Pt remains symptomatic to r/o
gastritis / PUD. Peritoneal cultures negative. Pt was also seen
by pain service, who made several recommendations (see below).
Pt continued to have abdominal discomfort, though not pain with
morphine PR and acquiesed to CTA abdomen to definitively examine
mesenteric ischemia. CTA abdomen did not actually show any
definitive evidence of mesenteric ischemia. Specifically,
radiology felt pt had "dense atherosclerotic calcification of
the abdominal aorta and branch vasculature which remain patent
on post-contrast phases. No flow-limiting stenosis. No evidence
of enteric pathology, without evidence of bowel ischemia." Pt
did have significant fecal loading on CT, which was also seen on
non-contrast CT abdomen when she was previously admitted for
similar symptoms. Taken together, her abdominal pain is most
likely due to chronic constipation. Pt was confused regarding
her symptoms of diarrhea, and it was explained to her that
sometimes patients suffer from liquid loose bowel movements when
they are actually constipated. She was discharged on an
aggressive bowel regimen and Pt was instructed to use tap water
enemas if she is not having at least one large bowel movement
every day.
# pain control regimen: Pt is very belligerent and states
repeated that she "cannot take any oral pain medication." She
insists that she can only take IV medications, mainly IV
morphine and states that her other doctors told ___ that she
should "go to the ER" whenever she has pain for pain
medications. She completely refuses to try any oral pain
medications, stating that it will make her nauseated. She has
also refused acetaminophen, which she reports taking at home for
pain. She is upset that her morphine is diluted in 50mL NS and
run over 15 minutes rather than given as IV push. Pain seems to
be better by ___, but then worse again ___. Pt remained
very belligerent and abusive toward staff. Pt was seen by
chronic pain service, who recommended trial of tapentadol (a
combination SSRI / opiate) at 50mg po tid prn pain. This
medication is expected to have fewer nausea / vomiting
side-effects than pure opiate, but this med is not available in
hospital. Also recommended to take methadome 2.5mg po bid but Pt
reported excessive drowsiness. Her methadone was therefore
stopped, but kept morphine suppositories ___ PR q6 hrs PRN.
Discussed with her local ___ pharmacy in ___, who said
that they would definitely be able to supply. She was discharged
on this medication in addition to her gabapentin 100mg po daily.
Additionally, the cause of her abdominal pain is likely to be
worsening constipation as explained above, and she was
discharged on a strong bowel regimen and instructions to use tap
water enemas as needed to have a bowel movement daily. In the
future, she should be preferentially given morphine 5mg PR if
she is having similar pain and avoid IV morphine.
# Supratherapeutic INR: INR of 6.7 in the ED s/p 2.5mg PO
vitamin K. No clear indication for reversal but now will have to
monitor closely for subtherapeutic INR given mechanical valve.
INR initially down to 4.3 on ___, then back up to INR 6.1 on
___, INR 7.5 on ___, most likely due to levofloxacin
administration. INR corrected to 3.2 on ___, Pt was dosed
with 1mg warfarin, but INR down to 2.0 on ___, dosed 2.5mg
warfarin and increased to 2.1 on ___. Dosed w/ 4mg warfarin
and INR increased to 3.7. Pt was discharged on 2mg po warfarin
for the next two days w/ INR checks every ___,
___ as previously and managed per ___ clinic.
# Low grade temp: Tmax 99.6 at home. Not a true fever and no
clear infectious source other than whole body pain. This could
be representative of a viral illness with myalgias. Pt currently
without pain so difficult to assess. Pt with abdominal pain that
has been worked up. No signs of infection around HD line and PD
line per surgery assessment. Pt finished course of Cephalexin
yesterday for empiric treatment of possible superficial skin
infection around PD catheter. Repeat CMV viral load
undetectable. Chest XR w/ new LLL infiltrate in comparison to
CXR from last week. Pt completed course of azithromycin for
possible pneumonia.
# possible pneumonia: Pt with good O2 sat but new LLL infiltrate
on chest XR relative to prior XR from 1 week ago. Pt reports
having a chronic mild cough since ___ after her ICD
placement. She has no leukocytosis or fever. However, Pt is
reporting some non-specific malaise. Although this would
technically be considered a hospital-acquired pneumonia, given
her absence of symptoms, Pt was initially treated w/
levofloxacin, but switched to azithromycin on ___ due to
interaction w/ warfarin. She completed a 5 day course without
issue.
# Pleural effusions: Pt was incidentally found to have pleural
effusions R > L on her CT abdomen. This also noted on chest XR
previously but seems to small to moderate based on CT scan. Pt
was completely asymptomatic and per patient preference, we
deferred diagnostic thoracentesis, but instructed Pt to have a
follow-up chest XR in ___ weeks. If the effusion increases in
size or does not resolve, we suggested that the patient have
diagnostic thoracentesis to rule out exudative process.
# Adnexal mass: Pt was incidentally found to have R adnexal
cystic lesion ~ 3 x 4 cm, which was previously noted on a
non-contrast CT. Pt states that she has known about this lesions
for many years, ever since her hysterectomy. She reports that
she was told by her gynecologist that it was benign and that she
could have it removed if it ever became bothersome. Its size
appears to have remained unchanged over several years based on
her description. Pt deferred further workup for now, stating
that she preferred to speak with her gynecologist. We reiterated
the importance of her following through with this and suggested
that she see her gynecologist soon and may need additional
imaging or more invasive testing if her gynecologist were
concerned.
CHRONIC ISSUES:
# Mitral Regurgitation s/p mechanical MVR: INR goal ___.
Anticoagulation as above.
# ESRD s/p pancreas and kidney transplant: Worsening renal
function ___ chronic allograft nephropathy. Now on HD ___.
Continued home tacrolimus, sirolimus, prednisone, sevelamer
carbonate, nephrocaps, sulfameth/trimethoprim for ppx. Tacro
levels were appropriately therapeutic.
# Anemia: Hct 27.7 on admission, close to recent levels.
# CAD s/p CABG, HLD: cont home aspirin, rosuvastatin.
# Hypertension: on home carvedilol w/ HD
TRANSITIONAL ISSUES:
-Needs repeat chest XR in ___ weeks to document resolution or
improvement of pleural effusions. If not improving, may need
diagnostic thoracentesis to rule out exudative process.
-Needs follow-up regarding R adnexal cyst. Pt preferred to speak
with her prior gynecologist, but she may need additional imaging
or invasive testing.
-close monitoring of INR as before given mechanical mitral valve
and previously fluctuating INR
Medications on Admission:
3The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Nephrocaps 1 CAP PO DAILY
3. Polyethylene Glycol 17 g PO DAILY
This is the same as Miralax.
4. PredniSONE 5 mg PO DAILY
5. Rosuvastatin Calcium 10 mg PO DAILY
6. Sarna Lotion 1 Appl TP QID:PRN pruritis
7. Senna 2 TAB PO BID
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. Sirolimus 1 mg PO DAILY
10. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
11. Tacrolimus 1 mg PO Q12H
12. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
13. Temazepam 15 mg PO HS:PRN insomnia
14. Vitamin D 1000 UNIT PO DAILY
15. Warfarin 4 mg PO DAILY16
16. Carvedilol 3.125 mg PO NON-HD DAYS if SBP >125
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Nephrocaps 1 CAP PO DAILY
3. Polyethylene Glycol 17 g PO DAILY
4. PredniSONE 5 mg PO DAILY
5. Rosuvastatin Calcium 10 mg PO DAILY
6. Sarna Lotion 1 Appl TP QID:PRN pruritis
7. Senna 2 TAB PO BID
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. Sirolimus 1 mg PO DAILY
10. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
11. Tacrolimus 1 mg PO Q12H
12. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
13. Vitamin D 1000 UNIT PO DAILY
14. Carvedilol 3.125 mg PO NON-HD DAYS if SBP >125
15. Temazepam 15 mg PO HS:PRN insomnia
16. Gabapentin 100 mg PO DAILY
RX *gabapentin 100 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
17. Warfarin 2 mg PO DAILY16
take 2mg on ___, then INR check on ___ and await ___
___ clinic instructions
18. Morphine Sulfate 5 mg PR Q6H:PRN severe pain
RX *morphine 5 mg 1 Suppository(s) rectally q6 hours Disp #*45
Suppository Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
community acquired pneumonia
chronic constipation
end-stage renal disease with failed renal transplant on
hemodialysis
type 1 diabetes w/ pancreatic transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital because you had malaise and pain. You
may have a mild pneumonia (infection of your lung). You were
treated with antibiotics. We had the gastroenterology and pain
services see you for your abdominal pain, and made
recommendations. Your pain was well-controlled with rectal
morphine suppositories, and you did not experience any nausea or
vomiting with this medication, which you previously experience
with oral opiate pain killers. Your abdominal pain was most
likely caused by constipation. Your CT scan with contrast did
not show convincing evidence of mesenteric ischemia. We
therefore recommend a strong daily bowel regimen (Miralax ___
packets daily, two tabs of senna twice daily) and tap water
enemas as needed to have regular bowel movements.
Your INR, a measure of your blood clotting, was initially
elevated, and then too low. We gave you appropriate medications
to get your INR in the goal range of 3.0-3.5. You should take
your warfarin at 2mg daily for the next two days and then have
your INR checked on ___ as you previously were. The
___ clinic will be in touch with you regarding your
dosing.
There are two issues that you should follow-up with your other
providers.
1) You have a collection of fluid around your right lung.
Because this was seen previously on your chest X ray and you
were not symptomatic, this fluid was not analyzed. You should
have a repeat chest X-ray with your primary care physican in ___
weeks to evaluate the degree of this fluid. If it is increasing,
you may need to have this fluid analyzed, which you should
discuss with your PCP.
2) You have an adnexal (pelvic) cystic lesion of ~2 inches in
size. You mentioned that this chronic and that you knew about it
since your prior pelvic operation many years ago. You preferred
to follow-up with your gynecologist. We suggest that you discuss
this lesion with your gynecologist and determine whether you
need any additional imaging, such as an ultrasound.
Followup Instructions:
___
|
19759491-DS-43
| 19,759,491 | 22,470,178 |
DS
| 43 |
2194-07-16 00:00:00
|
2194-07-20 14:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Adhesive / percocet / sirolimus / Neomycin /
Dilaudid
Attending: ___.
Chief Complaint:
Dizziness complicated by chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with ESRD ___ failed renal transplants x2 now
on MWF HD, DMI ___ 2 pancreatic transplants (not on insulin),
CAD ___ CABG, CHF ___ pacemaker/ICD with an EF 35% ___, and
MR ___ mechanical MV replacement on warfarin now presenting with
several days of dizziness in setting of starting pregabalin and
new onset chest pain.
The patient reports that she was in her usual state of health
until several days prior to admission when she started getting
lightheadedness and dizziness with standing and feeling unsteady
while walking. She was recently started on lyrica and associates
taking it with the onset of her lightheadedness. Thus she
discontinued lyrica on ___ (about 4 days prior to
presentation). Of note, she had a recent admission in ___ with similar pre-syncopal sx and was found to have
signficant anemia with hgb of 5 and iNR of 15. She was afraid
that this was a similar presentation and went to the emergency
department.
At the OSH CT head was negative, labs were unremarkable except
for Cr in the 7s and INR 3.8. She was transferred to ___ given
her hx of transplant.
On transfer from ___ to ___ she started experiencing chest
pain. She describes the pain as spanning across her whole chest
and her chest being ___ to touch.
In the ED initial vitals were: 98.4 85 161/72 20 92%
- exam was notable for brown guiac positie stool
- Labs were significant for, wbc of 3.9, K of 6.1 ( although
hemolyzed), trop of 0.05, AST of 84 alkp 154 (again hemolyzed),
and INR of 3.5
- Preliminary CXR read was notable for Left retrocardiac opacity
concerning for pneumonia; bedside ultrasound shoed no evidence
of cardiac effusion
- Patient was given Ondansetron 4 mg IV ONCE , Morphine Sulfate
5 mg IV ONCE MR1, Morphine Sulfate 2 mg IV ONCE ,Pantoprazole 40
mg IV ONCE and Vanc/levofloxacin for suspected PNA.
On the floor, the patient continues to complain of chest pain,
and dizziness. Also reported having nausea. Also complaining of
her chronic hand pain which she reports is from neuropathy. She
denies any cough or dyspnea
Past Medical History:
# End stage renal disease secondary to FSGS, ___ pancreas/kidney
___, then a DDRT in ___ followed by a separate
pancreas transplant that year; currently listed ___
___ for kidney re-transplantation (not being
recommended for re-listing at ___, hemodialysis dependent
___.
# Systolic heart failure (EF 35% ___, ___ BiV
pacemaker/ICD placement ___.
# Coronary artery disease ___ CABG ___ (LIMA to LAD, rSVG
to pLVCA, rSVG to PDA)
# Mitral Regurgitation ___ mechanical MVR (On Warfarin)
# NSTEMI in ___ ___ PDA stenting (___) and DES x2 to RCA
___
# Mesenteric Ischemia
# Pleural effusion ___ VATS/pleurectomy ___
# Dyslipidemia
# Hypertension
# Diabetes mellitus type 1 (prior to pancreas transplant)
# PVD ___ R femoral-anterior tib bypass graft
# Chronic Anemia
# Menorrhagia ___ vaginal hysterectomy ___
# Charcot R foot
.
PAST SURGICAL HISTORY
# ___ simultaneous pancreas-kidney transplant in the mid ___
followed by a repeat renal transplant (___) and repeat
pancreas transplant (___)
# ___ retinal detachment and enucleation of left eye
# ___ D & C (___)
# ___ Hysterectomy (___)
# ___ TMJ surgery
# ___ CABG/MVR ___
# ___ R femoral-anterior tib bypass graft ___
Social History:
___
Family History:
Mother has history of CAD. No family Hx of DM. MGM had HTN but
lived to be ___. MGF had a CVA in his ___. Her father had RA that
was complicated by restrictive lung disease. PGF had renal
disease. PGM had small bowel CA in her ___.
Physical Exam:
EXAM ON ADMISSION:
Vitals: 98.5 127/65 94 18 955 RA
weight 56.7 kg
GENERAL: thin woman moaning in bed
HEENT: prostehtic left eye, EOMI,anicteric sclera, no nystagmus
with gaze
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: mechanical S1 S2; TTP along left anterior wall
LUNG: crackles bilaterally
ABDOMEN: soft non-tender non-distended
EXTREMITIES: 2+ pitting edema to the ankles; left foot wrapped
in kerlex (per pt has 2 healing ulcers; did not want bandage
removed)
Neuro: AOx 3, MAE, no nystagmus appreciated with lateral gaze;
pt deferred walking to asses ataxia; intact finger to nose and
RAM
Skin: right tunneled HD line
_
________________________________________________________________
EXAM ON DISCHARGE:
Vitals: T: 98.2 BP: 136/60 P: 88 R: 18 O2: 98%RA
General: Alert, oriented
Neck: refusing exam as patient says she is leaving the hospital
today
Lungs: refusing exam as patient says she is leaving the hospital
today
CV: refusing exam as patient says she is leaving the hospital
today
Abdomen: refusing exam as patient says she is leaving the
hospital today
Skin: refusing exam as patient says she is leaving the hospital
today
Pertinent Results:
LABS ON ADMISSION
___ 12:06AM BLOOD WBC-3.9* RBC-3.32* Hgb-10.9* Hct-33.8*
MCV-102* MCH-33.0* MCHC-32.4 RDW-17.2* Plt ___
___ 12:06AM BLOOD Neuts-76.5* Lymphs-16.2* Monos-6.2
Eos-0.8 Baso-0.3
___ 12:06AM BLOOD ___ PTT-50.1* ___
___ 12:06AM BLOOD Glucose-86 UreaN-78* Creat-7.8*# Na-137
K-7.3* Cl-97 HCO3-25 AnGap-22* (hemolyzed sample)
___ 12:06AM BLOOD ALT-23 AST-84* CK(CPK)-71 AlkPhos-154*
TotBili-0.2(hemolyzed sample)
___ 12:06AM BLOOD Lipase-81* (hemolyzed sample)
___ 12:06AM BLOOD cTropnT-0.05*
___ 12:21PM BLOOD Calcium-9.2 Phos-3.2 Mg-3.5*
___ 12:06AM BLOOD Albumin-3.5
___ 01:41AM BLOOD Lactate-1.6 K-6.1* (hemolyzed sample)
.
LABS ON DISCHARGE
___ 06:05AM BLOOD WBC-2.5* RBC-2.88* Hgb-9.5* Hct-29.5*
MCV-102* MCH-32.8* MCHC-32.0 RDW-16.8* Plt ___
___ 06:05AM BLOOD WBC-2.5* RBC-2.88* Hgb-9.5* Hct-29.5*
MCV-102* MCH-32.8* MCHC-32.0 RDW-16.8* Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD Glucose-97 UreaN-22* Creat-3.8*# Na-142
K-3.8 Cl-98 HCO3-33* AnGap-15
___ 06:05AM BLOOD Amylase-120*
___ 01:20PM BLOOD CK-MB-3 cTropnT-0.07*
___ 12:21PM BLOOD CK-MB-3 cTropnT-0.07*
___ 06:05AM BLOOD tacroFK-8.2
IMAGING
- ___ CHEST (PA & LAT):
A pacemaker defibrillator with right atrial and biventricular
leads is again noted in unchanged position. A right internal
jugular approach dialysis catheter present with tip in the right
atrium. An aortic valve replacement is also noted. The patient
is status post CABG. There is moderate cardiomegaly. The
mediastinal and hilar contours are stable with aortic
calcifications There is no pleural effusion or pneumothorax. The
lungs are well-expanded with increased interstitial markings,
consistent with mild edema. There is no focal consolidation
concerning for pneumonia.
- ___ EKG: V-paced, TWI in lateral leads I, AVL, V4, V5
(seen on prior); no acute ischemic changes.
Brief Hospital Course:
___ year old female with ESRD ___ failed renal transplants x2 now
on MWF HD, DMI ___ 2 pancreatic transplants (not on insulin),
CAD ___ CABG, CHF ___ pacemaker/ICD with an EF 35% ___, and
MR ___ mechanical MV replacement on warfarin presenting with
persistent dizziness for several weeks as well as Chest pain.
# Dizziness: Patient associates onset of dizziness with
initiation of pregabalin for chronic hand pain and that it was
worse with standing. Further history and characterization of the
problem was difficult due to the patient not wanting to
participate in a collaborative decision making process.
Pregabalin was stopped 3 days before admission and it is cleared
by dialysis. At the time of discharge she stated that she was
feeling better and not lightheaded when standing. She did not
allow the team to perform orthostatics. However, EKG and
telemetry for 48 hours did not show any arrythmias or blocks or
uncaptured pacemaker beats that would explain the presyncope.
# Chest Pain: Began to ocurr en route from outside hospital to
___. When she arrived the was treated with IV morphine in the
ED and admitted to the floor. EKG showed a paced rhythm with no
Scarbossa criteria. Troponins were elevated at 0.07 and remained
stable x 3 in the setting of ESRD. Pain resolved with tramodol
and did not return after her first dose. She was ___ free at
discharge and had no events on telemetry.
# ESRD.Status-post 2 failed renal transplants, on HD with MWF
schedule. She was mildly hyperkalemic to 6.1 on admission
although sample was slightly hemolyzed. Consulting with
Nephrology Transplant/Dialysis service. Under went 2 sessions
of HD while hospitalized.
# Diabetes melitus type 1. ___ functional pancreas transplant.
Not on insulin. Home tacrolimus and prednisone were continued.
Did not obtain accurate troughs of tacro due to patient refusing
blood draws. Lipase and amylase monitored.
# Chronic hand pain: Chronic hand pain likely neurologic in
nature. Continued her home lidocaine patches.
# Mechanical mitral valve replacement. INR supratherapeutic on
arrival at 3.7 Warfarin decreased to 3mg on HD #1. Was 2.3 on
discharge after restarting on 5mg daily (home dose) the day
before. Goal 2.5-3.5. Was bridged with Lovenox on discharge
until another INR drawn during next HD session.
# CHF: Pulmonary edema on CXR on arrival. Went to HD that
morning and 1L of ultrafiltrate taken off to get back to dry
weight of 51.1Kgs. Satting well and breathing without difficulty
on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES PRN eye dryness
2. Aspirin 81 mg PO DAILY
3. Collagenase Ointment 1 Appl TP DAILY
4. Nephrocaps 1 CAP PO DAILY
5. sevelamer CARBONATE 2400 mg PO TID W/MEALS
6. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
7. Tacrolimus 2 mg PO Q12H
8. Temazepam 15 mg PO HS:PRN insomnia
9. Warfarin 5 mg PO DAILY
10. Lidocaine 5% Patch 2 PTCH TD QPM pain
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
12. PredniSONE 5 mg PO DAILY
13. Omeprazole 40 mg PO DAILY
14. Epoetin Alfa 6600 UNIT IV 3X/WEEK (___)
15. Vitamin D 1000 UNIT PO DAILY
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Senna 17.2 mg PO BID:PRN constipaton
18. Atorvastatin 80 mg PO DAILY
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN eye dryness
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Collagenase Ointment 1 Appl TP DAILY
5. Lidocaine 5% Patch 2 PTCH TD QPM pain
6. Nephrocaps 1 CAP PO DAILY
7. Omeprazole 40 mg PO DAILY
8. PredniSONE 5 mg PO DAILY
9. Senna 17.2 mg PO BID:PRN constipaton
10. sevelamer CARBONATE 2400 mg PO TID W/MEALS
11. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
12. Tacrolimus 2 mg PO Q12H
13. Temazepam 15 mg PO HS:PRN insomnia
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*12
Tablet Refills:*0
15. Vitamin D 1000 UNIT PO DAILY
16. Warfarin 5 mg PO DAILY
17. Epoetin Alfa 6600 UNIT IV 3X/WEEK (___)
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. Enoxaparin Sodium 40 mg SC DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
presyncope
Secondary:
end stage renal disease
coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were feeling dizzy
when you stood up and you were having chest pain. We determined
that you were not having a heart attack but we could do no
further workup because you did not allow us to properly evaluate
you. Your symptoms have resolved by discharge.
Please take 6 mg Coumadin daily on ___ and ___.
Please take 40 mg Lovenox SC daily on ___ and ___.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19759491-DS-45
| 19,759,491 | 25,594,943 |
DS
| 45 |
2194-08-22 00:00:00
|
2194-08-24 16:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Adhesive / percocet / sirolimus / Neomycin /
Dilaudid / Lyrica
Attending: ___
Chief Complaint:
nausea/fever
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with ESRD s/p renal transplants x2 (both failed, now HD
dependent MWF), type 1 diabetes s/p pancreatic transplant x2
(functional graft) not requiring insulin, CAD, CHF who presented
to ___ in ___ today with fever, nausea, vomiting. She
was hemodynamically stable. OSH CT Abd/Pelvis without contrast
revealed gallbladder wall thickening, stranding around a failed
renal graft with distended bladder. No graft tenderness per ED.
She was given vanc/levoflox and 500mL NS and transferred to
___.
In the ED, initial vitals were 99.4 91 135/83 16 100% 2L NC. She
reported ___ hand pain (chronic) and was given 500cc, morphine
and Zofran. Labs notable for BUN 65, Cr 6.8, Bicarb 21. ALT 41,
AST 57, ALP 124. INR 6.6. Lactate normal. RUQ was performed with
no signs of acute cholecytitis. She was given her home
prednisone 5mg and tacrolimus 2mg in the ED.
On the floor, patient reports feeling better. She states she
never had abdominal pain and this was incorrectly reported. Her
main symptoms included fever to T100.8 this morning at home,
nausea, chills, and nonbloody vomiting.
ROS: +fever, nausea, vomiting, chills, hand pain (chronic).
Denies chest pain, dyspnea, abdominal pain, diarrhea,
constipation, dysuria, frequency. She makes negligible urine,
___ cup daily.
Past Medical History:
# End stage renal disease secondary to FSGS, s/p pancreas/kidney
___, then a DDRT in ___ followed by a separate
pancreas transplant that year; currently listed ___
___ for kidney re-transplantation (not being
recommended for re-listing at ___, hemodialysis dependent
___.
# Systolic heart failure (EF 35% ___, s/p BiV
pacemaker/ICD placement ___.
# Coronary artery disease s/p CABG ___ (LIMA to LAD, rSVG
to pLVCA, rSVG to PDA)
# Mitral Regurgitation s/p mechanical MVR (On Warfarin)
# NSTEMI in ___ s/p PDA stenting (___) and DES x2 to RCA
___
# Mesenteric Ischemia
# Pleural effusion s/p VATS/pleurectomy ___
# Dyslipidemia
# Hypertension
# Diabetes mellitus type 1 (prior to pancreas transplant)
# PVD s/p R femoral-anterior tib bypass graft
# Chronic Anemia
# Menorrhagia s/p vaginal hysterectomy ___
# Charcot R foot
.
PAST SURGICAL HISTORY
# s/p simultaneous pancreas-kidney transplant in the ___
followed by a repeat renal transplant (___) and repeat
pancreas transplant (___)
# s/p retinal detachment and enucleation of left eye
# s/p D & C (___)
# s/p Hysterectomy (___)
# s/p TMJ surgery
# s/p CABG/MVR ___
# s/p R femoral-anterior tib bypass graft ___
Social History:
___
Family History:
Mother has history of CAD. No family Hx of DM. MGM had HTN but
lived to be ___. MGF had a CVA in his ___. Her father had RA that
was complicated by restrictive lung disease. PGF had renal
disease. PGM had small bowel CA in her ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T98.8 128/57 HR90 RR18 100RA
GENERAL: Chronically ill appearing woman in no acute distress
HEENT: Left-sided ptosis from prior prosthetic eye implant, MMM
HEART: RRR, ___ systolic murmur with S1 click in LLSB and apex
LUNGS: Mild inspiratory crackles R base, no wheezing
ABD: nondistended, +BS, nontender in all quadrants
EXT: no ___ edema, minimal pulses DP and ___ bilaterally, foot
ulcer L sole but patient refuses to have bandage removed for
inspection
DISCHARGE PHYSICAL EXAM:
VS: 98.3 142/70 71 18 98% on RA
GENERAL: No acute distress
HEENT: Left-sided ptosis from prior prosthetic eye implant
HEART: RRR, ___ systolic murmur with S1 click in LLSB and apex
LUNGS: Mild inspiratory crackles R base, no wheezing
ABD: nondistended, +BS, nontender in all quadrants
EXT: no ___ edema
Pertinent Results:
ADMISSION LABS
___ 05:48PM LACTATE-1.4
___ 04:30PM GLUCOSE-96 UREA N-65* CREAT-6.8*# SODIUM-134
POTASSIUM-4.9 CHLORIDE-99 TOTAL CO2-21* ANION GAP-19
___ 04:30PM ALT(SGPT)-41* AST(SGOT)-57* ALK PHOS-124* TOT
BILI-0.3
___ 04:30PM LIPASE-47
___ 04:30PM ALBUMIN-3.6
___ 04:30PM WBC-7.2 RBC-3.14*# HGB-10.2*# HCT-31.3*#
MCV-100* MCH-32.3* MCHC-32.4 RDW-18.6*
___ 04:30PM NEUTS-89.3* LYMPHS-5.9* MONOS-3.5 EOS-1.0
BASOS-0.2
___ 04:30PM PLT COUNT-138*
___ 04:30PM ___ PTT-58.4* ___
DISCHARGE LABS
___ 07:10AM BLOOD WBC-3.1* RBC-3.35* Hgb-10.6* Hct-33.7*
MCV-101* MCH-31.6 MCHC-31.4 RDW-17.9* Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD ___ PTT-44.3* ___
___ 07:10AM BLOOD Glucose-89 UreaN-27* Creat-4.3* Na-142
K-4.5 Cl-102 HCO3-30 AnGap-15
___ 07:10AM BLOOD ALT-23 AST-26 AlkPhos-108* TotBili-0.3
___ 07:10AM BLOOD Calcium-9.4 Phos-3.1 Mg-2.6
___ 07:10AM BLOOD tacroFK-7.8
STUDIES
Cardiovascular ReportECGStudy Date of ___ 6:11:54 ___
Sinus rhythm with demand ventricular pacing. Compared to the
previous tracing
of ___ the rate has increased slightly. Otherwise, findings
are similar.
Read ___.
IntervalsAxes
___
___
RUQUS ___
IMPRESSION:
Distended gallbladder but compressible. No gallbladder wall
edema.
Sonographic ___ sign absent. Findings are unlikely to
represent acute
cholecystitis.
CXR ___
IMPRESSION:
Cardiomegaly is substantial, unchanged. Enema ___ catheter
in pacemaker leads in replaced valve are unchanged. There is
interval improvement ininterstitial pulmonary edema currently
mild. Small bilateral pleural effusions are noted. There is no
pneumothorax.
Brief Hospital Course:
___ with ESRD s/p renal transplants x2 (both failed, now on HD),
type 1 diabetes s/p pancreatic transplant x2 (functional graft),
CAD, CHF presenting with reported fever, nausea, vomiting,
transaminitis. Patient given dose of vancomycin and levoquin at
OSH. Abx stopped on arrival to ___. On floor pt initially
presented with fever, however N/V resolved. Patient remained
afebrile with resolution of her transaminitis in the hospital.
She was found to be supratherapeutic on her INR to 10 on ___
and given vitamin K 2.5mg x1. Her INR dropped to 2.8 on ___,
and was restarted on her coumadin at 5mg at discharge. She will
f/u with ___ clinic and have her INR drawn on ___. She
will start lovenox (home med) if her INR goes <2.5.
ACUTE ISSUES
# FEVER, NAUSEA, TRANSAMINITIS. Resolved today, LFTs WNL. Most
likely represented a viral syndrome which is resolving. Held
antibiotics after presentation. Patient has improved throughout
her stay in the hospital. She has no positive source of
bacterial infection. Patient will follow up with her PCP.
CHRONIC ISSUES
# MECHANICAL MV. On warfarin but with history of very labile
INR. Patient with known poor time in therapeutic range (last
stats show 15.4%). On ___, supratherapeutic with INR 10.2.
Patient give 2.5mg vitamin K PO x1 on ___. ___
clinic was contacted and patient will return home on warfarin
5mg and follow up with ___ clinic over the phone on ___
after have INR checked at ___ lab near her home. Pt has
Lovenox at home in case INR falls below 2.5 and she will bridge
with home dose per ___ clinic instructions.
# ESRD on ___ HD: With failed renal graft. Cont home prednisone,
tacrolimus, TMP/SMX, caps, and sevelamer.
# Noninsulin-dependent diabetes mellitus/status post functional
pancreatic transplant. No longer requiring insulin or checking
fingersticks regularly. Last HbA1c 5.0% in ___.
# Thrombocytopenia: Platelet count near baseline.
# Chronic hand pain: Continued lidocaine patches to each hand.
# chronic systolic heart failure: Euvolemic on exam.
# Vitamin D deficiency: Continued home cholecalciferol.
TRANSITIONAL ISSUES
-patient will leave on Warfarin 5mg; she will have INR checked
on ___ at ___ lab and contact the ___ clinic
with instructions on titrating doses
-patient will also have to restart her lovenox if her INR is
<2.5 on next draw; patient has medication at home and has
already contacted ___ clinic
-pt will follow up with Transplant Team per her regularly
scheduled appt
-she will follow up with her PCP after discharge
-___ will continue all of her home medications
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES PRN dry eye
2. Aspirin 81 mg PO DAILY
3. Epoetin Alfa 8000 UNIT IV 3X/WEEK (___)
4. Lidocaine 5% Patch 1 PTCH TD QPM each hand
5. Nephrocaps 1 CAP PO DAILY
6. PredniSONE 5 mg PO DAILY
7. Senna 17.2 mg PO BID:PRN constipation
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
10. Tacrolimus 2 mg PO Q12H
11. Temazepam 30 mg PO HS:PRN insomnia
12. Vitamin D 1000 UNIT PO DAILY
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES PRN dry eye
2. Aspirin 81 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QPM each hand
4. Nephrocaps 1 CAP PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. PredniSONE 5 mg PO DAILY
7. Senna 17.2 mg PO BID:PRN constipation
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
10. Tacrolimus 2 mg PO Q12H
11. Temazepam 30 mg PO HS:PRN insomnia
12. Vitamin D 1000 UNIT PO DAILY
13. Epoetin Alfa 8000 UNIT IV 3X/WEEK (___)
14. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
15. Warfarin 5 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Viral URI; Supratherapeutic INR
SECONDARY: s/p renal/pancreas transplant, chronic foot ulcers/
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take part in your care during your stay
here at ___. You came into the hospital after having a fever,
nausea and vomitting. You were given a single dose of
intravenous and oral antibiotic at an outside hospital. You
symptoms were consistent with a viral upper respiratory
infection. Your nausea and vomitting improved without
intervention. Your fevers resolved. You received dialysis during
your admission, and will resume your normal schedule after
leaving the hospital. You should continue to weigh yourself
every morning, call MD if weight goes up more than 3 lbs.
Thank you for allowing us to participate in your care during
your stay in the hospital.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19759491-DS-48
| 19,759,491 | 21,588,507 |
DS
| 48 |
2194-10-13 00:00:00
|
2194-10-13 14:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Adhesive / percocet / sirolimus / Neomycin /
Dilaudid / Lyrica
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
hemodialysis
History of Present Illness:
___ w/ ESRD s/p SPK ___ (both grafts failed) and repeat DDRT
___ (also failed) now on HD, T1DM with PAK transplant ___
(functional) discharged yesterday after being treated for
possible pancreatic transplant rejection, GI bleeding, and
shingles, + trop in setting of afib with RVR, now presenting
with fever and abdominal pain. During her hospitalization she
had ongoing abdominal pain and elevated LFTs/lipase, was treated
for pancreatic transplant rejection with increased Tacro doses
and Pred taper. She was afebrile x5 days prior to discharge (had
low grade temps otherwise during her admission). A thorough
infectious workup was negative and it was susptected that abd
pain was ___ constipation and VZV (zoster).
The patient woke up early this morning, having excruciating
abdominal pain in a bandlike pattern across her lower abdomen.
No back pain. + nausea, no emesis. Her mouth felt very dry. She
was concerned about transplant rejection and reported that the
pain is worse than when she was in the hospital. She initially
went to a nearby ED and was transferred here for further
management. Levaquin 750mg IV was given en route as well as
Morphine 10mg IM.
In the ED, her initial VS were 98.9 70 116/57 17 98% RA. Her
exam was notable for distractable RLQ tenderness, crackles in
the bilteral bases, and cellulitis of the RLE. Her labs were
notable for H/H 8.8/27.4, K 6.3 (5.4 on repeat), BUN 65, Cr 5.6,
Mg 3.0, Phos 5.8, INR 2.5, Amylase of 125, Lipase of 75, albumin
3.2. She was given morphine 1mg IV x1, ativan 1mg x 1,
insulin/D50/CaG, and was given 1g vancomycin for the cellulitis.
Blood cultures were sent. A CXR showed persistent mild pulmonary
edema. She was seen by transplant nephrology. Her lipase was
down from yesterday and pancreas US was normal, suggestive that
her abdominal pain was not any form of panc rejection currently.
She was admitted to the medicine service for further pain
management.
Past Medical History:
# End stage renal disease secondary to FSGS, s/p pancreas/kidney
___, then a DDRT in ___ followed by a separate
pancreas transplant that year; currently listed ___
___ for kidney re-transplantation (not being
recommended for re-listing at ___, hemodialysis dependent
___.
# Systolic heart failure (EF 35% ___, s/p BiV
pacemaker/ICD placement ___.
# Coronary artery disease s/p CABG ___ (LIMA to LAD, rSVG
to pLVCA, rSVG to PDA)
# Mitral Regurgitation s/p mechanical MVR (On Warfarin)
# NSTEMI in ___ s/p PDA stenting (___) and DES x2 to RCA
___
# Mesenteric Ischemia
# Pleural effusion s/p VATS/pleurectomy ___
# Dyslipidemia
# Hypertension
# Diabetes mellitus type 1 (prior to pancreas transplant)
# PVD s/p R femoral-anterior tib bypass graft
# Chronic Anemia
# Menorrhagia s/p vaginal hysterectomy ___
# Charcot R foot
PAST SURGICAL HISTORY
# s/p simultaneous pancreas-kidney transplant in the mid ___
followed by a repeat renal transplant (___) and repeat
pancreas transplant (___)
# s/p retinal detachment and enucleation of left eye
# s/p D & C (___)
# s/p Hysterectomy (___)
# s/p TMJ surgery
# s/p CABG/MVR ___
# s/p R femoral-anterior tib bypass graft ___
Social History:
___
Family History:
Mother has history of CAD. No family Hx of DM. MGM had HTN but
lived to be ___. MGF had a CVA in his ___. Her father had RA that
was complicated by restrictive lung disease. PGF had renal
disease. PGM had small bowel CA in her ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 97.8, 144/72, 79, 18, 100% RA.
General: NAD, drowsy but resting comfortably
HEENT: left eye prosthetic, anicteric, Mucus membranes dry
Chest: tunneled HD line in right chest, no erythema, nontender
CV: RRR, no m/r/g
Lungs: bibasilar crackles
Abdomen: soft, + tenderness predominantly in RLQ, distractable,
+BS, no rebound or organomegaly.
Ext: 2+ pitting edema to mid calf, red/warm RLE, right charcot
foot/plantar wart, left foot bandages
Neuro: A&Ox3, CNII-XII intact
DISCHARGE PHYSICAL EXAM
=======================
97.9 126/56-150/73 ___ 98% RA
GEN: NAD
HEENT: conjunctiva pink, sclera anicteric, MMM
NECK: supple, FROM, no LAD
CV: RRR, + mechanical heart sounds
LUNG: CTAP b/l
ABD: soft, ntnd, +BS
EXT: warm, blanchable erythematous patch on RLE improved from
yesterday's margination, LLE unchanged from previous admission
NEURO: grossly intact
Pertinent Results:
ADMISSION LABS
==============
___ 08:50PM BLOOD WBC-8.0 RBC-2.77* Hgb-8.0* Hct-26.0*
MCV-94 MCH-28.8 MCHC-30.6* RDW-17.7* Plt ___
___ 08:50PM BLOOD Neuts-91.1* Lymphs-4.4* Monos-4.2 Eos-0.2
Baso-0
___ 08:50PM BLOOD ___ PTT-30.9 ___
___ 08:50PM BLOOD Glucose-133* UreaN-57* Creat-5.0*# Na-137
K-5.8* Cl-97 HCO3-25 AnGap-21*
___ 08:50PM BLOOD ALT-17 AST-22 AlkPhos-87 Amylase-125*
TotBili-0.2
___ 08:50PM BLOOD Lipase-75*
___ 08:50PM BLOOD Albumin-3.2*
___ 06:00AM BLOOD Calcium-9.2 Phos-5.8* Mg-3.0*
___ 09:00PM BLOOD Lactate-1.4 K-5.4*
DISCHARGE LABS
===============
___ 05:50AM BLOOD WBC-7.0 RBC-3.12* Hgb-9.4* Hct-29.5*
MCV-95 MCH-29.9 MCHC-31.7 RDW-18.0* Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD ___ PTT-33.4 ___
___ 05:50AM BLOOD Glucose-99 UreaN-43* Creat-4.5*# Na-139
K-4.4 Cl-98 HCO3-30 AnGap-15
___ 05:50AM BLOOD Amylase-192*
___ 05:50AM BLOOD Lipase-170*
___ 05:50AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.8*
___ 05:56AM BLOOD Vanco-17.3
MICROBIOLOGY
============
BCx: No growth.
IMAGING/STUDIES
===============
___ ECG
Atrially sensed ventricularly paced rhythm. Underlying rhythm is
sinus rhythm. Compared to the previous tracing of ___ there
is no significant diagnostic change.
___ CXR
Persistent mild pulmonary edema. More confluent retrocardiac
opacity
potentially due to atelectasis accentuated by portable
technique. Consider PA and lateral if patient is amenable to
further characterize.
___ Pancreatic U/S
Normal ultrasound evaluation of the left lower quadrant
transplant pancreas.
Brief Hospital Course:
___ w/ ESRD s/p SPK ___ (both grafts failed) and repeat DDRT
___ (also failed) now on HD, T1DM with PAK transplant ___
(functional) discharged yesterday after being treated for
possible pancreatic transplant rejection, GI bleeding, and
shingles, + trop in setting of afib with RVR, now presenting
with fever and abdominal pain.
ACUTE ISSUES
============
# Abdominal pain: Pt noted abdominal pain was worse than that
during her prior admission. Based on her description, DDx
included transplant rejection, bowel ischemia, infection (C.
diff), ileus, constipation. Per transplant, likely not
transplant rejection (pain is also on the opposite side of her
transplant). Amylase and lipase values were downtrending from
previous admission and pancreatic US was also reassuring against
rejection. Pt has h/o mesenteric ischemia, hyperlipidemia.
However, given her description of the pain, ischemia is
unlikely. Pt is not having diarrhea, so infection less likely.
Pt could have a mechanical (less likely due to failure of
progression of pain) or functional ileus (more likely, also in
the setting of narcotics). Her exam was always soft with
distractible tenderness. She was given methylnaltrexone with
good relief suggesting constipation was the major underlying
cause. She was discharged home to resume her bowel regimen.
# Cellulitis: Pt has RLE that is red/warm/edematous. Pt also has
recent hospitalization and h/o VRE. Pt was continued vancomycin
with HD dosing, but did not improve intially. She was
subsequently started on ceftazidime to cover for possible
pseudomonas as well given history of diabetes and recent
hospitalizations. She was never febrile and her WBC was never
elevated. She was discharged to complete a 14d course as an
outpt in conjunction with her dialysis appointments.
CHRONIC ISSUES
==============
# s/p pancreas/kidney transplant (___), then a DDRT in ___
followed by a separate pancreas transplant ___. She continued
immunosuppressive regimen with tacro, prednisone 10 mg POqday.
She also Continued Bactrim and vitD/Ca ppx.
# ESRD on HD: On ___ HD.
- Continue on dialysis schedule as inpt.
- Continue sevelamer, nephrocaps
# CAD s/p CABG:
- Continue aspirin
# Mechanical MV: INR therapeutic on admission
- Continue warfarin 3mg daily
- Monitor daily INR
TRANSITIONAL ISSUES
===================
#Prednisone: dc on 20mg with taper to be defined at next
transplant outpatient appointment
#Cellulitis: on vanc and ceftazidime. Will be dosed at
outpatient HD sessions for a total course of 2 weeks (end
___
#Ativan: pt reports abd pain responds to ativan. Needs to be
followed for refills by PCP
___ of Care: on going dicussion with palliative care to
inform future directions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES PRN dry eye
2. Aspirin 81 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QPM each hand
4. Nephrocaps 1 CAP PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Ranitidine 150 mg PO QHS
7. Senna 17.2 mg PO BID:PRN constipation
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
10. Temazepam 30 mg PO HS:PRN insomnia
11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
12. Vitamin D 1000 UNIT PO DAILY
13. Warfarin 3 mg PO DAILY16
14. Epoetin Alfa 8000 UNIT IV 3X/WEEK (___)
15. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain
16. Bisacodyl 10 mg PR QHS constipation
17. Docusate Sodium 100 mg PO BID
18. Lorazepam 0.5 mg PO QHS insomnia/anxiety
19. PredniSONE 20 mg PO DAILY
20. Tacrolimus 2.5 mg PO Q12H
21. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
22. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eye
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR QHS constipation
5. Docusate Sodium 100 mg PO BID
6. Epoetin Alfa 8000 UNIT IV 3X/WEEK (___)
7. Lidocaine 5% Patch 1 PTCH TD QPM each hand
8. Lorazepam 0.5 mg PO Q4H:PRN abdominal pain, nausea
9. Nephrocaps 1 CAP PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Ranitidine 150 mg PO QHS
12. Senna 17.2 mg PO BID:PRN constipation
13. sevelamer CARBONATE 2400 mg PO TID W/MEALS
14. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
15. Tacrolimus 2.5 mg PO Q12H
16. Temazepam 30 mg PO HS:PRN insomnia
17. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
18. Vitamin D 1000 UNIT PO DAILY
19. Warfarin 3 mg PO DAILY16
20. CefTAZidime 1 g IV POST HD (___)
IF ON HD, administer dose on the ward after patient returns from
each hemodialysis session.
21. Vancomycin 1000 mg IV HD PROTOCOL
22. Mupirocin Ointment 2% 1 Appl TP BID
23. Collagenase Ointment 1 Appl TP DAILY
24. PredniSONE 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Cellulitis
Constipation
ESRD on HD
CHRONIC:
CAD s/p CABG
___
Mechanical MV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___:
You were hospitalized at ___ one day after discharge from your
previous admission for abdominal pain and right leg cellulitis.
Although the etiology of your abdominal pain was unknown,
laboratory tests and imaging showed that pancreatic transplant
rejection was unlikely. Your abdominal pain responded well to
anti-constipation medicines.
Your right leg celluitis was treated with vancomycin and
ceftazadime to treat the infection. You responded well as
evidenced by decreasing redness on your leg. You will continue
these medicines at dialysis as an outpatient for a total of a 2
week course.
Your INR was again labile during your stay, going from 2.5 to
3.6 in a little over 24 hours. You warfarin was held and your
INR settled in the therapeutic range of 2.5-3.5.
All the best for a speedy recovery!
Sincerely,
___ Treatment Team
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19759491-DS-49
| 19,759,491 | 21,820,577 |
DS
| 49 |
2194-11-01 00:00:00
|
2194-11-02 19:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Adhesive / sirolimus / Neomycin / Lyrica
Attending: ___.
Chief Complaint:
___ swelling and dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with multiple medical problems most notable for Type 1
Diabetes s/p pancreas and failed renal transplant, ESRD on HD
(MWF), CAD s/p CABG, and systolic CHF (LVEF 32% ___ who
presented with dyspnea and worsening ___ edema.
The patient was recently discharged on from ___ on ___ after
being treated for RLE cellulitis with Vancomycin and
Ceftazadime. Of note, given ESRD the patient does not use
Furosemide and usually requires HD to remove excess fluid. At
the time of discharge, she had dyspnea but now it is worse. She
thinks it is simmilar to when she has missed dialysis. She tells
me that she always has fevers, but cannot say when her last one
was. She was seen in ___ clinic on the morning of ___
where she was advised to present to the ED given concern for
volume overload. Of note, at that visit her foot ulcers were
stable and had no signs of infection. As a result, she missed
her planned HD session this afternoon. The patient denies any
changes in diet, cough, dysuria, fevers, chills, nausea, or
vomiting. She reports she has been compliant with all of her
medications.
Of note, the patient was recently admitted earlier this month
with abdominal pain, thought to be from constipation, as well as
RLE cellulitis treated with 14 days of abx.
Vitals in the ED: 97.0 86 146/70 16 100% RA.
Labs notable for: Cr 7.1, INR 2.1, Hct 29.6.
CXR showed: mild pulmonary vascular congestion/interstitial
edema
and a small left pleural effusion.
Patient given: doxycycline 100mg po x1.
Vitals prior to transfer: 98.6 82 174/82 16 100% R.A
On the floor, she is fatigued but feels well. She reports that
her dyspnea is at her baseline. Otherwise, no complaints. ROS
per HPI.
Past Medical History:
# End stage renal disease secondary to FSGS, s/p pancreas/kidney
___, then a DDRT in ___ followed by a separate
pancreas transplant that year; currently listed ___
___ for kidney re-transplantation (not being
recommended for re-listing at ___, hemodialysis dependent
___.
# Systolic heart failure (EF 35% ___, s/p BiV
pacemaker/ICD placement ___.
# Coronary artery disease s/p CABG ___ (LIMA to LAD, rSVG
to pLVCA, rSVG to PDA)
# Mitral Regurgitation s/p mechanical MVR (On Warfarin)
# NSTEMI in ___ s/p PDA stenting (___) and DES x2 to RCA
___
# Mesenteric Ischemia
# Pleural effusion s/p VATS/pleurectomy ___
# Dyslipidemia
# Hypertension
# Diabetes mellitus type 1 (prior to pancreas transplant)
# PVD s/p R femoral-anterior tib bypass graft
# Chronic Anemia
# Menorrhagia s/p vaginal hysterectomy ___
# Charcot R foot
PAST SURGICAL HISTORY
# s/p simultaneous pancreas-kidney transplant in the mid ___
followed by a repeat renal transplant (___) and repeat
pancreas transplant (___)
# s/p retinal detachment and enucleation of left eye
# s/p D & C (___)
# s/p Hysterectomy (___)
# s/p TMJ surgery
# s/p CABG/MVR ___
# s/p R femoral-anterior tib bypass graft ___
Social History:
___
Family History:
Mother has history of CAD. No family Hx of DM. MGM had HTN but
lived to be 98. MGF had a CVA in his ___. Her father had RA that
was complicated by restrictive lung disease. PGF had renal
disease. PGM had small bowel CA in her ___.
Physical Exam:
ADMISSION:
Vitals: Weight 54.05 kg, T 98.3 BP 142/72 HR 91 RR 20 SaO2 100%
on RA
GENERAL: NAD, sitting comfortably at the edge of the bed
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, Cushingoid faces
NECK: non-tender supple, no LAD, no JVD
CARDIAC: irregularly irregular, mechanical s1, normal s2, early
1/ systolic murmur at apex
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis or clubbing, has b/l ___ edema 1+ to
below knees, bilateral rubor of shins but no heat or tenderness,
right charcot foot/plantar wart
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ strength b/l ___
___: warm and well perfused
DISCHARGE:
99.7 133/69-152/68 ___ 18 100%RA
GEN: crying in pain, A&Ox3
HEENT: conjunctiva pink, sclera anicteric, MMM
NECK: supple, FROM, no LAD, JVP not elevated
CV:RRR, mechanical heart sounds
LUNG: CTAP b/l
ABD: benign
EXT: edema vastly improved, stasis dermatitis vastly improved
MSK: TTP over L patellar tendon, +tenderness with AROM and PROM,
no surrounding erythema, possible trace effusion, ankle and hip
exam WNL
NEURO: grossly intact b/l
Pertinent Results:
>> ADMISSION LABS:
___ 01:30PM BLOOD WBC-5.8 RBC-3.14* Hgb-8.9* Hct-29.6*
MCV-94 MCH-28.3 MCHC-30.0* RDW-18.3* Plt ___
___ 01:30PM BLOOD Neuts-90.1* Lymphs-6.8* Monos-2.9 Eos-0.1
Baso-0.1
___ 06:14PM BLOOD ___ PTT-44.4* ___
___ 01:30PM BLOOD Plt ___
___ 01:30PM BLOOD Glucose-168* UreaN-82* Creat-7.1*# Na-136
K-4.2 Cl-96 HCO3-21* AnGap-23*
___ 01:30PM BLOOD Calcium-9.2 Phos-4.6* Mg-3.2*
___ 06:26AM BLOOD tacroFK-11.5
.
>> DISCHARGE:
___ 06:40AM BLOOD WBC-4.9 RBC-3.03* Hgb-8.2* Hct-27.9*
MCV-92 MCH-27.1 MCHC-29.4* RDW-17.2* Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-82 UreaN-42* Creat-4.5*# Na-138
K-4.6 Cl-97 HCO3-27 AnGap-19
___ 06:40AM BLOOD Amylase-128*
___ 06:40AM BLOOD Lipase-88*
___ 06:40AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.7*
___ 06:40AM BLOOD tacroFK-5.9
.
>> IMAGING:
KNEE PLAIN FILMS:
No fracture. Popliteal stent. Dense, tubular atherosclerotic
calcifications.
Mild prepatellar soft tissue swelling
.
>> MICROBIOLOGY:
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
___ w/ h/o CAD s/p 3V CABG, sCHF with LVEF 35% s/p ICD
placement, ESRD on HD ___ s/p DDRT failed x2, ___ s/p
pancreatic transplant with recent hospitalization treated for
low grade rejection, and two recent hospitalizations within the
past month treating for cellulitis with vancomycin and
ceftazidime presents with e/o of volume overload in the context
of missing dialysis and pt request to decrease volume removed
from UF.
.
>> ACTIVE ISSUES:
___ Swelling/Dyspnea: Pt came in with evidence of volume
overload with swelling in the face, legs, and inspiratory
crackles in her lungs b/l. When asked the pt admitted to missing
dialysis that day. Review of the records revealed that the pt
has requested less volume removed during dialysis sessions to
prevent cramping. Her weight on admission was 54 kg, at least
6kg over her dry weight. She underwent dialysis which improved
her symptoms.
.
#Leg Redness: Pt had two separate admissions this month for
cellulitis of the right and then left legs. She completed a
course of vancomycin and ceftazidime as outpatient at dialysis.
On admission, the pt.s exam was not consistent with cellulitis,
but rather stasis dermatitis exacerbated by missed dialysis
session. The redness decreased and returned to her baseline
pigmentation after dialysis.
.
#Fevers: The pt is well known to this writer for 3 admissions
over the past month for subjective fevers. She has been pan
cultured numerous times, all with no growth. Amylase and lipase
levels were WNL on this admission. The pt never had a documented
fever during this admission, yet she still complained of fevers
and night sweats. Given the pt.s age and lack of findings on
extensive evaluation, it was thought these fevers were
representative of menopause. The pt refused symptomatic
treatment
.
#L Knee Pain: acute, and limited to the knee. There was concern
for pseudogout vs gout. Plain film did not reveal a fracture or
acute process. The pt refused arthrocentesis, so she was treated
symptomatically with tramadol. Patient was evaluated by the
rheumatology service, and recommended continued tramadol for
knee pain, and consideration of ultrasound guidance of
aspiration, which patient refused. Further, uric acid, although
not as helpful in acute gout situations, was not evaluated.
Further, patients symptoms continued despite increased steroid
levels for her transplant immunosuppressive workup, which argues
against gout or pseudogout as a cause. It was thought that her
knee pain most likely represented a prepatellar bursitis, and
would resolve with symptomatic treatment.
.
# S/p Kidney/Pancreas Transplant, and then DDRT in ___. Patient
continued to have tacrolimus levels checked daily, and was
ultimately adjusted to 2 mg daily for immunosuppression.
Further, patient also had adjustment in her prednisone dose to
20 mg. Daily labs of lipase and amylase were obtained, and
possibly concerning for a chronic rejection type picture. To
further elucidate, an HLA-antibody screen for Donor specific
antibodies (both HLA-1 and HLA-II) was sent prior to her
discharge, however would not be run in assay until ___.
Results will be forwarded to Dr. ___.
.
>> CHRONIC ISSUES:
# ESRD on HD: As described above, patient was kept on normal
dialysis schedule, and was continued on home sevelamer,
nephrocaps, and EPO with HD.
.
# CAD s/p CABG: Patient did not have any chest pains during
admission, and was continued on aspirin.
.
# Mechanical MVR: Patient with anti-coagulation for prosthetic
valve, and extensive history of very labile INRs. Patient INR
was carefully monitored, and warfarin dose was titrated to 2 mg
daily upon discharge. Patient was also given prescription to
obtain an ___ after discharge on ___, and will have results
sent to the ___ clinic for more careful
titration.
.
>> TRANSITIONAL ISSUES:
#Knee Pain: Likely secondary to prepatellar bursitis. Pt seen by
rheum who suggested arthrocentesis however the pt decline.
Patient also was given steroids while inpatient. Patient was
given symptomatic pain control, and track as outpt.
.
#Subjective Fevers: extensive work up over three admissions in
___ alone and never a documented fever while an inpatient.
Given pt's age, we feel it most likely represents menopause. Pt
refused symptomatic treatment.
.
# Transplant: Patient with elevated mildly lipase/amylase.
Prednisone dose increased to 20 mg daily. HLA-antibody donor
sent, f/u with transplant surgery as outpatient.
.
# INR: Patient with mechanical valve, INR 2.5-3.5, difficult to
control as outpatient, will need close f/u. Given prescription
to obtain INR at lab.
.
# Dialysis: Patient to continue HD per regular schedule.
Dialysis center was called prior to discharge to notify of
patient's weight and discharge disposition.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain
2. Artificial Tears ___ DROP BOTH EYES PRN dry eye
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR QHS constipation
5. Docusate Sodium 100 mg PO BID
6. Epoetin Alfa 8000 UNIT IV 3X/WEEK (___)
7. Lidocaine 5% Patch 1 PTCH TD QPM each hand
8. Lorazepam 0.5 mg PO Q4H:PRN abdominal pain, nausea
9. Nephrocaps 1 CAP PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Ranitidine 150 mg PO QHS
12. Senna 17.2 mg PO BID:PRN constipation
13. sevelamer CARBONATE 2400 mg PO TID W/MEALS
14. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
15. Tacrolimus 2.5 mg PO Q12H
16. Temazepam 30 mg PO HS:PRN insomnia
17. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
18. Vitamin D 1000 UNIT PO DAILY
19. Warfarin 3 mg PO DAILY16
20. Mupirocin Ointment 2% 1 Appl TP BID
21. Collagenase Ointment 1 Appl TP DAILY
22. PredniSONE 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain
2. Collagenase Ointment 1 Appl TP DAILY
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
4. Epoetin Alfa 8000 UNIT IV 3X/WEEK (___)
5. Lidocaine 5% Patch 1 PTCH TD QPM each hand
6. Mupirocin Ointment 2% 1 Appl TP BID
7. Nephrocaps 1 CAP PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Ranitidine 150 mg PO QHS
10. Senna 17.2 mg PO BID:PRN constipation
11. sevelamer CARBONATE 2400 mg PO TID W/MEALS
12. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
13. Temazepam 30 mg PO HS:PRN insomnia
14. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*20
Tablet Refills:*0
15. Vitamin D 1000 UNIT PO DAILY
16. Artificial Tears ___ DROP BOTH EYES PRN dry eye
17. Aspirin 81 mg PO DAILY
18. Bisacodyl 10 mg PR QHS constipation
19. PredniSONE 20 mg PO DAILY
20. Tacrolimus 2 mg PO Q12H
RX *tacrolimus 1 mg 2 capsule(s) by mouth twice daily Disp #*120
Capsule Refills:*0
21. Warfarin 2 mg PO DAILY16
RX *warfarin 2 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
22. Outpatient Lab Work
INR draw on ___ and ___ as anti-coagulated. Please
communicate results to Healthcare Associates, ___
anticoagulation at (___)
23. Lorazepam 0.5 mg PO Q4H:PRN abdominal pain, nausea
RX *lorazepam 0.5 mg 1 tab by mouth every 8 hours as needed Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
ESRD
___
Stasis dermatitis
SECONDARY:
CAD s/p CABG
Pancreatic Transplant
Renal transplant x2 (failed)
Mechanical Mitral Valve
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___:
You were hospitalized at ___ for leg swelling and pain. This
was likely related to the missed dialysis session on the day of
admission as well as requesting less taken off to avoid
cramping. You were admitted and received dialysis which
decreased your swelling and leg redness. You subsequently
developed swelling in your knee. We got X rays which did not
reveal any fracture. We wanted to attempt a drainage of any
fluid to determine the etiology of this pain, but you refused.
Thus the only thing we could offer was increased pain control
with tramadol. You also continued to complain of continued
fevers and night sweats. You never spiked a fever during this
admission. As an extensive infectious work up has been performed
in your 3 admissions this month and nothing has turned positive,
and given your age, we thought these night sweats likely reflect
menopause. You refused medications for symptomatic control.
While here, you were seen by the transplant doctors, and they
have changed your immunosuppression targets. You also had blood
tests drawn to evaluate the status of your transplants, which
will be discussed with your outpatient doctors.
The following changes were made to your medication
1. CHANGE Tacrolimus 2 mg daily
2. CONTINUE Prednisone 20 mg daily
3. CHANGE Bisacodyl 10 mg twice daily for constipation.
4. CHANGE Warfarin 2 mg daily
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Please follow up with your primary care doctor and
your kidney transplant doctors as ___ outpatient.
All the best for a speedy recovery,
Your ___ Team
Followup Instructions:
___
|
19759616-DS-17
| 19,759,616 | 23,558,212 |
DS
| 17 |
2148-06-23 00:00:00
|
2148-06-24 17:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Bradycardia
Major Surgical or Invasive Procedure:
Dual-Chamber Pacemaker Placement ___
History of Present Illness:
This ___ year old with history of osteoporosis and osteoarthritis
who presented to her PCP's office for 1 week of fatigue and
ankle swelling and was found to be in complete heart block on
ECG. She is currently admitted for placement of pacemaker.
The pt has been performing physical therapy in preparation from
a right knee surgery in ___. At physical therapy, she
noticed that her ankles were starting to swell. This prompted
her presentation to her PCP's office, where ECG was performed
which showed a heart rate in the ___ with complete dissociation
and narrow-complex escape rhythm. Patient reports intermittent
SOB for the past "few weeks" and increased fatigue. Denies any
chest pain, nausea, vomiting or diarrhea. No recent travel.
Symmetric leg swelling. No fever or chills, no rashes.
In the ED, initial vitals were 97.6 37 142/48 18 100% RA. Labs
were significant for 1 set of negative troponins, normal CBC,
unremarkable chem panel with K5.8 (hemolyzed), repeat 4.2.
Bilateral lower extremity doppler showed no evidence of DVTs,
and CXR showed mild cardiomegaly without evidence of acute
cardiopulmonary disease.
Currently the patient reports feeling well. She denies chest
pain, shortness of breath, palpitations, light-headedness. She
only reports mild ankle swelling, and otherwise feels well.
On review of systems, she denies nausea, vomiting, diarrhea,
dysuria, abdominal pain.
Past Medical History:
Sciatica
Syncope/collapse - in the setting of low blood pressures,
genearlly in the AM
Osteopenia
Bronchiectasis
Multiple lung nodules currently being followed by CT
___ (mycobacterium avium-intracellulare)
Leg cramps
Dizziness
Social History:
___
Family History:
Mother with a hx of angina; Died at age ___. Father had "enlarged
heart" and died of MI at age ___.
Physical Exam:
ADMISSION EXAM:
VS: Wt:62.8kg T:97.6 BP:136/53 HR:30 RR:18 O2:98%RA
General: Well-appearing female in NAD; sitting up in bed;
comfortable, conversational
HEENT: PERRL, MMM
Neck: JVP elevated about 10 cm
CV: S1S2 Bradycardic; no murmurs, rubs, or gallops
Lungs: Clear to auscultation bilaterally; no wheezes, rales,
rhonchi
Abdomen: Soft, nontender, nondistended, +BS
Ext: Trace swelling in ankles bilaterally; no pitting; full ROM
Neuro: Grossly intact
DISCHARGE EXAM:
VS: Wt:62.2<-62.8kg Tm:98.5 HR(33-74) BP:113-147/52-64 RR:16
O2:94%RA
General: Well-appearing female in NAD; sitting up in bed;
comfortable, conversational
HEENT: PERRL, MMM
Neck: JVP elevated about 8cm
CV: S1S2 Bradycardic; no murmurs, rubs, or gallops
Lungs: Clear to auscultation bilaterally; no wheezes, rales,
rhonchi
Abdomen: Soft, nontender, nondistended, +BS
Ext: Trace swelling in ankles bilaterally; no pitting; full ROM
Neuro: Grossly intact
Skin: ICD placement site CDI, no erythmea, minor tenderness to
palpation, no evidence of hematoma
Pertinent Results:
ADMISSION LABS:
___ 12:50PM BLOOD WBC-6.1 RBC-4.11* Hgb-13.3 Hct-41.2
MCV-100* MCH-32.4* MCHC-32.3 RDW-13.9 Plt ___
___ 12:50PM BLOOD Neuts-67.4 ___ Monos-7.0 Eos-1.7
Baso-0.9
___ 12:50PM BLOOD ___ PTT-28.0 ___
___ 12:50PM BLOOD Glucose-94 UreaN-21* Creat-0.9 Na-139
K-5.8* Cl-107 HCO3-25 AnGap-13
___ 12:50PM BLOOD cTropnT-<0.01
___ 12:50PM BLOOD Calcium-9.6 Phos-3.7 Mg-2.5
___ 12:50PM BLOOD TSH-2.5
___ 01:43PM BLOOD K-4.2
OTHER PERTINENT LABS:
___ 07:30AM BLOOD WBC-6.6 RBC-3.79* Hgb-12.3 Hct-38.5
MCV-102* MCH-32.6* MCHC-32.1 RDW-13.7 Plt ___
___ 07:30AM BLOOD Glucose-117* UreaN-23* Creat-0.8 Na-140
K-4.3 Cl-107 HCO3-26 AnGap-11
___ 07:30AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.9
STUDIES/REPORTS:
CXR (___): Hyperinflation and diminished vascularity
indicates severe emphysema. Regions of reticulation and ring
shadows in the right mid lung zone have been present since
___ but are more pronounced now. This could be due to
localized fibrosis or bronchiectasis. Any recent chest CT
scanning should be obtained to
see if there is any indication of active infection. Moderate
cardiomegaly is unchanged since ___. Small bilateral
pleural effusion is new. There is no pneumothorax or pulmonary
edema. Trans subclavian right atrial right ventricular pacer
leads follow their expected courses from the new left pectoral
pacemaker. No mediastinal widening.
DEVICE INTERROGATION REPORT (___):
Date of Interrogation: ___
Indication for implant: CHB
Reason for interrogation: post-implant follow-up
Device Brand: ___
Model: INGENIO ___ ___ / Serial No. ___
Date of Implant: ___
Presenting rhythm: AP-VP
Intrinsic Rhythm: NSR, CHB w ventricular escape <30 bpm
Programmed Mode: DDD 60-130 ppm / sAVD 60-150 ms / pAVD 80-200
ms; AMS on, rate >170 bpm
Battery Life: ___ years
RA lead:
Model Brand/Number: ___ ___ / ___
Intrinsic amplitude: 2.5 mV
Pacing impedance: 450 Ohms
Pacing threshold: 0.3 V at 0.4 ms
% Pacing: 43%
RV lead:
Model Brand/Number: ___ ___ / ___
Intrinsic amplitude: 10.3 mV
Pacing impedance: 535 Ohms
Pacing threshold: 0.4 V at 0.4 ms
%pacing: 97%
Diagnostic information: no detected high atrial or ventricular
rates
Programming changes: none
Summary: normal device function
ECHO (___): The left atrium and right atrium are normal in
cavity size. No atrial septal defect is seen by 2D or color
Doppler. The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild aortic
regurgitation.
Compared with the report of the prior study (images unavailable
for review) of ___, right ventricular function appears
normal and the degree of aortic regurgitation is greater.
___ DUPLEX (___): 1. No evidence of deep venous thrombosis
in the bilateral lower extremity veins. 2. Limited view of the
left peroneal veins.
PORTABLE CXR (___): Mild cardiomegaly. No evidence of
acute cardiopulmonary disease.
Brief Hospital Course:
This ___ year old with history of osteoporosis and osteoarthritis
who presented to her PCP's office for 1 week of fatigue and
ankle swelling and was found to be in complete heart block on
ECG, currently admitted for placement of pacemaker.
ACTIVE ISSUES:
# Complete heart block: Pt noted to have complete heart block on
ECG at PCP's office. Unclear etiology. No chest pain or elevated
troponin to suggest ACS. No tick bites or time spent outside
recently. Pt was overall asymptomatic, so placed on telemetry on
admission. Telemetry demonstrated complete heart block with
rates in the ___. Pt went for dual-chamber pacemaker placement
on ___, and tolerated the procedure well. Initially started on
IV vancomycin for antibiotic prophylaxis, and then when
discharged, switched to keflex ___ po TID on discharge for a
total course of 3 days of antibiotics. She will follow-up with
the device clinic as an outpatient.
CHRONIC ISSUES:
# Osteopenia: Held home calcium carbonate and evista during
admission and restarted at time of discharge.
***TRANSITIONAL ISSUES***
- Pt needs to continue to take Keflex ___ TID through ___
- Follow up in ___ device clinic in 1 week
- Follow up with Dr. ___
- CXR from ___ final read indicating possible severe
emphysema. This should be followed up as outpatient
- Code: FULL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Evista (raloxifene) 60 mg oral daily
2. Multivitamins 1 TAB PO DAILY
3. Magnesium Oxide Dose is Unknown PO ONCE
4. calcium carbonate-vitamin D3 600 mg(1,500mg) -200 unit oral
daily
5. Potassium Chloride Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. calcium carbonate-vitamin D3 600 mg(1,500mg) -200 unit oral
daily
2. Evista (raloxifene) 60 mg oral daily
3. Multivitamins 1 TAB PO DAILY
4. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) capsule(s) by mouth every six
(6) hours Disp #*8 Capsule Refills:*0
5. Cephalexin 500 mg PO Q8H Duration: 2 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth three times a day
Disp #*6 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Complete Heart Block
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
because it was found that you had a slow heart rate due to
complete heart block. For your slow heart rate you had a
pacemaker placed, which was tested and is functioning well. You
tolerated the procedure well.
Please follow-up in the cardiology device clinic as scheduled.
Continue to take the antibiotics until ___.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
19759865-DS-18
| 19,759,865 | 21,005,713 |
DS
| 18 |
2134-02-14 00:00:00
|
2134-02-14 17:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal Pian
Major Surgical or Invasive Procedure:
___ ex-lap, SBR, bladder repair
___ washout, TAC, SBR, L salpingectomy
History of Present Illness:
___ yo female with a history of neuroendocrine carcinoma who is
admitted with a pseudo-bowel obstruction. The patient states she
last had a bowel movement last ___, one week ago. She started
having abdominal pain on ___. She contacted her oncologist
and was passing gas so was thought to be constipated and was
started on daily senna and miralax. She states she continued to
feel poorly and continued to not have a bowel movement.
She states he abdominal pain is diffuse, severe, and constant.
She denies any nausea currently but did have nausea a couple of
times during the last week. She denies any shortness of breath,
dysuria, or rashes.
In the ED vital signs were notable for BP 191/113. Labwork was
notable for a potassium of 3 but otherwise unremarkable
including
lactate. A CT was done which showed a possible large bowel
obstruction. Surgery was consulted and thinks the patient most
likely has a pseudo bowel obstruction and recommends IV fluids
and NPO. She was give IV fluids, Dilaudid, Zofran, potassium,
and
amlodipine.
REVIEW OF SYSTEMS:
- All reviewed and negative except as noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
- Recurrent Jejunal Neuroendocrine Carcinoma
- ___: abdominal pain, fever, and chills. CT shows a
mass in the small bowel. Other testing not entirely documented
(in ___
- ___: s/p resection. Path showed T4N1 well-differentiated
NET of the jejunum. Her chromogranin A was elevated to 117
prior
to resection.
- ___: Imaging showed ___, but
chromogranin
remained elevated
- ___: negative octreotide scan (NV)
- ___: CT Torso showed multiple small mesenteric lymph
nodes
(largest 14mm) and two subcentimeter nodules along the liver
capsule, concerning for recurrent metastatic disease.
- ___: chromogranin 207, serotonin 2379
- ___: Initiated octreotide 20mg IM monthly
- ___: Liver Bx showed metastatic NET, well-differentiated,
Ki67 16.6%
PAST MEDICAL HISTORY:
sarcoidosis (Dx early 1990s)
HTN
thyroid nodule
SBO s/p resection (___)
Social History:
___
Family History:
Cancers in the family: sister with colon polyps
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: no acute distress
VITAL SIGNS: T:98.1 BP:117/70 HR:73 RR:16 O2:98RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NT/ND, no rebound or guarding,
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
ADMISSION LABS
=============
___ 02:09PM BLOOD WBC-7.2 RBC-4.30 Hgb-12.1 Hct-37.0 MCV-86
MCH-28.1 MCHC-32.7 RDW-14.9 RDWSD-46.9* Plt ___
___ 02:09PM BLOOD Neuts-75.3* Lymphs-16.0* Monos-8.2
Eos-0.0* Baso-0.1 Im ___ AbsNeut-5.39# AbsLymp-1.15*
AbsMono-0.59 AbsEos-0.00* AbsBaso-0.01
___ 02:09PM BLOOD ___ PTT-25.1 ___
___ 02:09PM BLOOD Glucose-112* UreaN-11 Creat-0.8 Na-145
K-3.0* Cl-100 HCO3-26 AnGap-19*
___ 06:50AM BLOOD ALT-13 AST-22 AlkPhos-87 TotBili-0.7
___ 06:50AM BLOOD Calcium-10.3 Phos-2.5* Mg-1.8
Micro
====
___ 1:35 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 5:10 pm BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
=======
___ CT Abd w and w/o contrast
1. Possible large bowel obstruction with a transition point in
the pelvis,
adjacent to the small bowel anastomosis. Adjacent soft tissue
is difficult to
exclude. Small volume pelvic free fluid. Enteric contrast
material reaches
the distal ascending colon. Could consider CT with rectal
contrast to further
assess the distal colon/pelvic soft tissue.
2. Known hepatic lesions are not appreciably changed since the
___
abdomen/pelvis MRI. Possible 1 cm soft tissue nodule in the
right lower
pelvis. Recommend attention on follow-up imaging.
3. Slightly more conspicuous mild intrahepatic biliary ductal
dilation.
Recommend correlation with liver function tests and consider
additional
work-up as clinically warranted.
___ CT Abd w and w/o contrast
1. Possible large bowel obstruction with a transition point in
the pelvis,
adjacent to the small bowel anastomosis. Adjacent soft tissue
is difficult to
exclude. Small volume pelvic free fluid. Enteric contrast
material reaches
the distal ascending colon. Could consider CT with rectal
contrast to further
assess the distal colon/pelvic soft tissue.
2. Known hepatic lesions are not appreciably changed since the
___
abdomen/pelvis MRI. Possible 1 cm soft tissue nodule in the
right lower
pelvis. Recommend attention on follow-up imaging.
3. Slightly more conspicuous mild intrahepatic biliary ductal
dilation.
Recommend correlation with liver function tests and consider
additional
work-up as clinically warranted.
___ 03:29AM BLOOD WBC-12.6* RBC-3.10* Hgb-8.8* Hct-25.7*
MCV-83 MCH-28.4 MCHC-34.2 RDW-16.8* RDWSD-49.1* Plt ___
___ 02:53PM BLOOD WBC-11.4* RBC-3.04* Hgb-8.7* Hct-25.7*
MCV-85 MCH-28.6 MCHC-33.9 RDW-17.0* RDWSD-52.1* Plt ___
___ 11:21PM BLOOD WBC-14.5* RBC-3.60* Hgb-10.2* Hct-30.3*
MCV-84 MCH-28.3 MCHC-33.7 RDW-17.1* RDWSD-51.8* Plt ___
___ 03:32AM BLOOD WBC-15.9* RBC-3.39* Hgb-9.5* Hct-28.7*
MCV-85 MCH-28.0 MCHC-33.1 RDW-16.9* RDWSD-50.8* Plt ___
___ 07:29AM BLOOD Hct-27.6*
___ 01:56PM BLOOD WBC-16.8* RBC-2.79* Hgb-8.0* Hct-23.8*
MCV-89 MCH-28.7 MCHC-32.3 RDW-17.2* RDWSD-55.4* Plt ___
___ 06:28PM BLOOD WBC-17.9* RBC-2.76* Hgb-7.8* Hct-23.9*
MCV-87 MCH-28.3 MCHC-32.6 RDW-17.1* RDWSD-52.8* Plt ___
___ 12:11AM BLOOD WBC-13.5* RBC-2.92* Hgb-8.3* Hct-25.0*
MCV-86 MCH-28.4 MCHC-33.2 RDW-16.9* RDWSD-52.2* Plt ___
___ 05:13AM BLOOD WBC-11.2* RBC-2.42* Hgb-6.7* Hct-20.9*
MCV-86 MCH-27.7 MCHC-32.1 RDW-16.6* RDWSD-51.8* Plt ___
___ 03:49PM BLOOD Hct-26.9*#
___ 05:52AM BLOOD WBC-12.0* RBC-3.03*# Hgb-8.4*# Hct-25.6*
MCV-85 MCH-27.7 MCHC-32.8 RDW-17.6* RDWSD-54.2* Plt ___
___ 05:45AM BLOOD WBC-11.9* RBC-2.88* Hgb-8.0* Hct-24.1*
MCV-84 MCH-27.8 MCHC-33.2 RDW-17.0* RDWSD-51.1* Plt ___
___ 05:43AM BLOOD WBC-13.5* RBC-3.08* Hgb-8.7* Hct-26.2*
MCV-85 MCH-28.2 MCHC-33.2 RDW-16.6* RDWSD-49.1* Plt ___
___ 05:00AM BLOOD WBC-15.8* RBC-3.26* Hgb-9.0* Hct-27.7*
MCV-85 MCH-27.6 MCHC-32.5 RDW-16.9* RDWSD-50.4* Plt ___
___ 05:45AM BLOOD WBC-11.9* RBC-2.88* Hgb-8.0* Hct-24.1*
MCV-84 MCH-27.8 MCHC-33.2 RDW-17.0* RDWSD-51.1* Plt ___
___ 05:43AM BLOOD WBC-13.5* RBC-3.08* Hgb-8.7* Hct-26.2*
MCV-85 MCH-28.2 MCHC-33.2 RDW-16.6* RDWSD-49.1* Plt ___
___ 05:00AM BLOOD WBC-15.8* RBC-3.26* Hgb-9.0* Hct-27.7*
MCV-85 MCH-27.6 MCHC-32.5 RDW-16.9* RDWSD-50.4* Plt ___
___ 06:25AM BLOOD WBC-15.2* RBC-3.20* Hgb-9.0* Hct-27.6*
MCV-86 MCH-28.1 MCHC-32.6 RDW-17.1* RDWSD-52.0* Plt ___
___ 04:15AM BLOOD WBC-13.7* RBC-2.71* Hgb-7.7* Hct-24.1*
MCV-89 MCH-28.4 MCHC-32.0 RDW-17.4* RDWSD-54.4* Plt ___
___ 11:20AM BLOOD WBC-13.4* RBC-2.88* Hgb-8.0* Hct-25.5*
MCV-89 MCH-27.8 MCHC-31.4* RDW-17.3* RDWSD-54.5* Plt ___
___ 05:02AM BLOOD WBC-10.9* RBC-2.71* Hgb-7.5* Hct-24.1*
MCV-89 MCH-27.7 MCHC-31.1* RDW-17.4* RDWSD-55.5* Plt ___
Brief Hospital Course:
MEDICINE COURSE ___:
# Pseudo-Bowel Obstruction - Likely the cause of her abdominal
pain. CT done in the ED showing possible large bowel
obstruction. Surgery consulted in the ED, think likely pseudo
bowel obstruction ___ use. They initially recommended
NPO and IV fluids. Lipase was found to be normal. Octreotide was
held. Patient received multiple enemas and PR Bisacodyl. Patient
has small bowel movement on ___ and 2 more on ___. Abdominal
KUB showed distended loops of bowel which looked stable on ___
and ___bd on ___ showed increased
distension of colon, with no perforation or pneumatosis. Medical
management with multiple enemas, PR Bisacodyl, oral citrate and
milk of mag was not successful in helping the patient. GI
performed flex sig and they were unable to place stent. Patient
was taken to OR on ___.
#Neuroendocrine Carcinoma: Receiving monthly octreotide, last
dose ___. Holding octreotide iso constipation/ LBO while in
the hospital.
#HTN - elevated blood pressure after holding home amlodipine and
losartan acutely given NPO. Home medications have been
subsequently restarted, losartan was increased to 100 daily.
Labetalol was added for blood pressure control. Continue
losartan 100 and amlodipine 10.
Continue labetalol 200mg TID (hold for SBP <140).
FICU COURSE:
The patient came to the FICU after her initial surgery on ___,
her abdomen was open at this time and she remained intubated and
sedated. Her BP was monitored and she was kept sedated and
intubated until she returned to the OR with colorectal surgery
on ___. Details of her problems below:
# LARGE BOWEL OBSTRUCTION due to neuroendocrine tumor S/P EX LAP
ON ___: Patient initially presented with a large bowel
obstruction, and ex-lap on ___ showed extensive metastasis
throughout the abdomen. S/p resection most of the bowel and
closure in OR on ___. She was treated with antibiotics:
Vancomycin & Meropenem ___ is last day. Palliative care was
consulted and met with the patient and the family. Her pain was
managed with a dilaudid gtt and then PCA upon extubation.
-Start TPN
# HYPOTENSION: IMPROVED
Was likely in setting of fluid shifts & blood loss
intra-operatively. She required neo & levophed in the OR on
___, and neo was quickly weaned off on arrival to the FICU.
Sepsis also possible. Much less concern for cardiac cause or PE,
given that hypotension occurred directly with sedation. She
improved in the ICU.
# ANEMIA: Patient had acute blood loss anemia in the OR, and
needed 4 units pRBCs with 2 units FFP. Her Hgb was monitored
closely and she was not transfused further in the FICU.
# RESPIRATORY FAILURE: Patient was intubated for her surgery,
and had no problems with oxygenation or ventilation throughout
surgery. Pt was intubated now s/p closure surgery. She was
extubated in the FICU and did well on room air. Incentive
spirometry was ordered to encourage air movement and prevent
atelectasis.
___:
Likely in the setting of poor renal perfusion with perioperative
hypotension and volume shifts. B/l Cr seems to be 0.8.
Downtrending now. Likely from ATN. Was monitored and began to
improve.
# HTN: Held home Losartan, Amlodipine, Labetalol while
hypotensive
Floor course ___:
___ transferred out of the FICU to floor, on NC, off
___
___ ___ ___ rehab, d/c'd basal pca rate,
+gas/fluid, amlodipine started for high blood pressure to 170s.
Patient ambulated.
___: Ordered Port placement for long-term TPN. PCA was
discontinued and switched to PO pain meds with good control.
___: JP dc'ed, TPN at goal, tele dc'ed.
___: tolerating small meals, cycled TPN@goal,
___: cystogram neg for leak, ua-, cxr equivocal for pna, 1L
for Cr 1.6 (1.4).
___: refused port placement, wants to wait to get it,
nervous about long term TPN.
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 spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: 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.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; and PRBCs transfusions were given when required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; 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. The patient was tolerating a small
frequent meal of low cab low 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.
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 spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: 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.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were given when required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; 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. The patient was tolerating small
frequent meals of low carb, low fat 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.
On ___ patient was discharged to rehab in good
conditions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Losartan Potassium 25 mg PO DAILY
3. LOPERamide 2 mg PO QID:PRN Diarrhea
4. Senna 8.6 mg PO DAILY:PRN Constipation
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
6. Simethicone 125 mg PO QID:PRN Abdominal Pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
3. Glucose Gel 15 g PO PRN hypoglycemia protocol
4. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
5. Metoprolol Tartrate 25 mg PO Q6H
6. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
7. Omeprazole 40 mg PO DAILY
8. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
9. amLODIPine 10 mg PO DAILY
10. HELD- Losartan Potassium 25 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until if needed (per PCP
and cardiology )
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
jejunal neuroendocrine tumor in ___ w/tumor recurrence,
malignant bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you at ___
___!
Please ___ 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. ___ 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, 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 ___ 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.
You should try to eat small frequent low fat low carb meals. you
will need a TPN for a long time , possibly for life, because the
left of bowel may not be sufficient to sustain your body with
required amount of nutrients.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
19759865-DS-20
| 19,759,865 | 28,735,953 |
DS
| 20 |
2134-06-21 00:00:00
|
2134-06-21 18:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
PICC removal
PICC insertion
History of Present Illness:
___ PMH of Metastatic jejunal NET (s/p mult abdominal resections
for malignant bowel obstruction now w/ end jejunostomy c/b
severe
short bowel syndrome, now on depot octreotide, everolimus, TPN
and daily mIVF (1L LR)) with recent admission for dehydration,
hyperkalemia, ___ from high ostomy output & short gut syndrome
who presents as a transfer from ___ for fever.
She presented to ___ for rigors and some mild abdominal pain. CT
a/p showed complex fluid collections c/f abscess. She received
cefepime, vancomycin, and Flagyl prior to transfer.
ED initial vitals were 100.4 98 106/67 16 100% RA
Exam in the ED showed : non-tender abdominal, but bilateral CVA
tenderness
ED work-up significant for:
-CBC: WBC: 5.1. HGB: 7.9*. Plt Count: 110*. Neuts%: 81.3*.
-Chemistry: Na: 141 (New reference range as of ___. K:
3.3* (New reference range as of ___. Cl: 105. CO2: 22.
BUN: 21*. Creat: 1.0. Ca: 8.5. Mg: 2.0. PO4: 3.1.
-Coags: INR: 1.2*. PTT: 28.0.
-LFTs: ALT: 26. AST: 38. Alk Phos: 123*. Total Bili: 1.4.
ED management significant for surgical consult, who recommended
RUQUS, broad spectrum IV ABx. She also received 40 mg IV
potassium.
On arrival to the floor, patient reiterates that up until 3 days
ago she was in USOH after her most recent discharge and doing
well. Then 2 days ago felt cold and ___ AM develop shaking
rigors, felt generally unwell and non-specific RLQ ab pain which
brought her to the ed.
Patient denies night sweats, headache, vision changes, neck
pain, photophobia. No dynophagia or dental pain.
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, cough, hemoptysis, chest pain, palpitations,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes. She denies pain at injection
site of octreotide from ___ and no pain at ___ site. No leg
swelling.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last clinic note by Dr ___:
"- ___: abdominal pain, fever, and chills. CT shows
a
mass in the small bowel. Other testing not entirely documented
(in ___
- ___: s/p resection. Path showed T4N1 well-differentiated
NET of the jejunum. Her chromogranin A was elevated to 117
prior
to resection.
- ___: Imaging showed ___, but
chromogranin
remained elevated
- ___: negative octreotide scan (NV)
- ___: CT Torso showed multiple small mesenteric lymph
nodes
(largest 14mm) and two subcentimeter nodules along the liver
capsule, concerning for recurrent metastatic disease.
- ___: chromogranin 207, serotonin 2379
- ___: Initiated octreotide 20mg IM monthly
- ___: Liver Bx showed metastatic NET, well-differentiated,
Ki67 16.6%
- ___: octreotide 20mg IM
- ___: admitted with nausea, vomiting, discovered to have
sigmoid bowel obstruction.
- ___ ex-lap, SBR, bladder repair
- ___ washout, TAC, SBR, L salpingectomy
- ___: Dotatate scan shows widespread disease in the
abdomen
- ___: octreotide 20mg IM (no dose since ___
PAST MEDICAL HISTORY:
Sarcoidosis (Dx early ___)
HTN
Thyroid nodule
SBO s/p resection (___)
Type II DM
Social History:
___
Family History:
Sister with colon polyps
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ 0029 Temp: 99.1 PO BP: 116/62 HR: 74 RR: 18 O2 sat: 96%
O2 delivery: RA
GENERAL: Well- appearing woman in no distress lying in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes dry, oropharynx
clear.
Poor dentition but no dental pain to palpation. No tongue or
palatal lesions. No lesions of posterior oropharynx or uvula.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly. Jejunostomy site
is c/d/I w/no slouging or erythema. ostomy with bilious thin
liquid c/w prior admissions from my experience w/her
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness. Foot exam bilaterally is without abnl.
MSK: glut site of IM injection w/o fluctuance or erythema
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout.
SKIN: No significant rashes. Left PICC site clean without
erythema, secretion, tenderness. No palpable cord
DISCHARGE PHYSICAL EXAM
========================
VS: 24 HR Data (last updated ___ @ 1203)
Temp: 97.9 (Tm 98.4), BP: 123/78 (117-146/62-86), HR: 77
(76-80), RR: 18, O2 sat: 99% (97-99), O2 delivery: Ra, Wt: 156.8
lb/71.12 kg
GENERAL: Well-appearing lady, in no distress sitting in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes moist, oropharynx
clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, ostomy bag full of liquid jejunal content,
normal bowel sounds, soft, non-tender, no guarding, no palpable
masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention and linear thought
process. CN II-XII intact. Strength full throughout. Sensation
to light touch intact.
SKIN: No significant rashes. Right PICC without drainage,
tenderness, erythema.
Pertinent Results:
___ 08:07PM BLOOD WBC-5.1 RBC-2.76* Hgb-7.9* Hct-25.1*
MCV-91 MCH-28.6 MCHC-31.5* RDW-13.9 RDWSD-45.7 Plt ___
___ 08:07PM BLOOD Neuts-81.3* Lymphs-14.4* Monos-3.7*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-4.12 AbsLymp-0.73*
AbsMono-0.19* AbsEos-0.00* AbsBaso-0.01
___ 08:57AM BLOOD Neuts-59.3 ___ Monos-14.1*
Eos-4.1 Baso-0.3 NRBC-0.3* Im ___ AbsNeut-3.66
AbsLymp-1.27 AbsMono-0.87* AbsEos-0.25 AbsBaso-0.02
___ 08:07PM BLOOD Glucose-120* UreaN-21* Creat-1.0 Na-141
K-3.3* Cl-105 HCO3-22 AnGap-14
___ 08:57AM BLOOD Glucose-115* UreaN-11 Creat-0.9 Na-142
K-4.2 Cl-100 HCO3-32 AnGap-10
___ 06:05AM BLOOD ALT-24 AST-38 LD(LDH)-264* AlkPhos-113*
TotBili-1.8* DirBili-1.4* IndBili-0.4
___ 08:57AM BLOOD ALT-26 AST-44* LD(LDH)-262* AlkPhos-180*
TotBili-0.7
___ 06:05AM BLOOD Calcium-8.4 Phos-1.9* Mg-1.9
___ 08:57AM BLOOD Albumin-3.3* Calcium-9.4 Phos-4.1 Mg-2.2
___ 05:17AM BLOOD Triglyc-187*
___ 05:17AM BLOOD 25VitD-8*
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| NON-FERMENTER, NOT
PSEUDOMONAS AERUGIN
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S 8 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S 1 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S 8 R
Right-sided PICC line has been placed with its tip projecting
over the
cavoatrial junction. Left-sided PICC line has been removed.
Lungs are clear. Cardiomediastinal silhouette is stable. There
is no pleural effusion. No pneumothorax is seen
Brief Hospital Course:
Mrs. ___ is a ___ year-old lady with metastatic jejunal NET
on everolimus s/p multiple SB resections c/b short bowel
syndrome now TPN/IVF-dependent who presented with fever and
rigors, found to havesepsis with K.pneumonia BSI and pelvic
fluid of uncertain significant who improved with broad
antibiotic coverage and PICC removal. Now stable on CTX with new
PICC in place, TPN restarted and monitored >___ for refeeding
syndrome.
#K.pneumonia Sepsis/BSI
Met sepsis criteria via fever, tachycardia, leukopenia,
positiveblood culture. Source remains unclear at this time and
may have included urinary (no OSH urine cx), CLABSI (PICC
pulled, tip cultured but negative cx), gut translocation. SIRS
resolved with broad antibiotic coverage. Narrowed to CTX based
on cultures, surveillance cultures are negative to date. Will
need to complete 14 day course of CTX 2g q24h on ___.
#Pelvic fluid: Found on OSH CT. Fluid is serous on CT
appearance, had mild peritoneal enhancement which was stable on
interval imaging at ___ suggesting more likely
malignancy-related enhancement. Colorectal surgery consulted who
recommended against fluid drainage as appears sterile and would
risk infection. Initially covered with metronidazole for this
possibility but discontinued on ___ given stable CT.
#Small Bowel Insufficiency
#High Jejunostomy output
#High risk for malnutrition
Small bowel insufficiency and TPN/IVF dependent secondary to
multiple SB resections. Jejunostomy output oscillated during
admission but was grossly similar to previous generating daily
-1500cc TBW (including TPN). Resumed 1L NS daily upon discharge.
Patient was started on loperamide 4mg q6h and uptitrated
psyllium 2WAF tid to minimize output. New PICC was placed and
patient started on TPN and monitored >___ for refeeding
syndrome.
#Hypokalemia
#Hypophosphatemia
Secondary to GI losses
Oncology repletion scales
#Pancytopenia
Multifactorial including everolimus and sepsis. Improved during
admission. Hb<7 at multiple times during admission but patient
declined transfusion.
#Metastatic jejunal NET
Metastatic to liver, s/p multiple bowel resections. Everolimus
held in setting of sepsis due to immunosuppresion (discussed
with primary oncologist Dr. ___. CT A/P with some evidence
of progression of disease. Treatment plan to be re-addressed in
the outpatient setting.
#HTN
#CAD
Held metoprolol and amlodipine in setting of hypovolemia.
Patient normotensive at all times, metoprolol and amlodipine
discontinued upon discharge.
#Type 2 DM
Patient without need for sliding scale for >48h on TPN. Insulin
discontinued.
#Vitamin D Deficiency: Extremely low in spite of supplementation
with 50,000U weekly
likely ___ rapid intestinal transit and absence of terminal
ileum. Discussed with nutrition, no IV formulation available.
Will attempt daily supplementation with 5000U.
TRANSITIONAL ISSUES
====================
1. Oncology follow-up: Patient to get dotatate scan on ___ and
f/u with Dr. ___ on ___.
2. Antibiotic course: Will need to complete a 14-day antibiotic
course of ceftriaxone 2g q24h through (and including) ___
3. Ostomy output / IVF: Ostomy output is on average 2500cc/day,
have been uptitrating loperamide and psyllium while in house.
Please monitor ostomy output ___ times/week. For now will need
to remain in 1L NS daily in addition to her TPN.
4. Vitamin D: Switched from 50,000 weekly to 5000 daily due to
profound deficiency. Please repeat in 1 month and adjust dose as
necessary.
5.Pending labs: Vitamins A, E, K pending upon discharge. Please
follow-up and supplement as needed
This patient's complex discharge plan was formulated and
coordinated over 90 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron ODT 8 mg PO Q8H
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Simethicone 120 mg PO QID
4. Everolimus 10 mg PO Q24H
5. Psyllium Wafer ___ WAF PO BID
6. Vitamin D ___ UNIT PO 1X/WEEK (TH)
7. amLODIPine 5 mg PO DAILY
8. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety
9. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
11. Metoprolol Tartrate 25 mg PO Q6H
12. Pantoprazole 40 mg PO Q24H
13. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H Duration: 10 Days
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV every
24 hours Disp #*8 Intravenous Bag Refills:*0
2. LOPERamide 4 mg PO Q6H
RX *loperamide 2 mg 2 tablets by mouth every six (6) hours Disp
#*100 Tablet Refills:*0
3. sodium chloride 0.9 % 1 liter intravenous DAILY
RX *sodium chloride 0.9 % 0.9 % 1 liter IV daily Refills:*3
4. Thiamine 100 mg PO DAILY Duration: 5 Days
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*5 Tablet Refills:*0
5. Psyllium Wafer 2 WAF PO TID
RX *psyllium 2 wafers by mouth three times a day Disp #*84 Each
Refills:*0
6. Vitamin D 5000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) [Ergocal] 2,500 unit 2
capsule(s) by mouth once a day Disp #*60 Capsule Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Ascorbic Acid ___ mg PO DAILY
9. LORazepam 0.5 mg PO Q8H:PRN nausea/vomiting/anxiety
10. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
11. Pantoprazole 40 mg PO Q24H
12. HELD- Everolimus 10 mg PO Q24H This medication was held. Do
not restart Everolimus until Dr. ___ recommends to resume
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Klebsiella pneumonia blood stream infection / sepsis
Intestinal insufficiency, high ostomy output
Pelvic ascites NOS
Severe vitamin D Deficiency
Pancytopenia
Metastatic jejunal neuroendocrine tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent, requires assistance
intermittently
Discharge Instructions:
Dear ___,
___ were admitted to the hospital due to a severe blood
infection. ___ were given antibiotics and improved. We had to
pull your old PICC line and place a new one. We restarted ___ on
your TPN. ___ will still need to be on fluids.
Please go to your appointments below and follow-up with Dr.
___ the next steps in your cancer treatment.
It was a pleasure to take care of ___.
Your ___ Team
Followup Instructions:
___
|
19759898-DS-17
| 19,759,898 | 24,630,656 |
DS
| 17 |
2129-02-27 00:00:00
|
2129-02-28 11:34:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Lower extremity weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of atrial fibrillation on Coumadin and recent
persistent episodes of NSVT who presents after having have legs
give out from underneath him twice today.
He has had a LinQ monitor placed, for which he is followed by
Dr. ___. Over the last few encounters documented in ___ he
has had persistent fatigue and dyspnea, that were not felt to be
due to his atrial fibrillation. A monitor was placed, and he has
had progressively more episodes of non-sustained ventricular
tachycardia. He has been started on amiodarone, and this was
increased to 200 mg daily very recently. He also had developed a
productive cough without fever, for which he was evaluated by
his PCP. A chest xray showed a RLL pneumonia, and he was placed
on Augmentin today is day ___. He seems to have tolerated
this, although he has a documented penicillin allergy. His cough
has persisted.
Today he was sitting on his balcony and went towards his
bedroom. His legs felt wobbly and as we walked his legs gave
out. He was not having chest pain or pressure or worsened
shortness of breath. He did not lose consciousness but did
strike his head. His wife helped him into bed, and there was no
concern for urinary incontinence or tongue biting. Soon after
this, he went to the bathroom and on the way back his legs gave
out again. He denies any precipitating palpitations or
pre-syncopal symptoms.
In the ED, initial vitals were: 97.5 110 113/68 100% RA
- Labs were significant for INR 2.7, BUN/Cr 63/6.5, CK-MB 5
with troponin of 0.09, H/H 10.2/32.3 which is stable from 12
days prior
- Imaging revealed no intracranial abnormality, persistent RLL
and new LLL opacities on CXR
- Cardiology was consulted and found that he had a 104 second
run of monomorphic VT at 1:45 pm at rate 158 bpm, and another
run for 148 seconds at 1:27 ___, coinciding with fall, as well as
other shorter runs.
- he was started on mexilitine 150 mg BID
- The patient was given mexilitine and levofloxacin
Vitals prior to transfer were 88 94/57 22 95% 1L
Upon arrival to the floor he endorses the above story and
continues to have a productive cough.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
CAD
CHF
Spinal stenosis
PFTs with decreased DLCO
Sleep apnea
CKD
Social History:
___
Family History:
Fa: HTN, mother died of breast ca
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.8 123/67 91 20 96% 1L (94% on RA, but wheezy)
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: regular rate, irregular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally except for mild
wheezing and ronchi at bilateral bases
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. PD site looks
uninfected
GU: No foley
Ext: Warm, well perfused, no peripheral edema
Neuro: motor function grossly intact with no focal deficit
DISCHARGE PHYSICAL EXAM:
Vitals: 97.8 123/67 91 20 96% 1L (94% on RA, but wheezy)
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: regular rate, irregular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. PD site looks
uninfected
GU: No foley
Ext: Warm, well perfused, no peripheral edema
Neuro: motor function grossly intact with no focal deficit
Pertinent Results:
ADMISSION LABS:
___ 03:14PM BLOOD WBC-6.2 RBC-3.46* Hgb-10.2* Hct-32.3*
MCV-93 MCH-29.5 MCHC-31.6* RDW-16.9* RDWSD-57.6* Plt ___
___ 03:14PM BLOOD Neuts-75.2* Lymphs-11.5* Monos-9.9
Eos-2.6 Baso-0.5 Im ___ AbsNeut-4.65 AbsLymp-0.71*
AbsMono-0.61 AbsEos-0.16 AbsBaso-0.03
___ 03:14PM BLOOD ___ PTT-36.3 ___
___ 03:14PM BLOOD Glucose-110* UreaN-63* Creat-6.5* Na-142
K-3.4 Cl-100 HCO3-27 AnGap-18
___ 07:52AM BLOOD ALT-20 AST-27 LD(LDH)-219 AlkPhos-42
TotBili-0.4
___ 03:14PM BLOOD cTropnT-0.09* (baseline)
___ 03:14PM BLOOD CK-MB-5
___ 03:14PM BLOOD Calcium-9.4 Phos-4.5 Mg-2.5
___ 03:14PM BLOOD TSH-4.0
___ 03:21PM BLOOD Lactate-1.5
IMAGING / STUDIES:
ECG ___
Atrial fibrillation with a controlled ventricular response.
Frequent
ventricular ectopy versus aberrantly conducted beats. Right axis
deviation
with right bundle-branch block and possible anteroseptal
myocardial infarction of indeterminate age. Prolonged Q-T
interval. Compared to the previous tracing of ___ QRS
morphology in lead V1 is more consistent with right
bundle-branch block. Ventricular ectopy versus aberrant
ventricular conduction is new.
Intervals Axes
Rate PR QRS QT P QRS T
88 ___ 0 120 -56
CXR ___
FINDINGS:
The patient is rotated to the left. Bibasilar, more conspicuous
on the right, opacities appears slightly increased on the right.
Prominence of the perihilar pulmonary vasculature is also
slightly more conspicuous. No large pleural effusion is seen
although a pleural effusion would be difficult to exclude on the
left. There is no evidence of pneumothorax. The cardiac and
mediastinal silhouettes are stable with the cardiac silhouette
mild to moderately enlarged.
IMPRESSION:
Persistent cardiomegaly. Mild to moderate pulmonary vascular
congestion.
Increase conspicuity of right lower lobe opacity worrisome for
persistent
pneumonia, with left base opacity also seen.
CT Head W/O Contrast ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
The lateral ventricles are slightly asymmetric. There is
prominence of the ventricles and sulci suggestive of
involutional changes. Periventricular white matter
hypodensities are consistent with sequela of chronic small
vessel ischemic disease. An old right basal ganglia lacune is
present.
There is no evidence of fracture. Mucosal thickening is noted
in scattered anterior ethmoid air cells and fluid is seen in the
right frontal sinus. The remaining visualized paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
DISCHARGE LABS:
___ 07:52AM BLOOD WBC-5.9 RBC-3.43* Hgb-9.9* Hct-32.1*
MCV-94 MCH-28.9 MCHC-30.8* RDW-17.0* RDWSD-57.5* Plt ___
___ 07:52AM BLOOD ___ PTT-36.2 ___
___ 07:52AM BLOOD Glucose-106* UreaN-66* Creat-6.5* Na-140
K-3.7 Cl-99 HCO3-27 AnGap-18
___ 07:52AM BLOOD Albumin-3.4* Calcium-9.4 Phos-4.9* Mg-2.6
Legionella Antigen: negative.
Brief Hospital Course:
___ with ESRD on peritoneal dialysis, atrial fibrillation on
Coumadin, and progressive episodes of ventricular tachycardia
who presents with weakness and fall without clear evidence of
syncope.
# Weakness and fall: Patient presented with ___ weakness and fall
with head strike. CT head was negative and Reveal LINQ monitor
was interrogated and found to have an almost 2 min run of VT
around the same time as the patient's symptoms. He was started
on Mexiletine 150 BID per the recommendation of his primary
cardiologist. Episode may have been exacerbated by concurrent
pneumonia but etiology still unclear. Upon discharge patient was
asymptomatic and was instructed to schedule close follow up with
his cardiologist.
# Ventricular tachycardia: Multiple episodes of monomorphic VT
on Reveal monitor. Started on mexiletine as above. TSH checked
and was normal. Trop at baseline and CK-MB normal at 5. Not a
good surgical candidate for ICD/ablation at this time given
comorbidities. Will defer to primary cardiologist. Home
amiodarone was continued.
REVEL INTEROGATION
Total of 379 events since implant. Over the past 1 month, he has
had multiple recordings of non-sustained ventricular
tachycardia,
typically <10s.
Today, there were 4 events:
VT at 13:45, lasting 1min45sec, mean rate of 158
VT at 9:04, lasting 7sec, mean rate of 154
VT at 6:17, lasting 7sec, mean rate of 162
VT at 1:27, lasting 2min28sec, mean rate of 162
# Pneumonia: Patient on augmentin day ___ without improvement
in symptoms, persistent cough, and worsening infiltrates on CXR.
He remained afebrile without an elevated white count.
Considering risks for atypical infection given PD and nursing
home exposure, he was started on Doxycycline 100mg BID and
Cefpodoxime Proxetil 400 mg daily. Ipratropium nebulizers were
also administered as well as cough suppressant for symptoms.
Instructed patient to follow up with his primary care physician
and consider repeat CXR in ___ weeks.
# Atrial fibrillation: Patient presented with history of atrial
fibrillation, he was therapeutic on current warfarin dose.
Warfarin continued without acute event and he was discharged
with a therapeutic INR of 2.9.
# ESRD on PD: Nephrology was notified but the patient did not
require dialysis during his brief hospital admission. To be
continued at home per normal schedule. He was continued on his
home medications and potassium was WNL on discharge. Consider
repeating potassium labs at next routine dialysis visit.
# Hypothyroidism: TSH was WNL at 4.0, levothyroxine was
continued.
TRANSITIONAL ISSUES:
# To follow up with cardiology for mexiletine duration and
adjustment.
# Please follow up with PCP for pneumonia to ensure resolution.
Consider repeat CXR in ___ weeks.
# Potassium normal on admission, stopped supplementation. Please
repeat routine labs at next dialysis visit to ensure resolution.
# Patient within therapeutic range on warfarin. Discharge INR
2.9. please recheck in 1 week.
# CODE STATUS: FULL CODE
# CONTACT: wife ___ ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Start: ___, First Dose: Next Routine Administration Time
2. Amiodarone 200 mg PO DAILY
3. Zolpidem Tartrate 10 mg PO QHS
4. Furosemide 40 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Cyanocobalamin 500 mcg PO DAILY
7. Calcitriol 0.5 mcg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Levothyroxine Sodium 112 mcg PO DAILY
10. Warfarin 4 mg PO 5X/WEEK (___)
11. Warfarin 6 mg PO 2X/WEEK (MO,TH)
12. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Calcitriol 0.5 mcg PO DAILY
4. Cyanocobalamin 500 mcg PO DAILY
5. Furosemide 40 mg PO DAILY
6. Levothyroxine Sodium 112 mcg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Warfarin 4 mg PO 5X/WEEK (___)
9. Warfarin 6 mg PO 2X/WEEK (MO,TH)
10. Zolpidem Tartrate 10 mg PO QHS
11. Tamsulosin 0.4 mg PO QHS
12. Cefpodoxime Proxetil 400 mg PO Q24H
RX *cefpodoxime 200 mg 2 tablet(s) by mouth daily Disp #*20
Tablet Refills:*0
13. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
14. Mexiletine 150 mg PO Q12H
RX *mexiletine 150 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Non-sustained Ventricular Tacycardia
Pneumonia
SECONDARY DIAGNOSES:
End Stage Renal Disease on peritoneal dialysis
Coronary artery disease s/p stents to RCA and LAD in ___
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you here at ___
___. You came to us after a passing out episode that
occurred around the same time as a long run of ventricular
tachycardia that was discovered on your Reveal LINQ monitor. You
were started on a new medication called mexiletine to try and
prevent this from happening again. You also had a worsening
pneumonia that we discovered on repeat chest x-ray. You were
stable and without fevers so we discharged you on a new 10-day
course of antibiotics to be taken as described below. We also
spoke with your primary cardiologist, Dr. ___ agreed
with our plan and will follow up with you in clinic to see how
long you should remain on the anti-arrhythmic medications.
You new medications are outlined below:
1. Mexiletine 150 mg to be taken twice a day for your heart
arrhythmia.
2. Doxycycline Hyclate 100 mg to be taken twice daily for 10
days starting today.
3. Cefpodoxime Proxetil 400 mg to be taken once daily (you
should take the two pills of 200 mg together in the morning) for
10 days starting today.
You should follow up in ___ weeks with your primary care doctor
and your cardiologist for follow up of your pneumonia and your
abnormal heart rhythm.
Thank you for choosing ___ for your healthcare needs.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19760478-DS-4
| 19,760,478 | 27,674,522 |
DS
| 4 |
2153-12-31 00:00:00
|
2154-01-01 10:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Erythromycin Base / Demerol / Dilaudid / Codeine /
Iodine Containing Agents Classifier / morphine / minocycline
Attending: ___.
Chief Complaint:
trauma: pedestrian struck by bike, head strike, +LOC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old F who was out walking her dog when
she was struck by a bicyclist. Reportedly she was unconscious
for 5 mins. EMS reports GCS on scene was 13. GCS 15 upon arrival
to ED. Upon evaluation patient reports occipital head pain and
nausea but denies any double vision, blurry vision, weakness,
numbness or tingling.
Past Medical History:
1) Chronic Hep C- liver biopsy revealing chronic hepatitis C,
grade ___ inflammation and stage 1 fibrosis. no treatment with
inteferon. + vaccination for hepatitis A and B,
(2) Status post three R hip replacements- first at age ___ for
avascular necrosis, last in ___. Received blood transfusion
with first hip tx thought to be source of hep C.
(3) History of ovarian cysts.
Social History:
___
Family History:
Father d. ___ CAD complications, h/o colon polyps.
Mother Alive and well in her ___
Brother with HTN
Physical Exam:
Discharge PE:
VS: Temp 98.7 HR 60 BP 99/52 RR 18 SPO2 99% RA
Gen: NAD, A&Ox3
HEENT: pupils reactive to light bilaterally, mild anisocoria
<1mm, EOMI, ~2.5cm circular abrasion on occiput w/o evidence of
hematoma, neck supple and nontender
CV: RRR
Pulm: clear, normal work of breathing
Abd: soft, NT/ND
Ext: WWP, No CCE, Abrasion Left anterior shin
Pertinent Results:
___:23AM BLOOD Glucose-114* Lactate-2.2* Na-136 K-4.6
Cl-102 calHCO3-24
___ 09:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:20AM BLOOD EDTA ___
___ 09:20AM BLOOD Lipase-81*
___ 09:20AM BLOOD estGFR-Using this
___ 09:20AM BLOOD UreaN-21* Creat-0.6
___ 09:20AM BLOOD UreaN-21* Creat-0.6
___ 09:20AM BLOOD WBC-4.6 RBC-3.65* Hgb-11.0* Hct-35.0
MCV-96 MCH-30.1 MCHC-31.4* RDW-13.5 RDWSD-47.5* Plt ___
___ 09:20AM BLOOD Plt ___
___ 09:20AM BLOOD ___ PTT-22.8* ___
___ CT C-spine No acute cervical spinal fracture or
traumatic malalignment
___ CT head Several small nondisplaced fractures L
occipital bone
___ CT C/A/P No evidence of acute intrathoracic or
intraabdominal injury
___ tib fib No fracture.
___ CT head 2 no new findings, stable to improved 2 mm
likely subdural hematoma
Brief Hospital Course:
The patient presented to the Emergency Department transported by
EMS after being struck as a pedestrian by a bicyclist. Pt was
evaluated upon arrival to ED by acutre care surgery. She was
noted to have a posterior scalp hematoma overlying her occiput
at the time and given findings and her history of head strike
with +LOC was sent for cross sectional imaging. This revealed a
small 2mm likely venous SDH and multiple small occipital bone
fractures. Neurosurgery was consulted and recommended discharge
with no neurosurgical followup. The patient developed
anisocoria thereafter in the ED as well as ongoing nausea,
emesis and vertigo. She was sent for a repeat head CT which
revealed no new findings or hemorrhage and interval diminution
in previously noted SDH. The patient was admitted to ___ for
observation and monitoring.
Neuro: The patient was alert and oriented throughout
hospitalization. Her nausea and vertigo were managed with
zofran and meclizine and improved throughout her hospital stay.
Her anisocoria was also less pronounced at time of discharge and
the patient denied visual changes. She had no loss of acuity.
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/GU/FEN: The patient was given a regular diet once stable
which she tolerated well
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: ___ 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. She will follow up in ___
clinic.
Medications on Admission:
denies
Discharge Medications:
1. Meclizine 12.5 mg PO Q8H:PRN Pain
RX *meclizine 12.5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*25 Tablet Refills:*0
2. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*25 Tablet Refills:*0
3. Acetaminophen 1000 mg PO TID
4. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
-2 mm likely subdural hematoma adjacent to the left cerebellar
hemisphere
-Several small nondisplaced fractures of the left occipital
bone, extending from the skull base superiorly.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ and
underwent observation and monitoring after your head trauma. You
are recovering well and are now ready for discharge. Please
follow the instructions below to continue your recovery:
Contact your personal physician or the ___ Department if
you have:
-Repeated vomiting
-Severe or worsening headache Severe or worsening dizziness
-Or any worsening symptom that alarm you
Followup Instructions:
___
|
19760514-DS-20
| 19,760,514 | 21,606,869 |
DS
| 20 |
2165-07-21 00:00:00
|
2165-07-22 11:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Constipation
Major Surgical or Invasive Procedure:
2 manual disimpactions ___
History of Present Illness:
___ 4wks s/p tricuspid valve repair for severe nonischemic
cardiomyopathy with h/o biventricular IVCD and chronic afib on
coumadin p/w no BM x 4d as well increasing intermittent crampy
lower abdominal pain. Last had small (golf ball sized) BM 4 days
ago. States recently BMs have been small and loose with
occasional hard balls of stool. Normally has BMs 2x/day. Has
tried prune juice, MOM, and OTC suppository. Denies any
nausea/vomitting in the past week (had some just after discharge
on ___, which he'd attributed to K+ supplements). Denies
fevers, nightsweats, cp, sob. Had difficulty w/fluid overload
and titrating torsemide and metolazone since discharge 3wks PTA
but has been doing well recently from that standpoint.
.
In ED VS were 97.3 89 98/63 20 99%. Labs were remarkable for
INR 1.9, Lipase 74, AST 70, Tbili 2.3, Dbili 0.7, hct 33.8
(baseline ___, Cr 1.5 (baseline 1.0), lactate 2.9. Blood
cultures drawn. Abdominal CT showed large amounts of feces in
colon. Given morphine 5mg and zofran 2mg. Cardiology cleared him
from their standpoint. Vitals on transfer were 98.0, 82, 89/64,
12, 99%RA.
.
On arrival to the floor, vitals were 96.1, 92/64, 81, 18, 96%RA.
Patient with persistent abdominal pain, no further bowel
movements but would like to try to go.
.
Review of systems:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea. No
recent change in bladder habits. No dysuria. Denied arthralgias
or myalgias.
Past Medical History:
CHF (EF ___ in ___
s/p Tricuspid valve replacement for TR
s/p biventricular pacer/ICD placement ___
s/p removal of pacer/ICD
s/p Left achilles tendon repair
s/p Sinus Surgery
chronic atrial fibrillation
nonischemic dilated cardiomyopathy
chronic dysphagia
Social History:
___
Family History:
Mother: ___ failure
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam:
VS: 96.1, 92/64, 81, 18, 96%RA
GA: AOx3, NAD
HEENT: PERRLA. difficulty with forming words, atrophy of facial
muscles. dry MM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 nml. no murmurs/gallops/rubs.
Pulm: CTAB no crackles, wheezes, rhonchi
Abd: soft, minimally distended, tender to moderate palpation
diffusely, worst in RLQ, tympanitic. +BS. no g/rt. neg HSM. Per
ED, heme pos brown stool w/o rectal impaction.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: petechiae on shins b/l
Neuro/Psych: A&Ox3. CNs II-XII grossly intact. ___ strength in
U/L extremities. sensation intact to LT. gait WNL.
Discharge Exam:
VS: 97.8, 98/65, 82, 18, 96%RA
GA: AOx3, comfortable, resting
HEENT: difficulty with forming words, atrophy of facial muscles,
appears scleroderma-like. dry MM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 nml. no murmurs/gallops/rubs.
Pulm: CTAB no crackles, wheezes, rhonchi
Abd: soft, NT, ND. +BS. no g/rt. neg HSM.
Rectal: No stool in rectum
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: petechiae on shins b/l
Neuro/Psych: A&Ox3. CNs II-XII grossly intact. ___ strength in
U/L extremities. sensation intact to LT. gait WNL.
Pertinent Results:
Admission Labs:
___ 02:20PM BLOOD WBC-7.0 RBC-3.63* Hgb-11.6* Hct-33.8*
MCV-93# MCH-32.0 MCHC-34.4 RDW-15.9* Plt ___
___ 02:20PM BLOOD Neuts-79.6* Lymphs-11.8* Monos-5.9
Eos-2.1 Baso-0.6
___ 02:20PM BLOOD ___ PTT-37.8* ___
___ 02:20PM BLOOD Glucose-113* UreaN-43* Creat-1.5* Na-137
K-5.1 Cl-86* HCO3-41* AnGap-15
___ 02:20PM BLOOD ALT-29 AST-70* AlkPhos-116 TotBili-2.3*
DirBili-0.7* IndBili-1.6
___ 02:20PM BLOOD Lipase-74*
___ 02:20PM BLOOD Calcium-9.6 Phos-2.9 Mg-2.8*
___ 06:50AM BLOOD Digoxin-0.7*
___ 02:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
___ 02:36PM BLOOD Lactate-2.9* K-4.5
Discharge Labs:
___ 06:30AM BLOOD WBC-7.0 RBC-3.43* Hgb-10.8* Hct-32.0*
MCV-93 MCH-31.5 MCHC-33.7 RDW-15.5 Plt Ct-86*
___ 06:30AM BLOOD ___
___ 06:30AM BLOOD Glucose-101* UreaN-44* Creat-1.5* Na-137
K-3.5 Cl-90* HCO3-38* AnGap-13
___ 06:30AM BLOOD ALT-25 AST-33 LD(LDH)-193 AlkPhos-107
TotBili-2.8*
___ 06:30AM BLOOD Albumin-3.9 Calcium-9.3 Phos-3.5 Mg-3.2*
Urine lytes:
___ 10:28PM URINE Hours-RANDOM UreaN-534 Creat-65 Na-<10
K-69 Cl-<10
___ 10:28PM URINE Osmolal-375
Microbiology: ___ blood culture NGTD
Imaging:
___ Ct abd and pelvis w/o contrast:
1. Limited study due to lack of oral and IV contrast.
2. Moderate right pleural effusion with adjacent atelectasis.
3. Mild ascites.
4. Distended colon with substantial fecal loading. No
obstruction seen.
5. Normal small bowel caliber.
6. Colonic diverticulosis, with no secondary signs of
diverticulitis.
7. Appendix equivocally seen, without secondary signs of
appendicitis.
8. Spondylolisthesis L4/5 with associated L4 pars defects.
9. Fatty infiltration of the liver.
Brief Hospital Course:
___ 4wks s/p tricuspid valve repair for severe nonischemic
cardiomyopathy (EF25-30%) with h/o biventricular IVCD and
chronic afib on coumadin p/w severe constipation, nausea and
abdominal pain as well as ___ in the context of overdiuresis.
.
Acitve Issues:
# Constipation/Abdominal pain/nausea: On CT scan in the ED,
patient was noted to have significant fecal loading throughout
the entire colon, which is likely explaining his symptoms. No
other acute abdominal pathology was noted. In the ED, rectal was
negative for stool. Denies taking any oxycodone (prescribed
last month after valvular surgery) and was rarely taking his
prescribed bowel regimen. Patient had been seeing Cardiology
regularly since his discharge the month prior and came in
overdiuresed and volume depleted, which could have contriubted
to his constipation. Patient was admitted and overnight he was
given lactulose, docusate, senna, bisacodyl PR, miralax, soap
suds enema, and magnesium citrate. After the magnesium citrate,
he passed a minimal amount of liquid stool, however was
distended, nauseous and vomiting. The morning following
admission, stool was felt in the rectum and a rectal
disimpaction was performed with moderate success during
disimpaction and in the hour following it. Patient was given an
enema which he could not tolerate and manual disimpaction was
again attempted that afternoon. A moderate amount of stool was
evacuated, a mineral oil enema was administered and overnight
patient passed a large amount of stool (first hardened stool,
then a large amount of diarrhea). The following morning,
patient's symptoms had completely resolved and he was feeling
much improved, tolerating PO food. He was discharged with
miralax standing daily, docusate standing BID, and senna BID
prn.
.
# ___: On admission, patient had a creatinine of 1.5 (baseline
1.0) and a K+ of 5.1 (on potassium supplements for hypokalemia
at home). His diuretics were held (torsemide) as well as his
potassium chloride. He was given a 500cc bolus overnight. Repeat
Cr the next morning was 1.7. Likely caused by decreased PO
intake, aggressive diuresis as an outpatient with torsemide and
metolzaone, and worsened overnight with stool softners and
osmotic agents. Urine lytes show patient is pre-renal. Patient
was put on maintenance fluids of NS at 75cc/hr. His Cr was
trending down on discharge (1.5). Dr. ___ came by and gave
further recommendations concerning his CHF management: no
metolazone, take torsemide 40mg daily and K+ supplements 10mg
TID.
.
#Metabolic alkalosis: Patient with bicarbonate of 41 on
admission, likely due to contraction alkalosis: decreased PO
intake, overly agressive diuresis. He was maintainted on IVFs
and his bicarb was trending down on discharge (38).
.
Chronic Issues:
# Elevated LFTs: Chronic issue (___), GI is aware. On
admission, patient with AST 70, Tbili 2.3, and Dbili 0.7. Lipase
74. No RUQ or epigastric pain. Bili has been elevated in the
recent past. LFTs returned to normal for the remainder of the
admission, with the exception of Tbili (2.8-2.9). Patient was
monitored for symptoms.
.
# Anemia: 32.0-35.6 over admission, which is slightly above
recent baseline (___), possibly due to overdiuresis. No
evidence of bleeding. Hct was trended.
.
# Afib: Patient maintained on warfarin 5mg daily (held the day
of discharge for an INR 3.1 (goal ___. He was also continued
on digoxin (dig level 0.7) at his home dose. Metoprolol was held
over admission give SBP in the ___ and per patient report, he
was not taking this at home. Dr. ___ continuing
the digoxin at the same dose and the metoprolol 12.5 Qdaily on
discharge.
.
# Cardiomyopathy/CHF: No symptoms, signs of CHF exacerbation.
Continued home ASA 81, held torsemide given ___ and apparent
overdiuresis. Due to hospitalization, patient missed his
appointment with Dr. ___. Dr. ___ the patient inhouse on
the day of discharge and made several recommendations: no
metolazone, take torsemide 40mg daily and K+ supplements 10mg
TID. The patient was scheduled for a follow up appointment with
Dr. ___ from discharge.
.
# Chronic dysphagia: Continued omeprazole.
.
# Insomnia: Continued home trazadone.
.
Transitional Issues:
Patient was scheduled to see his PCP this ___ morning for
post-discharge follow up, to ensure patient is having regular
bowel movement and for an INR check. He was scheduled to see Dr.
___ next ___ for further management of his
CHF.
Medications on Admission:
#. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation. *was not taking
daily.
#. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
#. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
#. digoxin 125mcg tablet PO Qday (started last ___
#. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day:
indication afib- INR goal 2.0-3.0
#. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). *has not been taking.
#. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily). *unsure if
taking or not.
#. torsemide 80 mg Tablet Qday (took 60mg today)
#. potassium chloride 10 mEq Tablet Extended Release Sig: 2
Tablets Extended Release PO TID.
#. trazadone 50mg Qhs
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___: Do not take today, ___.
4. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
Disp:*30 packet* Refills:*2*
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO three times a day.
10. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: 0.5 Tablet Extended Release 24 hr PO once a day.
11. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Constipation
Secondary Diagnosis:
CHF
s/p Tricuspid valve replacement for TR
s/p biventricular pacer/ICD placement ___
s/p removal of pacer/ICD
s/p Left achilles tendon repair
s/p Sinus Surgery
chronic atrial fibrillation
nonischemic dilated cardiomyopathy
chronic dysphagia
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 constipation and after
several oral medications, enemas and manual disimpaction, your
constipation has been resolved and you are passing liquid stool
which should resolve within the next day. You will need to stay
on an aggressive daily bowel regimen to prevent this from
happening again. Additionally, we spoke with Dr. ___
your heart failure medications and his recommendations are
below.
Please make the following changes to your bowel regimen:
- TAKE miralax 1 packet by mouth daily.
- TAKE Docusate sodium 100mg tablet by mouth twice daily.
- TAKE Senna 8.6mg 1 tablet twice daily as needed
Please make the following changes to your heart medication
regimen:
- DO NOT TAKE your warfarin today. Restart warfarin 5mg daily
tomorrow.
- TAKE torsemide 40mg by mouth daily
- TAKE Metoprolol 12.5mg by mouth daily
- TAKE Digoxin 125mcg tablet by mouth daily
- TAKE potassium chloride 10 mEq Tablet Extended Release 1
tablet by mouth three times a day.
- STOP metolazone
Continue all other medications as prescribed.
Followup Instructions:
___
|
19760514-DS-21
| 19,760,514 | 27,402,238 |
DS
| 21 |
2165-08-05 00:00:00
|
2165-08-06 13:38:00
|
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:
Cardiac catheterization
History of Present Illness:
This is a ___ yo M who is 5 weeks s/p tricuspid valve replacement
for severe nonischemic cardiomyopathy with h/o Bi-V IVCD (lead
causing wide open TR) and chronic afib on coumadin, who p/w one
day history of worsening DOE and orthopnea. Pt has noted DOE
with walking since his operation on ___. Three days ago his
DOE increased. Two nights ago, he noted increased orthopnea and
had 2 episodes of PND. He saw his cardiologist, Dr. ___
f/u yesterday, at which point he had no complaints. After the
appointment he noted increased DOE, occurring after a few steps.
All of these were acute changes from the past few weeks. No
appreciable increase in edema. Denies prior PND. Denies CP. Has
had nonproductive cough since leaving hospital on ___ for
constipation. No f/c. No n/v/d. Came in today because of acute
change in symptoms.
.
On ___ this AM, pt received 100mg IV lasix. Went for RHC after
which swan was placed. Now being admitted to CCU for milrinone
+/- lasix gtt for fluid management.
.
On arrival to CCU, pt was comfortable without complaints.
Past Medical History:
s/p Tricuspid valve replacement for TR
s/p biventricular pacer/ICD placement ___
s/p removal of pacer/ICD
s/p Left achilles tendon repair
s/p Sinus Surgery
chronic atrial fibrillation
nonischemic dilated cardiomyopathy
chronic dysphagia
Social History:
___
Family History:
Mother with renal failure. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION
VS - HR 70 BP 89/59 97%RA
GENERAL - thin elderly M in NAD, comfortable, appropriate, AAOx3
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, JVD ___ up neck @30 degrees
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, nl S1-S2. No RV heave noted.
Heart sounds distant.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 2+ bilateral pitting edema.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, grossly non-focal
.
DISCHARGE
GENERAL - thin elderly M in NAD, comfortable, appropriate, AAOx3
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD appreciated
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, nl S1-S2. No RV heave noted.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no edema.
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, grossly non-focal
Pertinent Results:
ADMISSION LABS
___ 03:25PM BLOOD WBC-6.1 RBC-3.48* Hgb-11.2* Hct-33.6*
MCV-96 MCH-32.3* MCHC-33.5 RDW-16.5* Plt ___
___ 03:25PM BLOOD Neuts-77.9* Lymphs-15.0* Monos-4.8
Eos-1.8 Baso-0.5
___ 03:25PM BLOOD ___ PTT-40.0* ___
___ 03:25PM BLOOD Glucose-90 UreaN-47* Creat-1.7* Na-138
K-4.7 Cl-94* HCO3-34* AnGap-15
___ 05:39AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.2.
.
CARDIAC ENZYMES
___ 03:25PM BLOOD cTropnT-0.03*
___ 07:25AM BLOOD CK-MB-3 cTropnT-0.03*
___ 07:25AM BLOOD CK(CPK)-33*
.
DISCHARGE LABS
.
PERTINENT LABS
.
PERTINENT STUDIES
CXR ___
FINDINGS: Frontal and lateral views of the chest were obtained.
The patient is status post median sternotomy. There are small
bilateral pleural effusions with overlying atelectasis. No overt
pulmonary edema is seen. The cardiac silhouette remains top
normal to mildly enlarged.
IMPRESSION: Small bilateral pleural effusions with overlying
atelectasis.
.
CARDIAC CATH ___
COMMENTS:
1. Resting hemodynamics revealed right and left filling
pressures with
RVEDP of 20 mmHg and PCW 27 mmHg. There was moderate pulmonary
artery
systoic hypertension with PASP of 53 mmHg. The cardiac index was
low at
1.9 L/min/m2.
.
FINAL DIAGNOSIS:
1. Biventricular elevated filling pressures.
2. Moderate pulmonary arterial hypertension.
.
ECHO ___
Conclusions
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is at least
15 mmHg. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. The left ventricular cavity
is dilated. Systolic function of apical segments is relatively
preserved. Overall left ventricular systolic function is
severely depressed (LVEF= 15%). [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] The right ventricular free wall
thickness is normal. The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are structurally normal. Moderate to severe (3+)
mitral regurgitation is seen. A bioprosthetic tricuspid valve is
present. The tricuspid prosthesis appears well seated, with
normal leaflet motion and transvalvular gradients. [Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be significantly UNDERestimated.] There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
IMPRESSION: Biatrial enlargement. Dilated, severely hypokinetic
left ventricle with relative preservation of the apical
segments. Dilated, hypokinetic right ventricle. Mild aortic
regurgitation. Moderate to severe mitral regurgitation.
Well-seated, normally functioning tricuspid annuloplasty ring.
Mild pulmonary artery systolic pressure.
.
Compared with the prior study (images reviewed) of ___,
there is worsening left ventricular global and regional systolic
function with a decrease in ejection fraction from 25% to 15%.
The severity of mitral regurgitation has increased minimally.
Mild pulmonary artery systolic hypertension is now appreciated;
its presence could not be determined previously.
___ TTE:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is top
normal/borderline dilated. There is severe global left
ventricular hypokinesis (LVEF = 25 %). The right ventricular
free wall thickness is normal. The right ventricular cavity is
mildly dilated with depressed free wall contractility. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. A bioprosthetic tricuspid valve is present. The tricuspid
prosthesis appears well seated, with normal leaflet motion and
transvalvular gradients.
Compared with the findings of the prior study (images reviewed)
of ___, systolic function of both ventricles is
improved.
Brief Hospital Course:
Mr. ___ is a ___ who is five weeks status post
tricuspid valve replacement for severe tricuspid regurgitation,
severe right ventricular enlargement, and severe right heart
failure, with recent removal of defibrillator coil that revealed
a massively dilated right atrium and right ventricle who is
presenting with worsening dyspnea on exertion.
.
#. ACUTE ON CHRONIC HEART FAILURE (RIGHT-SIDED, SYSTOLIC):
patient is ___ weeks s/p tricuspid valve replacement, now with
worsening right heart failure symptoms. TTE with worsening
systolic function as well with depressed EF. Attempts were made
with IV diuresis, but ultimately he required CCU admission for
milrinone. Initially he was started on milrinone alone and his
UOP was measured, and ultimately he required a lasix drip as
well to maintain good UOP. His cardiac output doubled with
milrinone therapy. Length of stay he was out approximately
___ net negative, his edema cleared, his lungs remained clear
and his JVP was no longer elevated. Symptomatically, he felt
much better, having improved exercise tolerance and a greatly
increased appetite. Milrinone was on for approximately 3.5
days, after which it and the lasix were stopped. He had a
repeat ECHO ~14 hours after cessation of his milrinone, showing
improved global function. He was started back on his home
torsemide without metolazone and maintained euvolemia.
.
#. AFIB/ectopy: patient therapeutic on warfarin with INR of 2.4.
Also rate-controlled with home digoxin and metoprolol. These
medications were continued throughout the admission. His afib
was rate controlled well, never having a rapid ventricular rate.
He did have a few episodes of ventricular ectopy with small
runs of NSVT although these were likely related to hypokalemia
and electrolyte shifts rather than the milrinone or other
intrinsic cardiac etiology.
.
#. ACUTE KIDNEY INJURY: Creatinine at 1.7 from a baseline in
late ___ of 1.0. Etiology is likely secondary to poor
forward flow rather than overdiuresis as his diuretics had
actually been decreased recently 1.5 weeks ago. His renal
function quickly improved with milrinone and at the time of
discharge was at his baseline.
Medications on Admission:
Omeprazole 20 mg EC PO BID
Aspirin 81 mg PO daily
Warfarin 5mg PO daily at 4pm
Trazodone 50mg PO qHS PRN insomnia
Polyethylene glycol 3350 17 gram/dose Powder one packet daily
Senna 8.6 mg Tablet PO BID
Docusate sodium 100 mg PO BID
Digoxin 125 mcg PO daily
Potassium chloride 10 mEq Tablet ER PO TID
Metoprolol succinate 12.5 mg PO daily
Torsemide 40mg PO daily
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. warfarin 5 mg Tablet Sig: ___ Tablets PO once a day.
4. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO three times a day.
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
10. torsemide 20 mg Tablet Sig: Three (3) Tablet PO once a day.
11. losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic systolic heart failure
Nonischemic cardiomyoapthy s/p ICD ___ later removed
Chronic AF
Chronic dysphagia
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 shortness of breath and
found to be in acute heart failure. You were given medication to
take off the extra fluid and no longer appear to be fluid
overloaded.
In the future- please call Dr. ___ the ___ right away
if you have symptoms of too much fluid: shortness of breath,
swelling in your feet or ankles, weight gain.
You should increase your Torsemide to 60mg daily. You will need
to have your electrolytes repeated in 1 week (you can have it
all done on ___ when you see Dr. ___.
Your INR has been low. You should increase your Coumadin to 5mg
alternating with 7.5mg daily. You should take 7.5mg tonight. You
will need to have your INR checked on ___.
You should resume your Digoxin (seems like you may have been on
and off this medication in the past).
Medication changes:
-INCREASE Coumadin to 7.5mg alternating with 5mg daily (take
7.5mg tonight)
-INCREASE Torsemide to 60mg daily
-ADD Losartan 12.5mg daily
-RESUME Digoxin 125mcg daily
For your heart failure diagnosis: Weigh yourself every morning,
call MD if weight goes up more than 3 lbs in 3 days or 5 lbs in
2 days. Follow a low salt diet and a fluid restriction of 1500
ml/ day.
Patient offered ___ services at home, declines the need for them
at this time. Please let us know if you reconsider.
Followup Instructions:
___
|
19760609-DS-18
| 19,760,609 | 21,655,473 |
DS
| 18 |
2188-01-09 00:00:00
|
2188-01-10 08:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
seafood
Attending: ___.
Chief Complaint:
acute pyelo
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presented to ___ on ___ with dysuria and urinary frequency
for the past week. Reports that on presentation she became worse
with rigors and chills. ___ evaluation notable for signs of
sepsis with tachycardia and fever with clinical diagnosis of
acute pyelonephritis based on positive UA and exam. She
received IV ceftriaxone and admitted to ___ obs. She continued
to have headache, mailaise, nausea and was febrile in the
afternoon on ___. She received levofloxacin on ___ at
midnight.
___ MD performed pelvic exam without findigns of cervical motion
tenderness. Chlamydia PCR positive as of ___.
13pt ROS otherwise
Past Medical History:
none
Social History:
___
Family History:
not pertinent
Physical Exam:
avss
well appearing
no cva tenderness
regular radial pulse
abdomen soft no suprapubic tenderness
anxious
Pertinent Results:
___ 11:41AM BLOOD WBC-9.9 RBC-3.75* Hgb-11.8* Hct-33.8*
MCV-90 MCH-31.4 MCHC-34.8 RDW-12.5 Plt ___
___ 08:55PM BLOOD WBC-12.5* RBC-4.25 Hgb-13.3 Hct-38.8
MCV-91 MCH-31.4 MCHC-34.4 RDW-12.2 Plt ___
___ 11:41AM BLOOD Neuts-78.9* Lymphs-11.6* Monos-8.7
Eos-0.8 Baso-0
___ 08:55PM BLOOD Neuts-84.7* Lymphs-10.5* Monos-4.2
Eos-0.4 Baso-0.1
___:41AM BLOOD Glucose-95 UreaN-5* Creat-0.8 Na-140
K-3.8 Cl-110* HCO3-23 AnGap-11
___ 08:55PM BLOOD Glucose-143* UreaN-14 Creat-0.9 Na-136
K-3.7 Cl-101 HCO3-21* AnGap-18
___ 09:12PM BLOOD Lactate-3.7*
___ 09:21AM BLOOD Lactate-1.0
IMPRESSION:
Preliminary ReportFindings concerning for acute pyelonephritis
involving the left kidney, as
Preliminary Reportabove. Fall due bladder is not well-distended,
and appears diffusely mildly
Preliminary Reportthick wall, which may relate to underlying
infection. Moderate amount of
Preliminary Reportpelvic free fluid.
___ 10:06 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
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
___ ___ ___ Microbiology Lab
Results
___ 10:41 am SWAB
**FINAL REPORT ___
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Final
___:
CHLAMYDIA TRACHOMATIS.
Positive by PANTHER System, APTIMA COMBO 2 Assay.
C. trachomatis organism viability cannot be inferred
since target
nucleic acid may persist after treatment in the absence
of viable
organisms.
Although the specificity of the chlamydia assay is very
high, the
positive predictive values may be suboptimal in
patients without
risk factors or compatible symptoms. Therefore,
positive results
should be interpreted in their clinical context.
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final ___: Negative for Neisseria gonorrhoeae by
___
System, APTIMA COMBO 2 Assay.
Brief Hospital Course:
___ with acute pyelonephritis with E.coli >100k on urine
culture.
Order IV ceftriaxone
symptomatic control of symptoms with tylenol, ibuprofen, and
zofran and morphine if needed
She received three days of parenteral antibitiotics and will
continue to take cipro 500mg bid for 4 additional days.
Chlamydia
given azithromycin 1000mg PO x1
received ceftriaxone for risk of gonorrhea co-infection
I recommended obtaining HIV testing but she initiall declined
Recommend her to obtain HIV testing in future.
I counselled her to notify her sexual partners of STI and to use
barrier protection. she refused
Discharge Medications:
1. Acetaminophen 325-650 mg PO/PR Q4H:PRN Pain
2. Ibuprofen 400 mg PO Q8H:PRN Pain
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
RX *ciprofloxacin HCl 500 mg ` tablet(s) by mouth twice a day
Disp #*8 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
you were treated for kidney infection with antibiotics
you will remain on antibiotics for four more days
Followup Instructions:
___
|
19760933-DS-12
| 19,760,933 | 23,552,799 |
DS
| 12 |
2110-01-31 00:00:00
|
2110-01-31 11:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
shrimp
Attending: ___.
Chief Complaint:
esophageal perforation rule out
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH of recent seizures without diagnosis presents as
transfer from ___ with concern for esophageal
perforation. He was in his usual state of good health yesterday
until he began vomiting uncontrollably (every ___ minutes from
midnight to 2AM) in the setting of significant alcohol
consumption and questionably bad food at a graduation party.
After multiple episodes of emesis, he developed severe mid
epigastric chest pain and his vomit turned dark brown. The pain
was unrelenting overnight and he presented to ___
in the AM where is was thermodynamically stable, though CT scan
demonstrated pneumomediastinum tracking along the esophagus and
extending into the visualized lower neck, concerning for
esophageal perforation. He was started on protonix and
imipenim/Cilastin and transferred to ___ for further
management.
Upon presentation to ___ ED, he was HDS with HCT of 37.9. Of
note, he has had 2 prior episodes of pneumothorax, the first in
setting of repeated vomiting (___) and the second developed
spontaneously (___). They were both managed non-operatively.
Past Medical History:
Undiagnosed seizure disorder, most recently on in ___
prior episodes of pneumothorax in setting of significant
vomiting
(in ___ and ___, Right wrist cyst excision.
Social History:
___
Family History:
Non-contributory.
Physical Exam:
VS: 98.3 60 125/80 16 98% NC
Gen: Well-nourished young man, grimacing pain, no acute distress
HEENT: Normocephalic. No enlarged lymph nodes. No evidence of
blood in oropharynx.
CV: RRR, no additional heart sounds
Pulm: Non-labored breathing. Diminished breath sounds in left
upper lobe. No crackles.
Abd: Thin, soft, non-tender, non distended. No guarding or
rebound tenderness. No mid epigastric pain with palpation.
Ext: No edema.
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW
RDWSD Plt Ct
___ 06:40 5.5 4.64 12.5* 37.9* 82 26.9 33.0 14.9
43.8 187
___ 14:50 10.3* 4.67 12.7* 37.9* 81* 27.2 33.5 14.6
42.5 205
___ Ba swallow :
Normal esophagram. No extraluminal contrast extravasation to
suggest
esophageal perforation.
___ Chest CT :
-Extensive mediastinal emphysema, extending into the
prevertebral space in the neck, which is partially imaged.
Evidence of extrapleural extension in the left apex and right
base. No definite luminal defect in the esophagus is seen.
-No evidence of pneumothorax or pleural effusion.
-Multiple nodules in peribronchovascular distribution, measuring
less than 6 mm, possibly due to aspiration. Given the patient's
age, no further follow-up is needed.
-Mild bronchial wall thickening, nonspecific.
Brief Hospital Course:
___ was transferred from ___ on ___. In the
ED an esophgram was obtained which was negative for a leak. He
was admitted for observation, made NPO and started on augmentin.
His diet was advanced to clears after a negative esophagram and
was well tolerated. On ___, he was advanced to a regular
diet and again, tolerated it well. A repeat CXR showed no
pneumothorax and a small amount of mediastinal air, his WBC was
5K and he was afebrile. He did have some diarrhea after
starting Augmentin but was encouraged to take yogurt over the
next few days. He will call us if it becomes problematic. After
a ubeventful stay he was discharged to home on ___ and will
follow up with Dr. ___ in a few weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 750 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
3. LevETIRAcetam 750 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pneumomediastinum secondary to severe vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for concern that you had a tear in your
esophagus. An esophogram showed no such tear. You were started
on prophylactic antibiotics and your diet was gradually advanced
to regular . You are know read for discharge. Complete your
antibiotic course and you will be called with a follow up
appointment.
Please come to the ED or call our office at ___ if you
experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
___
|
19761356-DS-18
| 19,761,356 | 21,898,274 |
DS
| 18 |
2140-04-29 00:00:00
|
2140-04-29 15:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
transfer from OSH with lower abdominal pain and diarrhea x 2
days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ presents with acute onset worsening abdominal pain x 2 days.
The pain is crampy and primarily located in his lower abdomen.
It is associated with 2 days of watery diarrhea that is
greenish/yellow in color. No blood. Denies fever, chills,
emesis, melena, and dysuria. He did have some mild nausea.
Poor PO intake the past 2 days due to the pain. Reports normal
volume and color of urine. The pain was exacerbated by any
movement and only relieved when lying still. He does report
abdominal distension. He does report occasional use of NSAIDS,
but nothing out of the ordinary. No recent sick contacts or
exotic foods. No recent antibiotics. He does have a history of
1 episode of diverticulitis where his pain was primarily located
in the RLQ. He has never had a colonoscopy.
Past Medical History:
PMH: HTN, bipolar affective disorder, hyperlipidemia, diabetes,
diverticulitis (treated with antibiotics outpatient)
.
PSH: lap umbilical hernia repair ___, vocal cord polyp
excision ___
Social History:
___
Family History:
No history of Crohn's disease or ulcerative colitis
Physical Exam:
On admission:
PE: 98.0, 74, 177/110, 16, 97% on room air
Gen: no distress, alert and oriented x 3
HEENT: PERLA, EOMI, anicteric, NGT in place, mucus membranes dry
Chest: RRR, lungs clear bilaterally
Abd: obese, disteneded with some tympany, tenderness to
palpation diffusely but moreso in the lower abdomen, no rebound
or guarding
Rectal: normal tone, guaiac negative
Ext: no edema, warm
---
On discharge:
VSS
Gen - NAD, AO x 3
Heart - RRR
Lungs - CTAB
Abd - obese, soft, NT, ND
Extrem - no edema
Pertinent Results:
___ 02:00AM WBC-9.7 RBC-4.67 HGB-12.2* HCT-37.4* MCV-80*
MCH-26.2* MCHC-32.7 RDW-14.4
___ 02:00AM PLT COUNT-185
___ 02:14AM LACTATE-1.5
___ 02:00AM GLUCOSE-84 UREA N-23* CREAT-1.0 SODIUM-144
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-26 ANION GAP-14
---
CT abd/pelvis (OSH): dilated loops of fluid filled small bowel
with potential transition in RLQ (decompressed terminal ileum),
diffusely thickened small bowel wall, free fluid in RLQ with
locules of air adjacent to cecum concerning for free air, free
fluid in pelvis and around the liver
___ - CT A/P
Long-segment ileitis with free fluid in the abdomen and pelvis.
No free intraperitoneal air detected. Differential diagnosis
includes infectious, inflammatory and ischemic etiologies.
Brief Hospital Course:
Mr. ___ was transferred from ___ with abdominal
pain and a CT scan (without PO contrast) that showed dilated
small bowel and questionable extraluminal air. Since he was
stable, a repeat CT scan with PO contrast was done to better
evaluate his bowel. This repeat CT scan showed long segment
ileitis and no free air.
The patient was admitted to the floor with an NGT. He was kept
NPO with IVF. On the morning of HD2, his NGT (which had low
output) was discontinued secondary to discomfort. He was
transitioned to clear liquids and had decreased pain and
tenderness on exam. He had regular flatus and BMs.
On HD 3, he tolerated a regular diet. He was voiding and
ambulating independently. His pain had resolved, and he was
non-tender on exam.
Of note, the patient had consistently high blood pressures up to
200 systolic and 100 diastolic during his hospital stay. He has
a history of poorly treated HTN. While NPO, he received IV
hydralazine as needed for blood pressure control. All of his
home blood pressure medications were resumed, and 25 mg of
hydrochlorothiazide daily was added for better blood pressure
control. The patient was encouraged to follow up with his PCP
for continued blood pressure management and with a GI doctor for
work-up of his ileitis.
Medications on Admission:
omeprazole 20mg bid, clomiphene cietrate, atenolol 100mg daily,
metforming 1000mg daily, venlafaxine ER 150mg daily, lisinopril
20mg daily, lamotrigine 200mg daily, bupropion XL 300mg daily,
doxazosin 8mg daily, simvastatin 40mg daily
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*14 Tablet Refills:*0
2. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*21 Tablet Refills:*0
4. Amlodipine 10 mg PO DAILY
5. Atenolol 100 mg PO DAILY
6. BuPROPion (Sustained Release) 300 mg PO QAM
7. Doxazosin 8 mg PO DAILY
8. LaMOTrigine 200 mg PO DAILY
9. Lisinopril 20 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
11. Nicotine Patch 14 mg TD DAILY
12. Omeprazole 20 mg PO BID
13. Simvastatin 40 mg PO DAILY
14. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Enteritis
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call the Acute Care Surgery clinic or return to the Emergency
Department if you have:
- worsening abdominal pain not relieved by medication
- persistent nausea or vomiting
- inability to eat or drink
- inability to pass flatus or have a BM
- fever greater than 101
- any other symptoms that are concerning to you
You will need to see a Gastroenterologist after your acute
infection resolves. This can be arranged through a referral
from you PCP, ___.
Your blood pressure was extremely high while you were admitted
to the hospital. We resumed all of you home medications but
also had to start Hydrochlorothiazide 25mg daily to help control
your blood pressure better. You should follow up with your PCP
to have your blood pressure checked.
Followup Instructions:
___
|
19761472-DS-6
| 19,761,472 | 29,723,082 |
DS
| 6 |
2190-03-25 00:00:00
|
2190-03-27 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:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Mr. ___ is a ___ year old male with a history of CAD s/p MI and
PCI in ___, CABG x4 ___ (left internal mammary artery to
left anterior descending; saphenous vein graft to the obtuse
marginal branch, saphenous vein graft to the diagonal branch,
saphenous vein graft to the right coronary artery), COPD, HTN,
and OSA, who presents with 1 day worsening epigastric pain,
radiating to the back, identical to anginal symptoms that he's
had in the past.
He presented to Dr. ___ office on ___ for increasing chest
pressure. EKG showed SR, Old IMI, STTWA in lateral leads and TWI
in
precordial leads more pronounced raising the possibility of
anterolateral ischemia. He was referred to the ED for a ___ and
Stress Test. CT A was negative for PE. Trp were negative. He was
referred for stress testing pMIBI. Nuclear testing showed
partially reversible, moderate perfusion defect in the
inferolateral wall. Trp were negative and he was observed,
discharged with medical treatment. Since then he endorsed
continued chest pain. He describes this as a "gas pain." He
feels bloating in his stomach, no chest pressure or SOB. This is
partially relieved with SL nitro. He experienced this last
night, sharper in intensity and again this morning. He took 2x
SL nitro this am with mild relief. He then went to his scheduled
f/u appointment with Cardiac Surgery. He experienced these
symptoms again, was given SL nitro, 325 ASA and transferred to
the ED for further evaluation.
Of note: His previous admission for CABG in ___:
Previously admitted on ___ with cath showing multivessel CAD.
TTE EF ___. He underwent CABG ___. ___ course was
complicated by Afib with RVR, requiring amiodorone gtt. He was
discharged on POD#5. The day after discharge he fell onto his
chest. He has not been without chest pain since his surgery.
Some pain is related to his sternotomy site. It was not healing
at the distal site and draining initialy. Better now. He states
the gas pains he has been exprienceing though are his angina
equivalent, similar to how he felt prior to his initial
presentation for MI in ___. AT baseline he is able to walk
___ yards before getting SOB.
In the ED, initial vitals were 96.2, HR 81 BP 123/95, RR14, SPO2
99% RA.
-He was given SL NG x3 and Morphine IV 5mg x2
-Discussed with cardiology attending. Given positive stress and
return of symptoms, will admit to ___ to consider for cath.
Labs:
8.5<12.3/38.8<300
INR 1.1
Trp <0.01
LFTs wnl
Na 139, K 4.5, Cr 1.1
Studies:
CXR: Right base atelectasis is seen without definite focal
consolidation. There may be minimal pulmonary vascular
congestion, improved since the prior study. The patient is
status post median sternotomy and CABG. The cardiac and
mediastinal silhouettes are stable. No pneumothorax is seen.
On arrival to the floor, he denies chest pain. Denies SOB. Feels
the best he has since arrival. He is worried that if he gets
morphine again, his respirations will slow down. He does not use
a CPAP at night for OSA dur to intolerance but stats that he
might need some supplemental O2.
Review of sytems:
(+) Per HPI, notes ___ weight loss
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath. Denies 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:
Anxiety
Arthritis
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease s/p PCI
Depression
Hypertension
Myocardial Infarction, ___
Obstructive Sleep Apnea (does not uses CPAP)
Social History:
___
Family History:
Brother - history of premature coronary artery disease
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 97.8, 138/96, 72, RR 18 SPO2= 98RA
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: Regular rhythm, no m/r/g, no pericardial rub
Chest: Well healed prior sternotomy scar, distal edge not fully
approximated, no drainage, warmth, erythema surrounding to
suggest infection
Lungs: CTAB, no w/r/r, strong inspiratory effort
Abdomen: soft, NT, obese, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
DISCHARGE PHYSICAL EXAM
Vitals: T= 97.4 HR ___ BP 143/81 RR=20 SPO2 100RA
Telemetry: SR, PVCs
Weight: 124.8kg
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: Regular rhythm, no m/r/g, no pericardial rub
Chest: Well healed prior sternotomy scar, distal edge not fully
approximated, no drainage, warmth, erythema surrounding to
suggest infection, no pain to palpation overlying surgical scar
Lungs: CTAB, no w/r/r, strong inspiratory effort
Abdomen: soft, NT, obese, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
Pertinent Results:
ADMISSION LABS
___ 03:00PM ___ ___
___ 03:00PM ___
___
___ 03:00PM ___
___ IM ___
___
___ 03:00PM PLT ___
___ 03:00PM cTropnT-<0.01
___ 03:00PM ALT(SGPT)-31 AST(SGOT)-26 ALK ___ TOT
___
___ 03:00PM ___ UREA ___
___ TOTAL ___ ANION ___
DISCHARGE LABS
___ 06:25AM BLOOD ___
___ Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD ___
___
___ 12:46PM BLOOD ___
___ 06:25AM BLOOD ___
PERTINENT LABS DURING ADMISSION
___ 05:30AM BLOOD ___
___ 03:15PM BLOOD ___
___ 06:40AM BLOOD ___
___ 03:25PM BLOOD ___
___ 06:25AM BLOOD ___
___ 12:46PM BLOOD ___
STUDIES
TTE ___
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the mid anteroseptum and
anterior wall and distal septum. The remaining segments contract
normally. Overall left ventricular systolic function is low
normal (LVEF ___. Doppler parameters are indeterminate for
left ventricular diastolic function. Right ventricular chamber
size is normal with borderline normal free wall function. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___,
overall left ventricular function and wall motion abnormalities
appear similar, given the suboptimal image quality.
CT A/P ___. No evidence of retroperitoneal hematoma or abdominal/pelvic
hemorrhage.
2. Infrarenal abdominal aortic aneurysm extending into the
common iliac
arteries bilaterally, right larger than left.
3. Multiple hypodensities within the liver that are too small to
characterize,
but likely represent cysts.
4. Diverticulosis without diverticulitis.
Cath Report
LMCA: without significant disease
LAD: diffuse 40% mid stenosis
___ diagonal is with 90% origin, 80% proximal, and 90% distal
stenosis
Circumflex: mild disease throughout
___ Marginal is with 60% stenosis in the small upper pole and
70% stenosis in the large lower pole
RCA is with 90% distal stenosis in prior placed stent and
competitive flow beyond
___: Widely patent but small vessel and with evidence of
disatl graft pathology
___- 99% stenosis in the distal body of the jump graft to
the ___ diagonal. The lesion has a TIMI flow of ___ and has no
noted calcification. This lesion is further described as
tubular. An intervention was performed on the ___ diagonal with
a final stenosis of 0%. There were no lesion complications.
___- Widely patent
Brief Hospital Course:
___ y/o male with h/o CAD s/p MI and PCI x5 in ___, CABG x4
___ (left internal mammary artery to left anterior
descending; saphenous vein graft to the obtuse marginal branch,
saphenous vein graft to the diagonal branch, saphenous vein
graft to the right coronary artery), presenting with symptoms
consistent with unstable angina, concerning for ischemia.
# Unstable Angina. On admission the patient was initially chest
pain free. Troponin x2 were negative and no ischemic EKG changes
were seen. The differential included failed graft given CP at
rest on admission and also ___ syndrome given
symptoms 1 month out from CABG. He did not exhibit pericardia
rub on exam. An element of mechanical chest pain was also
contributing given that the patient fell on his sternum several
days after leaving the hospital in ___ following his CABG
and has been dealing with chronic sternal pain since then. He
underwent cath which showed distal occlusion of the diagonal
graft with tight mid lesion. 3x DES were placed. He was chest
pain free following the procedure, however developed acute chest
pain overnight with acute drop in Hgb. CT Abdomen/Pelvis was
obtained which did not show any evidence of retroperitoneal
bleed. His Hgb remained stable and did not require transfusion.
Hgb on discharge was 10.1. Troponin rose with peak 0.55, MB 39.
MB downtrended to 5 before discharge. Given recurrence of chest
pain, he was started on colchicine for treatment of possible
pericarditis in the setting of ___ syndrome being 1 month
post CABG. He will continue on this medication for ___ months,
with exact duration to be determined by his outpatient
cardiologist. He was started and continued on Plavix daily. A
TTE showed LVEF ___ with similar areas of hypokinesis
___, anterior wall and distal septum as seen on
prior imaging.
# HTN. He was continued on lisinopril 10mg and uptitrated on his
metoprolol from 12.5 to 25mg daily.
# HLD. Continued home Atorvastatin
# Anxiety/Depression. Continued home buproprion, sertraline, and
Lorazepam prn
# COPD/OSA. He did not demonstrate s/s exacerbation. He was
continued on albuterol prn.
*** Transitional Issues ***
Cardiology
- 3x DES placed to Diagonal Graft. Will need Plavix for at least
___ year (___)
- Uptitrated to Metoprolol Succinate 25mg daily
- On Colchicine 0.6mg BID to be continued for ___ months with
exact duration to be determined in outpatient cardiology follow
up.
PCP
- ___ repeat CBC as outpatient to trend
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Aspirin 81 mg PO DAILY
6. Sertraline 50 mg PO DAILY
7. Lorazepam 0.5 mg PO BID:PRN anxiety
8. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB, wheeze
9. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN SOB
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN SOB, wheeze
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. BuPROPion (Sustained Release) 300 mg PO QAM
5. Lisinopril 10 mg PO DAILY
6. Lorazepam 0.5 mg PO BID:PRN anxiety
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Sertraline 50 mg PO DAILY
9. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*60
Tablet Refills:*0
10. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN SOB
11. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
12. Colchicine 0.6 mg PO BID
RX *colchicine 0.6 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Coronary Artery Disease
s/p CABG
Secondary Diagnosis
Hypertension
Hyperlipidemia
Anxiety/Depression
COPD
OSA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. Briefly, you were hospitalized with abdominal pain,
concerning for cardiac type chest pain. You underwent
catheterization and had 3 stents placed into one of your grafts
that was blocked from the CABG in ___. You were placed on
the medication Plavix which you need to take everyday for at
least ___ year. You will also need to continue taking aspirin 81mg
daily for life. Furthermore for your chest pain you were started
on a medication called Colchicine which you should take for at
least ___ months, with exact duration to be determined by your
outpatient Cardiologist.
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
19761932-DS-9
| 19,761,932 | 23,269,310 |
DS
| 9 |
2174-10-30 00:00:00
|
2174-11-01 12:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Neurontin / Celebrex / Vioxx
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, emesis
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
___ with past medical history of duodenal stricture of unknown
cause s/p gastrojejunostomy at ___ ___ c/b anastomotic
ulcer & stricture s/p conversion to gastroduodenostomy ___
p/w acute on chronic abdominal pain, NBNB emesis x3 and nausea.
The pain
started at 2am last night after pizza for dinner, intermittent
sharp and crampy, worse in RUQ/LLQ, exarcerbated by po intake,
mildly relieved by pain meds. Vomitus of large food chunks,
NBNB. She is passing flatus, last BM this am. She continues
NSAID use as part of her pain regimen.
She has a history of chronic abdominal pain since her prior
surgeries and is followed by chronic pain clinic in ___
where she has gotten multiple celiac plexus blocks, last being
in ___. Over the past few months she has noted increasing
abdominal pain, nausea, emesis and po intolerance. She has been
on a
predominantly liquid diet since ___ also takes solids
occasionally. She had an EGD in ___ which showed an
anastomotic stricture (per patient, we don't have records of
this.
Past Medical History:
PMH:
Duodenal structure, ? Gastroparesis, Asthma, Herniated disc s/p
spinal fusion, spleic artery aneurysm s/p coiling, GERD, chronic
constipation
PSH:
Gastrojejunostomy ___, Gastroduodenostomy ___,
Csection ___, spinal fusion ___ yrs ago, J-tube placements
Social History:
___
Family History:
No hx of IBD or GI cancer
Physical Exam:
VS: 98.0, 104/60, 71, 16 98RA
HEENT: anciteric sclera, oropharynx clear
Neck: supple, without LAD
Lungs: clear to auscultation bilaterally without crackles or
wheezes
CV: regular rate and rhythm, no M/G/R
Abdomen: soft, non-distended, mid-line scar, mildly tender to
palpation in the LLQ and the RUQ and RLQ, bowel sounds positive,
no rebound tenderness
Ext: warm without clubbing/cyanosis/edema
Neuro: CNII-XII grossly intact and symmetric, no gross motor
deficits
Pertinent Results:
Pertinent Labs:
___ 05:19PM WBC-7.5 RBC-3.76* HGB-11.9* HCT-36.1 MCV-96
MCH-31.5 MCHC-32.9 RDW-12.1
___ 05:19PM LIPASE-44
___ 05:19PM ALT(SGPT)-104* AST(SGOT)-58* ALK PHOS-109*
TOT BILI-0.2
___ 05:19PM GLUCOSE-83 UREA N-10 CREAT-0.5 SODIUM-137
POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-23 ANION GAP-8
___ 05:25PM LACTATE-0.9
___ 06:50AM BLOOD WBC-7.6 RBC-3.83* Hgb-11.8* Hct-36.1
MCV-94 MCH-30.7 MCHC-32.6 RDW-12.1 Plt ___
___ 06:50AM BLOOD ___ PTT-32.2 ___
.
Microbiology:
# Blood Culture (___): No growth.
.
Pathology:
# Duodenal mucosal ___: Within Normal Limits.
.
Imaging/Studies:
# UGI (___): 1. No evidence of obstruction although barium
remained in the stomach for over 20 minutes before passing into
the duodenum. 2. No contrast extravasation.
# EGD (___): Normal mucosa in the esophagus, food residue
seen in stomach. Otherwise normal mucosa. Anatomy suggestive of
duodeno-jejunostomy seen. Duodeno-jejunostomy site was normal.
Both the limbs of duodeno-jejunostomy entered and were widely
patent.
Brief Hospital Course:
Ms. ___ is a ___ year female with past medical history
significant for a duodenal stricture with gastrojejunostomy in
___ converted to gastroduodenostomy in ___
for acute on chronic abdominal pain who presented with increased
post-prandial abdominal pain as well as nausea/emesis. She was
admitted to the ___ surgical service to determine if her
symptoms were caused by an anastomic leak. Her presenting
symptoms did not correlate well with dysfunction of the
anastomosis and gastric outlet obstruction. She continued to
have nausea, emesis, and abdominal pain despite being given
anti-emetics and analgesics. She also had anorexia secondary to
the fear that she would vomit after eating. She had an upper GI
series performed on ___ which showed no evidence of
obstruction although barium remained in the stomach for over 20
minutes before passing into the duodenum and no contrast
extravasation. The gastrenterology service was consulted and it
was suggested that she receive an EGD to assess the patency of
the anastamosis. The EGD performed on ___ showed: normal
mucosa in the esophagus, food residue seen in stomach, normal
mucosa, anatomy suggestive of duodeno-jejunostomy seen,
duodeno-jejunostomy site was normal, both the limbs of
duodeno-jejunostomy entered and were widely patent. She was
relieved to find out that her anastamosis appeared to be
functioning properly. She was started on a two week course of
erythromycin in an attempt to decrease her nausea. As there did
not appear to be a surgically correctable etiology for her
current symptoms, she was discharged home and instructed to
follow up with her outpatient gastroenterologist to undergo
further testing (ie colonoscopy versus capsule endoscopy).
Medications on Admission:
1. Ibuprofen
2. MS ___ 30mg TID
3. Methadone 10mg TID
4. Morphine 15mg QID prn (takes every night and usually ___
other times)
5. Prilosec 40mg Daily
6. Welbutrin 300mg Daily
7. Fiorocet ___ tab Q6H: PRN headache
Discharge Medications:
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Erythromycin 250 mg PO Q6H Duration: 2 Weeks
RX *erythromycin [Ery-Tab] 250 mg 1 tablet,delayed release
(___) by mouth every six (6) hours Disp #*56 Tablet
Refills:*0
3. Methadone 10 mg PO TID
4. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain
5. Omeprazole 40 mg PO DAILY
6. Ondansetron 4 mg PO Q4H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
7. Morphine SR (MS ___ 30 mg PO Q8H
8. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
Discharge Disposition:
Home
Discharge Diagnosis:
Question of Gastroparesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 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.
JP 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).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
19761953-DS-20
| 19,761,953 | 20,597,923 |
DS
| 20 |
2170-12-19 00:00:00
|
2170-12-20 00:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Intermittent right leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman, previously healthy,
who has noticed intermittent right lower extremity weakness for
the past ___ days. He feels like his foot has been heavier, and
yesterday, there were a few instances where he could not move
his
toes/feet. He went to OSH, where head CT showed linear high
attenuation in left frontal parafalcine region.
In ___, he was evaluated for ringing in his ears, and brain
MRI showed right frontal gliosis, and right basal ganglia old
lacunar infarcts.
He had no preceding trauma, no headache, and no other associated
signs or symptoms.
Past Medical History:
Anxiety, depression, and "learning disability." On disability.
Social History:
___
Family History:
Father had a stroke in his ___ or ___, and he also had triple
bypass surgery.
Physical Exam:
ADMISSION EXAMINATION
=====================
Vitals: T: 97.5 P: 76 R: 18 BP: 136/90 SaO2: 95% on room air.
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: warm, well-perfused
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 2 -- said ___. Able to
relate history without difficulty. Inattentive, unable to ___
backwards, but could do forward. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name ___ objects,
but difficult with low-freq (said leaf instead of feather, and
said "some kind of plant" instead of cactus). Able to read
without difficulty. Speech was not dysarthric. Able to follow
both midline and appendicular commands. Pt was able to register
3
objects but recalled ___ at 5 minutes. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Fundoscopic
exam revealed no papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE 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.
No extinction to DSS. Romberg absent.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 3+ 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
DISCHARGE EXAMINATION
=====================
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple
Pulmonary: Normal work of breathing
Cardiac: warm, well-perfused
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, cooperative; some difficulty recalling
details of past history. Language is fluent with intact
comprehension. Speech was not dysarthric. Able to follow both
midline and appendicular commands.
-Cranial Nerves:
II, III, IV, VI: PERRL. EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: No pronator drift bilaterally.
Delt Bic Tri WrE FE IP Quad Ham TA
L 5 5 5 5 ___ 5 5
R 5 5 5 5 ___ 5 5
-Sensory: No deficits to light touch or extinction to DSS.
-DTRs: ___.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: Deferred.
Pertinent Results:
___ 06:30AM BLOOD WBC-7.3 RBC-5.00 Hgb-15.0 Hct-43.4 MCV-87
MCH-30.0 MCHC-34.6 RDW-11.4 RDWSD-36.0 Plt ___
___ 06:30AM BLOOD Glucose-103* UreaN-13 Creat-0.9 Na-143
K-4.2 Cl-104 HCO3-26 AnGap-13
___ 07:40AM BLOOD ALT-17 AST-17 CK(CPK)-99 AlkPhos-72
TotBili-0.2
___ 07:40AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:30AM BLOOD TotProt-6.7 Cholest-253*
___ 07:40AM BLOOD Albumin-4.0 Calcium-9.1 Phos-4.0 Mg-2.2
___ 02:56PM BLOOD D-Dimer-227
___ 06:30AM BLOOD %HbA1c-5.2 eAG-103
___ 06:30AM BLOOD Triglyc-261* HDL-44 CHOL/HD-5.8
LDLcalc-157* LDLmeas-167*
___ 06:30AM BLOOD TSH-1.2
___ 06:30AM BLOOD CRP-0.8 ESR-2
___ 07:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 9:15 am BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
___ 9:20 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
___ 10:13 AM CHEST (PA & LAT)
No acute intrathoracic process.
___ 3:19 ___ MRA BRAIN W/O CONTRAST; MR HEAD W/O CONTRAST
1. Acute to subacute infarcts of varying ages within the left
frontal and
superior parietal lobes as detailed above, without evidence of
hemorrhagic
transformation. These are likely embolic in nature.
2. Trace subarachnoid hemorrhage overlying the left superior
frontal gyrus and within the left central sulcus, as seen on the
preceding CT. The relationship of this trace subarachnoid
hemorrhage to the acute to subacute infarcts is uncertain.
3. Small old lacunar infarct within the head of the right
caudate nucleus and an old infarct within the left middle
frontal gyrus in the left ACA-MCA border zone.
4. Punctate chronic microhemorrhage in the left lateral
occipital temporal
gyrus.
5. Mildly degraded MRA head due to motion artifact. No evidence
for
flow-limiting stenosis or aneurysm. Infundibulum at the origin
of the
aplastic right P1 segment.
___ 6:44 ___ CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC &
RECONS
1. Stable mild left frontal and left central sulcus subarachnoid
hemorrhage. No new hemorrhage.
2. Chronic left frontal and right caudate head infarcts. Small
acute to early subacute left frontal and superior parietal
infarct are better seen on the preceding MRI.
3. No flow-limiting stenosis in the major intracranial or
cervical arteries.
4. 2 ___ esophageal diverticulum.
___ 14:03 TTE
Good image quality. Premature appearance of agitated saline in
the left heart at rest c/w a stretched patent foramen ovale or
small atrial septal defect. Normal study. Normal biventricular
cavity sizes, regional/global systolic function. No valvular
pathology or pathologic valvular flow identified. Mild pulmonary
artery systolic hypertension.
Brief Hospital Course:
___ man with history notable for anxiety, depression,
prior left frontal infarct, reported history of learning
disability, and ___ transferred from OSH after presenting with
episodic right leg weakness, found to have left parafalcine
convexal subarachnoid hemorrhage. Follow-up MRI demonstrated
multiple foci of left frontal and superior parietal lobe
ischemic infarcts without evidence of significant
cerebrovascular disease on CTA, overall suggestive of a
cardioembolic etiology of infarcts. A TTE was performed that
demonstrated PFO with no valvular or embolic source - in
discussion with his cardiologist, PFO presence was known and
found previously. We recommended TEE to better assess his PFO
for likely closure, though Mr. ___ instead elected to have
his follow-up evaluation performed as an outpatient at ___
___. These findings were discussed with his
outpatient cardiologist, Dr. ___, at ___, who
agreed to obtain follow-up TEE, Duplex venous ultrasound of the
lower extremities, and cardiac monitoring to assess for
paroxysmal atrial fibrillation following discharge from ___.
MRV or CTV of the pelvis may also be considered to assess for
DVTs. In the meantime, aspirin 81 mg daily and atorvastatin 40
mg daily were started for secondary stroke prevention.
TRANSITIONAL ISSUES
1. Outpatient transesophageal echocardiogram with consideration
for PFO closure.
2. Outpatient Duplex venous ultrasound of the lower extremities;
consider CTV/MRV pelvis if negative to assess for DVT.
3. Outpatient cardiac monitoring for 30 days to assess for
paroxysmal atrial fibrillation.
4. Ongoing medication adherence counseling.
5. Cardiology Follow up
6. Neurology Follow up
Medications on Admission:
1. ARIPiprazole 20 mg PO DAILY
2. BusPIRone 15 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 (One) tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 (One) tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. ARIPiprazole 20 mg PO DAILY
4. BusPIRone 15 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
1. Multifocal left hemispheric ischemic infarcts
2. Convexal subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
evaluation of intermittent right leg weakness. Your initial CT
scan showed a small area of bleeding on the surface of your
brain, and a follow up MRI of your head showed signs of an old
stroke as well as multiple small new strokes. As your blood
vessel imaging did not show signs of significant vascular
disease, it is likely that the clots leading to your strokes
came from your heart. In discussing with your outpatient
cardiologist, you were previously found to have a connection
between your heart chambers (patent foramen ovale - PFO) that
may predispose you to strokes. An ultrasound of your heart
(transthoracic echocardiogram) was performed with prelim read
confirming the PFO with no other valvular abnormalities. We
strongly recommended a follow-up endoscopic study
(transesophageal echocardiogram), but you instead elected to
have this procedure done as an outpatient. This was discussed
with your cardiologist, who will follow up with you to schedule
the transesopagheal echocardiogram, ultrasound studies of your
legs, and heart rhythm monitoring.
In the meantime, we again started you on aspirin and a
cholesterol medication (atorvastatin) to reduce your risk of
future strokes.
Please follow up with your primary care provider and
cardiologist within the next week. Please also follow up with
Neurology within the next ___ months; if you would like follow
up at ___, please contact ___ for an appointment.
It was a pleasure taking care of you at ___.
Sincerely,
___ Neurology
Followup Instructions:
___
|
19761977-DS-16
| 19,761,977 | 21,116,145 |
DS
| 16 |
2181-09-09 00:00:00
|
2181-09-09 14:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Symptomatic Bradycardia
Major Surgical or Invasive Procedure:
___: dual chamber pacemaker placement
History of Present Illness:
___ with no cardiac history, HTN, L adrenalectomy presenting
with symptomatic bradycardia as transfer. Had mild SOB/"feels
like heart is working harder" x 1 week but didn't think to go to
hospital. At OSH, EKG lying down was "normal" but standing up
was "abnormal." Concerned about mild SOB symptoms. Not told
about CHF or afib history in the past, has CHF in the family. No
sick contacts, no recent infection, had sinus infection ___
months ago that has resolved for quite some time now.
Denies associated chest pain, chest pressure, nausea, vomiting.
Does report feeling of breathlessness and shallow breathing.
Reports having a similar episode last week when he was sitting
lasting several hours not associated with exercise. Reports
swimming laps last night without any symptoms
No new stressors, no recent travel.
In the ED initial vitals were: 97.9 45 164/118 16 97% RA.
EKG: sinus arrhythmia and bradycardia to 45-50. No ST changes.
Labs/studies notable for: trop neg x 1, normal Chem7, Cr 1.0,
urine tox and UA negative.
CXR:
Subtle opacity at the left lung base may relate to overlying
structures, but subtle consolidation is not excluded. Consider
repeat with PA and lateral views for further and better
evaluation, if patient able.
Vitals on transfer: 51 139/86 13 97%.
On the floor patient recounted similar history as above with the
following additions. He's been feeling fatigued/tired for the
last ___ months. In the last week, he's only had difficulty
catching his breath and the work of breathing feels "harder",
however denies DOE or orthopnea. Last ___ morning at work
for ___ hours, he experienced some lightheadedness like the room
was spinning. It self resolved. Again today morning, during his
nutritionist appointment, he noted to to the staff that he again
was feeling lightheaded, but without any room spinning today.
They took a HR on him which was notable to bradycardia. He notes
that both episodes occurred in the morning and suddenly without
any inciting factors. He notes he has been actively trying to
loose weight through diet and exercises as well in the last ___
months (does light weights and swimming) and he has successfully
lost 6 lbs. He is able to climb stairs and ambulate without
difficulty. He denies any symptoms of feeling lightheaded/dizzy,
palpitations, or chest pain with these activities. He says his
HRs increase with ambulation. He is very compliant with CPAP and
wears it every night. Diagnosed with OSA ___ years ago.
Currently, he denies any dizziness/lightheadedness, or symptoms
he experienced earlier. Has some generalized fatigue only and is
hungry.
He notes that in the past he was hospitalized for severe HTN,
where he was seen by a cardiologist then. At that admission,
they discovered L adrenal gland tumors that were later resected.
Since, his blood pressures have been stable and only required a
small dose of HCTZ.
Lastly, few months ago he had a sinus infection treated with
Amoxacillin, now completely resolved. He denies any recent bug
bites, travel, or rash.
Otherwise 12-point ROS negative. Specifically denies fevers,
chills, chest pain, chest pressure, cough, cold, rashes,
palpitations, DOE, orthopnea, diarrhea, constipation, abdominal
pain, melena, BRBPR, dysuria, lower extremity edema.
Past Medical History:
Hypokalemia
OSA, uses CPAP
Adrenal adenoma s/p resection
Primary hyperaldosteronism
Colonic adenoma
Right ear hearing loss
HTN
History of tobacco use
Elevated PSA
Pulmonary nodule
Heart palpitations in past
Social History:
___
Family History:
Brother: ___, early CAD/PVD. Prostate Cancer, Genetic
Disorder, HTN, ___
Father: ___, arthritis, melanoma, hearing loss, HTN
Mother: arthritis, genetic disorder, HTN
Sister: ovarian cancer, DM, genetic disorder, ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T97.9 BP 151/96 HR 63 RR 18 O2 SAT 98RA
Weight: pending.
GENERAL: Male in NAD, sitting comfortably in bed in NAD, AOx3
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. MMM.
NECK: Supple with JVP of 7 at 30 degrees
CARDIAC: Bradycardic, otherwise soft S1/S2, no murmurs
appreciated
LUNGS: CTAB, no wheezes, rales, ronchi
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm, well perfused, no edema appreciated.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas noted.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM:
=========================
VS: T 97.6 BP 130/85 (120-140/80-90) HR 60 (50-60s) O2Sat 94% RA
GENERAL: pleasant man, sitting comfortably in chair, alert and
awake, speaking in full sentences, in NAD
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. MMM.
NECK: Supple with JVP to clavicle
CARDIAC: RRR, otherwise soft S1/S2, no murmurs appreciated
LUNGS: CTAB, no wheezes, rales, ronchi
ABDOMEN: +BS, soft, NTND, no rebound or guarding.
EXTREMITIES: Warm, well perfused, no edema appreciated.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas noted.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:00PM BLOOD WBC-6.3 RBC-4.82# Hgb-15.3 Hct-44.9
MCV-93 MCH-31.7 MCHC-34.1 RDW-12.1 RDWSD-41.1 Plt ___
___ 01:00PM BLOOD Neuts-53.1 ___ Monos-11.7 Eos-1.6
Baso-0.6 Im ___ AbsNeut-3.32 AbsLymp-2.03 AbsMono-0.73
AbsEos-0.10 AbsBaso-0.04
___ 01:00PM BLOOD ___ PTT-32.5 ___
___ 01:00PM BLOOD Glucose-103* UreaN-22* Creat-1.0 Na-139
K-3.7 Cl-104 HCO3-23 AnGap-16
___ 01:00PM BLOOD CK-MB-3
___ 01:00PM BLOOD cTropnT-<0.01
___ 07:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:00PM BLOOD Calcium-9.6 Phos-2.7 Mg-2.0
___ 01:00PM BLOOD TSH-0.93
___ 01:46PM BLOOD Lactate-1.3
NOTABLE LABS:
=============
___ 01:00PM BLOOD CK-MB-3
___ 01:00PM BLOOD cTropnT-<0.01
___ 07:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:00PM BLOOD TSH-0.93
___ 01:46PM BLOOD Lactate-1.3
DISCHARGE LABS:
===============
___ 06:00AM BLOOD WBC-6.2 RBC-4.87 Hgb-15.5 Hct-46.1 MCV-95
MCH-31.8 MCHC-33.6 RDW-12.0 RDWSD-41.7 Plt ___
___ 06:00AM BLOOD ___ PTT-30.7 ___
___ 06:00AM BLOOD Glucose-97 UreaN-25* Creat-1.2 Na-140
K-4.0 Cl-104 HCO3-24 AnGap-16
___ 06:00AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.2
MICRO:
=======
Lyme IgG (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Lyme IgM (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Negative results do not rule out B. burgdorferi infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody.
IMAGING:
========
___ Imaging CHEST (PA & LAT)
No pneumothorax. Pacer leads in standard position
___ Cardiovascular ECHO
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. Mild symmetric left ventricular
hypertrophy with normal cavity size, and regional/global
systolic function (LVEF >55 %). The estimated cardiac index is
normal (>=2.5L/min/m2). The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The
descending thoracic aorta is mildly dilated. The aortic valve
leaflets (?#) appear structurally normal with good leaflet
excursion. 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: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Dilated thoracic aorta.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
___ Imaging CHEST (PORTABLE AP)
Subtle opacity at the left lung base may relate to overlying
structures, but subtle consolidation is not excluded. Consider
repeat with PA and lateral views for further and better
evaluation, if patient able.
Brief Hospital Course:
Mr. ___ is a ___ year old man with no cardiac history, HTN, L
adrenalectomy who presented with episodes of lightheadedness and
was found to have new bradycardia and SA block.
#Symptomatic Bradycardia:
Patient found to have SA exit block, most consistent with type
II block given p wave intervals consistent before p-waves
dropped. Prior EKGs with sinus rhythm. His TSH was normal, Lyme
serologies were negative, and had no inciting events. He
underwent a TTE which showed no acute changes. EP was consulted
and he had a permanent dual chamber pacemaker placed on ___
without complication. He was given 3 day course of antibiotics
for surgical prophylaxis (vancomycin, transitioned to Keflex on
discharge). His pacemaker was interrogated after placement with
normal device function. CXR with appropriate lead placement.
Patient was discharged home with plans to follow up in clinic
with Dr. ___.
TRANSITIONAL ISSUES:
#Medication changes:
- Added Keflex ___ q6h for 2 days (last day ___
[] Patient with lightheadedness and SOB, believed to be ___
symptomatic bradycardia. Please follow up with patient on
resolution of symptoms s/p pacemaker placement.
# CODE: Full Code (confimred)
# HCP: ___ (husband), ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sildenafil 20 mg PO PRN sexual activity
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Vitamin D 5000 UNIT PO DAILY
5. B Complex Plus Vitamin C (vitamin B comp and C no.3) UNKOWN
oral daily
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth q6h PRN Disp
#*60 Tablet Refills:*0
2. Cephalexin 500 mg PO Q12H Duration: 2 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*3 Capsule Refills:*0
3. Aspirin 81 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Sildenafil 20 mg PO PRN sexual activity
6. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Symptomatic Bradycardia
SECONDARY DIAGNOSES:
====================
Hypertension
Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were recently admitted to ___
___.
Why I was here?
- You had a slow heart rate
What happened while I was here?
- You had a permanent pacemaker placed to help your heart beat
at a regular rate.
What I should do when I go home?
- Continue to take all medications as directed
- Continue to take the antibiotics for the next 2 days (last day
___
- Follow up with Dr. ___ in 1 week to interrogate your
pacemaker device
- Do not lift your arm above your head for 6 weeks
- Do not drive for 1 week
Thank you for allowing us to care for you,
Your ___ Care Team
Followup Instructions:
___
|
19762009-DS-10
| 19,762,009 | 21,754,957 |
DS
| 10 |
2122-11-20 00:00:00
|
2122-11-20 11:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with a PMH of COPD
(moderate, on chronic 2L O2), OSA, HFpEF, OSA (not on CPAP) who
is admitted with influenza and COPD exacerbation.
Pt reports being in her USOH until 2 days PTA. She attended
Bingo
___ night when she developed a tickle in her throat and a
slight cough. 1 day PTA (___) she developed worsening cough
and
slight dyspnea, but no change in her O2 requirements. On ___
she developed myalgias and arthralgias which prompted her to
seek
medical attention. Did not receive her flu shot this year. Has
been compliant with all home medications. Use her inhalers
regularly and did not use any rescue albuterol inhalers. Her
weight was 247, which she says is very good for her. No
worsening
of her chronic ___ edema, no orthopnea or PND. No fevers or
chills. Appetite has been normal. Bowel function and urine have
been normal. She says this feels very similar to her prior COPD
exacerbation in ___, but she has not had significant
wheezing. No sick contacts or recent travel. Denies headache,
rhinorrhea, PND, sneezing, rash. She has no other focal
complaints.
ED COURSE:
- Initial VS: 97.8 90 148/64 22 95% 2L NC
- Exam notable for: decreased air movement, stopping mid
sentence
to take a breath, frequently coughing. diffuse wheezing, peak
flow 110 pre nebs and did not improve post (though limited by
effort). EKG: unchanged from prior, no ST-T wave changes
- Labs: VBG 7.33/67, HCO3 33. WBC 10.4. FluA+. proBNP 77.
- Imaging showed: CXR w/ no e/o PNA or significant pulm edema.
- Pt received: prednisone 40mg, duoneb x1, azithro and
oseltamivir.
- VS prior to transfer: 98.6 91 113/78 20 94% 2L NC
ROS: 10 point ROS reviewed and negative except as per HPI
PAST MEDICAL HISTORY:
COPD (moderate - GOLD II FEV1 59%)
OSA - not on CPAP
Chronic exertional hypoxemia
HFpEF
HTN
HLD
Morbid obesity
Ventral hernia - s/p b/l rectus muscle flaps + prolene mesh
implant
CCY
ALLERGIES: NKDA
SOCIAL HISTORY: ___
FAMILY HISTORY: Reviewed and found to be non-contributory to
this
admission
Physical Exam:
___ year old woman with a PMH of COPD
(moderate, on chronic 2L O2), OSA, HFpEF, OSA (not on CPAP) who
is admitted with influenza and COPD exacerbation.
Pt reports being in her USOH until 2 days PTA. She attended
Bingo
___ night when she developed a tickle in her throat and a
slight cough. 1 day PTA (___) she developed worsening cough
and
slight dyspnea, but no change in her O2 requirements. On ___
she developed myalgias and arthralgias which prompted her to
seek
medical attention. Did not receive her flu shot this year. Has
been compliant with all home medications. Use her inhalers
regularly and did not use any rescue albuterol inhalers. Her
weight was 247, which she says is very good for her. No
worsening
of her chronic ___ edema, no orthopnea or PND. No fevers or
chills. Appetite has been normal. Bowel function and urine have
been normal. She says this feels very similar to her prior COPD
exacerbation in ___, but she has not had significant
wheezing. No sick contacts or recent travel. Denies headache,
rhinorrhea, PND, sneezing, rash. She has no other focal
complaints.
ED COURSE:
- Initial VS: 97.8 90 148/64 22 95% 2L NC
- Exam notable for: decreased air movement, stopping mid
sentence
to take a breath, frequently coughing. diffuse wheezing, peak
flow 110 pre nebs and did not improve post (though limited by
effort). EKG: unchanged from prior, no ST-T wave changes
- Labs: VBG 7.33/67, HCO3 33. WBC 10.4. FluA+. proBNP 77.
- Imaging showed: CXR w/ no e/o PNA or significant pulm edema.
- Pt received: prednisone 40mg, duoneb x1, azithro and
oseltamivir.
- VS prior to transfer: 98.6 91 113/78 20 94% 2L NC
ROS: 10 point ROS reviewed and negative except as per HPI
PAST MEDICAL HISTORY:
COPD (moderate - GOLD II FEV1 59%)
OSA - not on CPAP
Chronic exertional hypoxemia
HFpEF
HTN
HLD
Morbid obesity
Ventral hernia - s/p b/l rectus muscle flaps + prolene mesh
implant
CCY
MEDICATIONS:
The Preadmission Medication list is accurate and complete
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Furosemide 20 mg PO DAILY
3. Losartan Potassium 25 mg PO DAILY
4. Spironolactone 25 mg PO BID
5. Tiotropium Bromide 1 CAP IH DAILY
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
ALLERGIES: NKDA
SOCIAL HISTORY: ___
FAMILY HISTORY: Reviewed and found to be non-contributory to
this
admission.
PHYSICAL EXAM:
VS:98.9 136 / 81 98 18 94 2L Nc
GEN: NAD, pleasant female, obese, NAD
Eyes: anicteric, non-injectd
ENT: MMM, grossly nl OP, fair dentition
Neck: supple, non-tender, no LAD
Chest: Distant breath sounds bilaterally, less in bases. Slight
rales in RLL. No wheezing or rhonchi. Normal work of breathing.
CV: RRR, nl S1/S2. II/VI SEM at RUSB and precordium. no r/m. 2+
rad/DP pulses. JVD not elevated.
GI: Obese, protruding hernia. soft, NT/ND, NABS
GU: No foley
EXT: 1+ edema b/l to mid shin. No c/c. WWP
SKIN: No rashes or lesions c/f infection.
NEURO: AAOx3, CN II-XII intact. Strength is preserved in b/l
___ major flexors/extensors. Sensation grossly preserved in
b/l
___.
PSYCH: Mood and affect appropriate.
discharge
97.3 125/74 76 18 93RA
aox3 feeling better
limited air movement posteriorly, no clear wheezes heard
improved aeration anteriorly
regular pulse
moderate 1+ pitting edema to bilateral shins
Pertinent Results:
___ 04:20PM BLOOD WBC-10.4* RBC-4.97 Hgb-13.8 Hct-45.3*
MCV-91 MCH-27.8 MCHC-30.5* RDW-15.3 RDWSD-50.6* Plt ___
___ 07:21AM BLOOD WBC-10.9* RBC-4.64 Hgb-13.0 Hct-41.8
MCV-90 MCH-28.0 MCHC-31.1* RDW-15.3 RDWSD-50.5* Plt ___
___ 07:21AM BLOOD Creat-0.7 Na-136 K-4.3
___ 04:20PM BLOOD proBNP-77
___ 07:05PM BLOOD ___ pO2-26* pCO2-58* pH-7.36
calTCO2-34* Base XS-3
OTHER BODY FLUID
OTHER BODY FLUID VIRAL, MOLECULAR FluAPCR FluBPCR
___ 16:47 POSITIVE*1 NEGATIVE
FINDINGS:
Cardiac silhouette size is mildly enlarged but unchanged.
Mediastinal and
hilar contours are normal. Pulmonary vasculature is normal.
Subsegmental
atelectasis is noted in the right lower lobe. Lungs are
otherwise
hyperinflated with moderate centrilobular emphysema again noted,
better
assessed on the prior CT. Remainder of the lungs are clear. No
pleural
effusion, focal consolidation, or pneumothorax is present. Mild
degenerative
spurring is seen in the thoracic spine.
IMPRESSION:
No radiographic evidence for pneumonia. Moderate emphysema.
Brief Hospital Course:
___ year old woman with a PMH of COPD (moderate, on chronic 2L
O2), OSA, HFpEF, OSA (not on CPAP) who is admitted with
influenza and COPD exacerbation.
# Acute on Chronic Hypoxic Respiratory Failure
# Influenza A Respiratory Infection
# COPD Exacerbation: FluA positive.
She improved with supportive care that included a burst of
prednisone and use of oxeltamivir for influenza. Initial use of
azithromycin was soon discontinued on admission. She will use
supplemental oxygen with activity and at night.
# HFpEF: Appears modestly hypervolemic with peripheral edema but
this is likely chronic. BNP not very elevated.
- Continues on home losartan, furosemide, and spironolactone
- may benefit from increased dose of furosemide once she
recovers
from the flu if peripheral edema persists
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Furosemide 20 mg PO DAILY
3. Losartan Potassium 25 mg PO DAILY
4. Spironolactone 25 mg PO BID
5. Tiotropium Bromide 1 CAP IH DAILY
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. OSELTAMivir 75 mg PO BID
RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*5
Capsule Refills:*0
3. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Furosemide 20 mg PO DAILY
7. Losartan Potassium 25 mg PO DAILY
8. Spironolactone 25 mg PO BID
9. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
influenza
acute copd exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
you were hospitalized with influenza and acute copd exacerbation
you were treated with prednisone and an anti-viral medication,
Tamiflu
continue to use your oxygen
speak with pcp about increasing your Lasix dose as you still
have pitting edema of your ankles
Followup Instructions:
___
|
19762009-DS-8
| 19,762,009 | 27,717,790 |
DS
| 8 |
2122-04-02 00:00:00
|
2122-04-02 17:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fever to 104, leukocytosis, shortness of breath
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
In brief, this patient is a ___ year old woman with PMH
significant for HTN, prior diastolic CHF (EF > 55%), and COPD
not on supplemental oxygen prior to surgery, and recent open
cholecystectomy and ventral hernia repair with mesh, who
presents POD ___ s/p found to have fever to 104 and leukocytosis.
Her post-op course during most recent admission was notable for
questionable COPD exacerbation with need for BIPAP immediately
post-op in the PACU. She was discharged on ___ on 2L nasal
cannula, and doing well at rehab, without trouble breathing,
chest pain, or discomfort around the wound site. Today, she was
found to be febrile, so was transferred to ___,
where she had leukocytosis to 23. Therefore, she was transferred
to ___ for further management. She was initially on the ACS
service, but is transferred to medicine for concern for
hypoxemia.
In the ED patient's vital signs were Temp. 98.7, HR 113, BP
180/90, RR 28, 100% nebulizer. Labs notable for leukocytosis to
23.7 with 92% neutrophils. Chemistry within normal limits with
normal lactate. CT abdomen WET READ showed for Inflammatory
change, skin thickening, and a small amount of fluid in the
region of the ventral hernia repair, concerning for cellulitis.
No walled-off fluid collection. CXR without evidence of
pulmonary edema or pleural effusion.
Since admission to the floor, her breathing has improved, and
she feels well, without any pain around the wound site. She
emphasizes that her shortness of breath only occurred in the ED
here at ___ in the setting of anxiety and that she felt well
prior to transfer. She denies chest pain, pain around the
incision site, abdominal pain, and pain in her calves.
Past Medical History:
Past Medical History:
-HTN
-HLD
-CHF
-COPD
-s/p open cholecystectomy and large umbilical hernia repair
Social History:
___
Family History:
Positive for diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
==============================
PHYSICAL EXAM:
Vitals: 98.6 107/58 105 20 94 2L
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: clear to auscultation bilaterally, with loud breath
sounds, no wheezes, rales, or ronchi; mild crackles at the bases
bilaterally
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly;
large midline stapled incision with increased erythema and
induration around and below the navel, along the incision site
to the site of the drain, without fluid weeping from the
incision site. Drain in place, with 15 ml serosanguinous fluid.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no pain or tenderness in calves
Neuro: CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM
==============================
PHYSICAL EXAM:
Vitals: 99.0 121/73 84 21 99 3LNC
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: mild expiratory wheeze on the right, crackles at the
bases bilaterally
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly;
large midline stapled incision with erythema around and below
the navel, along the incision site to the site of the drain,
without fluid weeping from the incision site. Improved since
yesterday. Drain in place in RLQ, draining serosanguinous fluid,
less bloody than yesterday.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, or cyanosis,
1+ pedal edema bilaterally
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
==========================
___ 03:51AM BLOOD Hct-UNABLE TO
___ 07:30AM BLOOD Neuts-92.4* Lymphs-2.4* Monos-3.4*
Eos-0.4* Baso-0.3 Im ___ AbsNeut-21.92*# AbsLymp-0.57*
AbsMono-0.81* AbsEos-0.09 AbsBaso-0.07
___ 07:30AM BLOOD Plt ___
___ 03:51AM BLOOD Glucose-162* UreaN-16 Creat-0.9 Na-134
K-4.2 Cl-92* HCO3-28 AnGap-18
___ 03:51AM BLOOD estGFR-Using this
___ 03:51AM BLOOD proBNP-1276*
___ 04:50AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.1
___ 04:50AM BLOOD Vanco-7.9*
___ 03:51AM BLOOD
___ 03:55AM BLOOD Lactate-1.5
DISCHARGE LABS
==========================
___ 05:50AM BLOOD WBC-12.9* RBC-3.72* Hgb-10.3* Hct-34.3
MCV-92 MCH-27.7 MCHC-30.0* RDW-15.9* RDWSD-53.4* Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD Glucose-126* UreaN-15 Creat-0.5 Na-138
K-4.4 Cl-97 HCO3-33* AnGap-12
___ 05:50AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.2
Brief Hospital Course:
=====================
BRIEF HOSPITAL COURSE
=====================
In brief, this patient is a ___ year old woman with PMH
significant for HTN, prior diastolic CHF (EF > 55%), and COPD
not on supplemental oxygen prior to surgery, and recent open
cholecystectomy and ventral hernia repair with mesh, who
presents POD ___ s/p found to have fever to 104 and leukocytosis.
Her post-op course during most recent admission was notable for
questionable COPD exacerbation with need for BIPAP immediately
post-op in the PACU. She was discharged on ___ on 2L nasal
cannula, and doing well at rehab, without trouble breathing,
chest pain, or discomfort around the wound site. ___ she was
found to be febrile, so was transferred to ___,
where she had leukocytosis to 23 and was transferred to ___
for further management. She was initially on the ACS service,
but was transferred to medicine for concern for hypoxemia.
In the ED patient's vital signs were Temp. 98.7, HR 113, BP
180/90, RR 28, 100% nebulizer. Labs notable for leukocytosis to
23.7 with 92% neutrophils. CT abdomen showed inflammatory
change, skin thickening, and a small amount of fluid in the
region of the ventral hernia repair, concerning for cellulitis.
No walled-off fluid collection. CXR without evidence of
pulmonary edema or pleural effusion. Physical exam was notable
for increased erythema and induration around the incision site
and drain, and she was treated empirically for cellulitis with
Vancomycin, Flagyl, and Cefepime before her antibiotics were
narrowed to Keflex ___ QID for 7 days ___ - ___.
While in the hospital, her breathing improved, and she was
weaned from 4L to 2L nasal cannula. She emphasized that her
shortness of breath only occurred in the ED here at ___ in the
setting of anxiety and that she felt well prior to transfer. She
denied chest pain, pain around the incision site, abdominal
pain, and pain in her calves. Her O2 sats remained in the low
___, with de-sats in the ___ while sleeping. She was prescribed
a CPAP but does not use it at home because of difficulties
obtaining the device. She was not on CPAP in the hospital but on
continuous telemetry, with Q4 vitals and continuous O2 with
nasal cannula.
The drain in her abdomen was removed by the surgery team.
=====================
TRANSITIONAL ISSUES
=====================
1. follow-up with PCP regarding CPAP
2. Finish antibiotics Keflex ___ QID for 7 days ___ -
___
3. Follow-up with surgery team.
CONTACT: ___, ___
CODE: presumed full
Medications on Admission:
HOME MEDICATIONS:
Per review of rehab med rec:
-Tylenol 1 gram every 8 hours
-albuterol neb every 6 hours PRN
-bisacodyl suppository 10 mg daily
-calcium carbonate 500 mg QID
-Colace 100 mg BID
-fleet enema daily PRN
-advair 250-50 BID
-Lasix 20 mg daily
-losartan 25 mg daily
-Maalox 10 ml every 4 hours PRN
-miralax daily PRN
-oxycodone 5 mg every 4 hours PRN pain
-senna 8.6 mg BID
-spironolactone 25 mg BID
-tiotropium capsule daily
CURRENT INPATIENT MEDICATIONS:
-Acetaminophen 650 mg PO/NG Q8H:PRN Pain - Mild
-Heparin 5000 UNIT SC BID
-Vancomycin 1000 mg IV Q 12H
-CefePIME 2 g IV Q12H
-MetroNIDAZOLE 500 mg IV Q8H
-Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
-MED Tiotropium Bromide 1 CAP IH DAILY
-MED Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
-Losartan Potassium 25 mg PO/NG DAILY
Discharge Medications:
1. Calcium Carbonate 500 mg PO QID:PRN heart burn
2. Cephalexin 500 mg PO Q6H
3. Docusate Sodium 100 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 8.6 mg PO BID:PRN constipation
6. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing,
shortness of breath
8. Bisacodyl ___AILY:PRN Constipation
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Furosemide 20 mg PO BID
11. Losartan Potassium 25 mg PO DAILY
12. Spironolactone 25 mg PO BID
13. Tiotropium Bromide 1 CAP ___ DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
cellulitis
SECONDARY DIAGNOSES:
hypertension
hyperlipidemia
diastolic CHF (EF>55%)
COPD
s/p open cholecystectomy and umbilical hernia repair
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 from your rehabilitation
facility because of a fever and a high white blood cell count.
While you were here in the Emergency Department, you experienced
difficulty breathing. You had a CT scan which, together with
your blood cell counts, suggested that you had a skin infection.
We treated you with antibiotics, and your skin infection
improved. The surgery team also removed your drain. Please
continue to take your antibiotics everyday, until you have
finished them.
While you were here, you had trouble breathing, especially at
night. Please follow up with your primary care doctor about
obtaining a CPAP machine to help you breathe better while you
sleep.
It has been a pleasure to be involved in your care!
Your ___ care team
Followup Instructions:
___
|
19762009-DS-9
| 19,762,009 | 25,866,039 |
DS
| 9 |
2122-05-20 00:00:00
|
2122-05-23 17:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Wound infection
Major Surgical or Invasive Procedure:
___: ___ pigtail placement
History of Present Illness:
Ms. ___ is a ___ year old woman with PMH of HTN, CHF,
COPD, s/p open cholecystectomy and ventral hernia repair with
mesh who is presenting with increased erythema around surgical
incision and purulent discharge from surgical site. The patient
refers that this started 3 days ago with spontaneous discharge
and the erythema persistently increasing. She denies any fevers
or other symptoms accompanied with the wound. She was evaluated
at an outside hospital and transferred here for further
evaluation of wound.
Past Medical History:
HTN, HLD, CHF, COPD, Large ventral hernia s/p repair by
bilateral rectus muscle flaps and prolene mesh implant 15x15 cm,
open cholecystectomy
Social History:
___
Family History:
Positive for diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: 98.0 81 158/80 19 94% 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, non tender, non distended. There is a surgical midline
incision with blanching erythema around it and a midline sinus
with purulent discharge in the superior aspect. The inferior
portion of the wound appears erythematous and warm to touch.
Ext: No ___ edema, ___ warm and well perfused
DISCHARGE PHYSICAL EXAM:
=========================
Pertinent Results:
ADMISSION LABS:
===============
___ 12:15AM BLOOD WBC-10.7* RBC-3.96 Hgb-10.6* Hct-34.9
MCV-88 MCH-26.8 MCHC-30.4* RDW-15.4 RDWSD-49.2* Plt ___
___ 12:15AM BLOOD Neuts-72* Bands-0 Lymphs-18* Monos-7
Eos-2 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-7.70*
AbsLymp-1.93 AbsMono-0.75 AbsEos-0.21 AbsBaso-0.00*
___ 12:15AM BLOOD ___ PTT-26.5 ___
___ 12:15AM BLOOD Glucose-132* UreaN-17 Creat-0.7 Na-138
K-3.8 Cl-99 HCO3-29 AnGap-14
___ 12:29AM BLOOD Lactate-1.7
MICRO:
=======
DISCHARGE LABS:
================
Brief Hospital Course:
Ms. ___ is a ___ year old woman s/p ventral hernia repair w/
mesh and h/o prior MRSA infections of pannus. She presented to
the Emergency Department on ___ with cellulitis of surgical
incision with draining pus and found to have a pannus abscess.
Given findings, the patient was admitted to the Acute Care
Surgery team.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was well managed with PO Tylenol.
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/GU/FEN: The patient was on a regular diet, which was well
tolerated. Patient's intake and output were closely monitored.
ID: The patient was taken to ___ and had a drain placed into the
abscess. She was started on IV vancomycin and zosyn, then
narrowed to vancomycin given prior culture data of MRSA pannus
infection. The borders of her cellulitis were marked and noted
to recede from the markings each day. Her temperature curve was
closely monitored without any fevers. Her WBC was not elevated.
Cultures from the abscess and a swab of the pus grew out MRSA
sensitive to Bactrim. The patient was then transitioned to PO
Bactrim to continue her course of treatment at home. Pannectomy
was discussed with patient to help reduce the recurrence of
infection. She will follow up in clinic to continue discussions
on surgical intervention.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and was on PO
antibiotics for her infection. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Furosemide 20 mg PO DAILY
3. Losartan Potassium 25 mg PO DAILY
4. Spironolactone 25 mg PO BID
5. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Abdominal wall cellulitis and abscess
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. You were recently admitted
to the ___ for an infection in
your abdominal wall. You were given IV antibiotics and had a
drain placed into a collection of fluid. The collection grew a
specific bacteria and your antibiotics were changed to an oral
antibiotic. You should follow up with Dr. ___ in clinic to
discuss surgery to remove areas of your abdominal wall that have
had multiple infections. You will take oral antibiotics
(bactrim) until you are seen by Dr. ___ in clinic.
Please follow the below instructions to continue your recovery
at home.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Increase in the area of redness over your abdomen or increase
in color.
*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:
___
|
19762081-DS-13
| 19,762,081 | 24,280,500 |
DS
| 13 |
2130-10-09 00:00:00
|
2130-10-11 01:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tetracycline
Attending: ___
___ Complaint:
Shortness of breath, altered mental status
Major Surgical or Invasive Procedure:
Rigid bronch + EBUS/TBNA + stent
History of Present Illness:
Ms. ___ is a ___ woman with no PMH who is admitted
to the MICU for management of COPD exacerbation and respiratory
failure.
The patient developed cough and shortness of breath on ___.
The cough began to worsen with productive clear, thick mucous
over the next 4 days so she visited her PCP. At her doctor's
office, she was found to have an O2 saturation of 88% on RA. She
was sent to the ___ at ___ for further care. In the ___
___ she patient was afebrile, normotensive, with a white
count of 8.11. CXR was non-specific but with patchy infiltrates
at the bases. They recommended admission but the patient
refused. She was given a 5 day course of prednisone 50mg, a 7
day course of levaquin 750mg, and albuterol.
Over the following ten days the patient continued to experience
persistent shortness of breath, cough productive of white
sputum, and congestion so she returned to the ___ at ___ on
___. The shortness of breath was worse with exertion and
laying flat. The patient also noted non-pleuritic chest pain.
Notably, she denied fevers or chills. Her Oxygen saturation was
noted to be in the ___. She was afebrile. EKG showed T wave
inversions inferiorly with ST depressions inferiorly with ST
elevations in V2 and V3. TropT was 0.084 Patient was given ASA.
A limited TTE was performed at the bedside by the ___ physician.
It was notable for "no evidence of pericardial effusion, and
normal cardiac activity". Repeat CXR showed evidence of mild
edema without significant pulmonary edema. The patient was given
20mg IV Lasix and transferred to ___ for further evaluation by
cardiology.
At ___ she was quite somnolent and in mixed hypoxic
hypercarbic respiratory failure. A CTA was performed which
showed .No evidence of pulmonary embolism or aortic abnormality.
A heterogeneous superior mediastinal mass which appears to be
contiguous with the left lobe of the thyroid which measures 6.1
x 7.0 cm (AP x TV) and is suspicious for goiter versus thyroid
neoplasm. Thyroid ultrasound and sampling is recommended.
3. Heterogeneous consolidation of the left lower lobe with
debris noted in
the segmental airways to the left lower lobe compatible with
aspiration
pneumonia.
4. Significant emphysematous changes of the lungs, mild
pulmonary edema, and
bronchial wall thickening which likely represents react small
airway disease.
5. Age indeterminate superior endplate deformity of L1.
Past Medical History:
No known past medical history-has not been to physician in ___
years
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL
==================
Vitals: T:98 BP:127/56 P:77 R:21 O2:100%CPAP
GENERAL: Alert, oriented, no acute distress
HEENT: CPAP Facemask on
NECK: supple, JVP not elevated, no LAD
LUNGS: tachypneic, mild bilateral end expiratory wheezes. No
crackles, 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
GU: Foley in place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No lesions.
NEURO: A&O x3. CN II-XII intact. Sensation, strength intact.
ACCESS: PIVs
DISCHARGE PHYSICAL
==================
Vitals: 98, 106/51, 65, 25, 93% on 2L NC
GENERAL: Alert, oriented, no acute distress
HEENT: MMM, OP clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Decreased breath sounds throughout. No crackles, 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
GU: Foley in place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No lesions.
NEURO: A&O x3. CN II-XII intact. Sensation, strength intact.
ACCESS: PIVs
Pertinent Results:
ADMISSION LABS
==============
___ 11:30PM BLOOD WBC-10.7* RBC-4.22 Hgb-12.8 Hct-43.3
MCV-103* MCH-30.3 MCHC-29.6* RDW-14.0 RDWSD-52.9* Plt ___
___ 11:30PM BLOOD Neuts-73.8* Lymphs-5.2* Monos-11.8
Eos-8.1* Baso-0.4 Im ___ AbsNeut-7.88* AbsLymp-0.56*
AbsMono-1.26* AbsEos-0.87* AbsBaso-0.04
___ 11:30PM BLOOD ___ PTT-28.2 ___
___ 11:30PM BLOOD Plt ___
___ 11:30PM BLOOD Glucose-144* UreaN-35* Creat-0.9 Na-138
K-4.7 Cl-97 HCO3-33* AnGap-13
___ 11:30PM BLOOD ALT-104* AST-50* AlkPhos-102 TotBili-0.3
DirBili-<0.2 IndBili-0.3
___ 11:30PM BLOOD ___
___ 11:30PM BLOOD Albumin-3.5 Calcium-8.8 Phos-4.1 Mg-2.1
___ 11:43PM BLOOD ___ pO2-75* pCO2-96* pH-7.21*
calTCO2-41* Base XS-6
___ 11:43PM BLOOD O2 Sat-89
___ 10:50PM URINE Color-Straw Appear-Clear Sp ___
___ 10:50PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 10:50PM URINE RBC-1 WBC-9* Bacteri-FEW Yeast-NONE Epi-3
TransE-<1
___ 10:50PM URINE CastHy-29*
___ 10:50PM URINE Mucous-RARE
PERTINENT LABS
==============
___ 02:35AM BLOOD ___ pO2-31* pCO2-95* pH-7.21*
calTCO2-40* Base XS-5
___ 03:59AM BLOOD Type-ART PEEP-5 FiO2-100 pO2-349*
pCO2-90* pH-7.23* calTCO2-40* Base XS-6 AADO2-282 REQ O2-53
Intubat-NOT INTUBA
___ 05:49AM BLOOD Type-ART pO2-65* pCO2-77* pH-7.27*
calTCO2-37* Base XS-4 Intubat-NOT INTUBA
___ 11:02AM BLOOD ___ pO2-54* pCO2-89* pH-7.24*
calTCO2-40* Base XS-6 Comment-GREEN TOP
___ 05:08PM BLOOD ___ pO2-123* pCO2-75* pH-7.28*
calTCO2-37* Base XS-6
___ 09:32PM BLOOD ___ pO2-68* pCO2-94* pH-7.22*
calTCO2-41* Base XS-6
___ 02:57AM BLOOD ___ pO2-26* pCO2-79* pH-7.29*
calTCO2-40* Base XS-6
___ 12:17PM BLOOD ___ pO2-30* pCO2-87* pH-7.27*
calTCO2-42* Base XS-8
___ 09:34AM BLOOD ___ pO2-32* pCO2-81* pH-7.31*
calTCO2-43* Base XS-10
___ 08:08PM BLOOD Type-ART O2 Flow-4 pO2-66* pCO2-64*
pH-7.40 calTCO2-41* Base XS-11 Intubat-NOT INTUBA
___ 05:34AM BLOOD ___ pO2-30* pCO2-82* pH-7.33*
calTCO2-45* Base XS-12
___ 12:20AM BLOOD ___ pO2-97 pCO2-59* pH-7.39
calTCO2-37* Base XS-7
___ 08:28AM BLOOD T4-5.2
___ 08:28AM BLOOD TSH-0.72
___ 03:00AM BLOOD TSH-1.4
___ 08:28AM BLOOD VitB12-745
___ 11:30PM BLOOD cTropnT-0.08*
___ 06:34AM BLOOD cTropnT-0.08*
MICRO
=====
___ 10:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
CFU/mL.
___ 12:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:30 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:15 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
___ 9:25 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Time Taken Not Noted Log-In Date/Time: ___ 8:48 am
BRONCHOALVEOLAR LAVAGE BAL LEFT LOWER LOBE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): SQUAMOUS EPITHELIAL CELLS.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
~5000 CFU/mL Commensal Respiratory Flora.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
YEAST.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies if
pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
STUDIES/IMAGING
===============
___ ECG
Sinus rhythm. Diffuse repolarization abnormalities that are
non-specific.
Clinical correlation is suggested. No previous tracing available
for
comparison.
___ CXR
IMPRESSION:
1. Bibasilar airspace opacities most likely represent
atelectasis.
2. Hyperexpansion consistent with COPD.
3. Upper mediastinal widening for which contrast-enhanced chest
CT is again recommended.
___ TTE
The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
No aortic regurgitation is seen. No mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Mildly dilated, mildly hypokinetic right ventricle.
No clinically significant valvular regurgitation or stensosis.
Moderate pulmonary artery systolic hypertension.
___ CXR
IMPRESSION:
Compared to prior chest radiographs since only ___, most
recently
___.
Initial radiographs showed severe hyperinflation due to
emphysema, a large
predominantly left-sided cervicothoracic mass, most commonly
thyroid, severely narrowing the trachea and displacing it to the
right.
Mild pulmonary edema developed on ___, collected in the
lower lungs. That has partially improved, although small left
pleural effusion remains. Mild cardiomegaly stable. No
pneumothorax.
Because of the persistent basal opacification, chest radiographs
are
recommended to exclude concurrent aspiration and early
pneumonia.
___ RUQ US
IMPRESSION:
1.8 cm echogenic lesion in the right hepatic lobe demonstrates
posterior
attenuation likely representing a lipomatous or fibrotic lesion.
Recommend comparison with prior imaging or further
characterization with MR liver.
___ CTA CHEST
IMPRESSION:
1.No evidence of pulmonary embolism or aortic abnormality.
2. A heterogeneous superior mediastinal mass which appears to
be contiguous
with the left lobe of the thyroid which measures 6.1 x 7.0 cm
(AP x TV) and is
suspicious for goiter versus thyroid neoplasm. Thyroid
ultrasound and
sampling is recommended.
3. Heterogeneous consolidation of the left lower lobe with
debris noted in the segmental airways to the left lower lobe
compatible with aspiration
pneumonia.
4. Significant emphysematous changes of the lungs, mild
pulmonary edema, and bronchial wall thickening which likely
represents react small airway disease.
5. Age indeterminate superior endplate deformity of L1.
___ CXR
IMPRESSION:
Compared to chest radiographs ___ through ___.
Small left pleural effusion is larger. Mild left basal
atelectasis unchanged. Right lung grossly clear. Hyperinflation
is due to emphysema. Heart size top-normal. No pulmonary
edema. No pneumothorax.
___ THYROID US
IMPRESSION:
Multinodular thyroid with a massive, heterogeneous, solid
retrosternal thyroid mass which is amenable to fine-needle
aspiration.
___ THYROID BIOPSY
INTERPRETATION
Non-specific CD4 dominant, T cell dominant lymphoid profile.
Diagnostic immunophenotypic features of involvement by a B-cell
non-Hodgkin lymphoma are not seen in specimen.
Correlation with clinical, morphologic (see separate pathology
report ___ and other ancillary findings is recommended.
Flow cytometry immunophenotyping may not detect all abnormal
populations due to topography, sampling or artifacts of sample
preparation.
Thyroid tissue with mixed micro- and macrofollicular
architecture, see note.
Note: The follicular cells are positive for thyroglobulin.
Multiple levels are examined. While no overtly malignant
features are seen in this sampling, the presence of invasion
cannot be evaluated in a biopsy specimen. Correlation with
clinical and imaging findings is recommended. This case was
reviewed by Dr. ___.
- Follicular cells, colloid material and cyst contents;
consistent with thyroid tissue.
- Some of the follicular cells show nuclear membrane
irregularity and nuclear grooves; papillary carcinoma cannot be
ruled out.
___ CXR
IMPRESSION:
Comparison to ___. New parenchymal opacities at the
left and the right lung bases, nodular in appearance and with
air bronchograms. In
addition, an atelectasis on the left and a mild pleural effusion
on the right is visualized. Overall, the findings are highly
suspicious for pneumonia or aspiration. The large left
mediastinal mass with deviation of the trachea is stable.
___ CXR
IMPRESSION:
With the exception of apparent slight decrease in size of
bilateral pleural effusions, there has not been a relevant
change in the appearance of the chest since the recent study of
1 day earlier.
___ CXR
IMPRESSION:
Substantial deviation of the trachea to the right is related to
known
multinodular goiter. Current examination demonstrate severe E
narrowed
trachea in the coronal plane up to 10 mm with no substantial
change as
compared to ___. Heart size and mediastinum are
stable.
Bilateral pleural effusions are moderate, unchanged associated
with bibasal atelectasis. There is interval improvement of
vascular congestion.
___ CT NECK
IMPRESSION:
1. Evaluation of the cervical soft tissues is limited in the
absence of
intravenous contrast, as well as by motion artifact at the level
of the
epiglottis and vocal cords. No tracheal narrowing or other
concerning
abnormalities are seen in the neck.
2. Large heterogenous mass with calcifications is again seen
extending from the left thyroid lobe into the mediastinum, with
rightward tracheal
displacement. The stent in the upper thoracic trachea
terminates
approximately 3 cm above the carina. There is mild
circumferential soft
tissue density within the mid to distal portions of the stent,
but tracheal compression of the level of the stent has decreased
compared to ___.
___ TTE
FOCUSED STUDY: No atrial septal defect is seen by 2D or color
Doppler. Regional left ventricular wall motion is normal.
Quantitative (biplane) LVEF = 61 %. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. The number of aortic
valve leaflets cannot be determined. 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. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
pulmonary artery pressure is higher. More tricuspid
regurgitation is detected. Right ventricular function appears
slightly improved.
___ CXR
IMPRESSION:
In comparison with the study of ___, there is little
overall change in the severe narrowing in deviation of the
trachea to the right by a large mediastinal mass. The stent
there is extremely difficult to detect on plain radiography,
though appears to have its upper border at the lower margin of
the right clavicle and extends to close to the lower margin of
the transverse arch of the aorta. Otherwise little change.
___ STRESS TEST
INTERPRETATION: ___ yo woman with active smoker and COPD, recent
dyspnea and URI c/b hypoxic respiratory failure and found to
have
thyriod mass requiring stent placement was referred to evaluate
ECG
changes and mild troponemia. The patient was administered 0.142
mg/kg/min of Persantine over 4 minutes. No chest, back, neck or
arm
discomforts were reported. No significant ST segment changes
were noted.
The rhythm was sinus with short PR interval at baseline.
Frequent atrial
irritability was noted during the procedure; frequent isolated
APBs,
occasional atrial couplets and atrial triplets. The hemodynamic
response
to the Persantine infusion was appropriate. Post-infusion, the
patient
was administered 125 mg Aminophylline IV.
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Frequent atrial irritability. Appropriate hemodynamic response.
Nuclear
report sent separately.
IMPRESSION:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
___ CXR
IMPRESSION:
Comparison to ___. The radiographic appearance of
the large
mediastinal mass is stable. There is no radiographically
evident stent
migration. Appearance of the heart and of the bilateral pleural
effusions is stable. No new parenchymal lesions.
___ CXR
IMPRESSION:
In comparison with the study of ___, there is little
overall change. Again there is hyperexpansion of the lungs
consistent with COPD. Large mediastinal mass is again seen
without evidence of stent migration. Bibasilar atelectatic
changes with probable small effusions.
DISCHARGE LABS
==============
___ 11:27PM BLOOD WBC-7.1 RBC-4.05 Hgb-12.1 Hct-39.8 MCV-98
MCH-29.9 MCHC-30.4* RDW-13.7 RDWSD-49.8* Plt ___
___ 11:27PM BLOOD Plt ___
___ 11:27PM BLOOD ___ PTT-29.4 ___
___ 11:27PM BLOOD Glucose-143* UreaN-17 Creat-0.5 Na-136
K-4.6 Cl-96 HCO3-33* AnGap-12
___ 11:27PM BLOOD Calcium-8.9 Phos-2.7 Mg-2.0
___ 12:20AM BLOOD ___ pO2-97 pCO2-59* pH-7.39
calTCO2-37* Base XS-7
Brief Hospital Course:
Ms. ___ is a ___ woman with no PMH who was admitted
to the MICU for respiratory failure in setting of COPD
exacerbation/pneumonia, subsequently found to have large
mediastinal mass on CT.
# Hypercarbic/hypoxemic respiratory failure - Initial ABG
___. Likely COPD exacerbation, worsened by pneumonia and
obstructive mediastinal mass (thyroid). Patient was initially
placed on BiPap in setting of hypercarbia and AMS. Mental
status soon improved, though CO2 remained quite high. Severe
emphysema on CT chest. Patient was treated initially with IV
steroids and Azithromycin for COPD exacerbation, transitioned to
Pred 60mg qd (course completed ___. Patient also received
albuterol/tiotropium nebs throughout admission.
Vancomycin/Cefepime were started given signs of LLL PNA on CT
chest, narrowed to CTX ___ for treatment of CAP. Patient did
not require ongoing BiPap, O2 requirement improved to 2L NC at
time of discharge with O2sats in low ___.
# COPD Exacerbation - No previous diagnosis. Emphysematous
changes on CT scan in setting of 50-pack-year smoker. Blood
gases consistent with chronic retainer.
Azithromycin/steroids/nebs/Bipap as above. Patient discharged
with new O2 requirement (2L NC).
# Pneumonia - Bilateral lower lobe opacities on CXR. Confirmed
on CT scan ___. Patient was initially on Vanc/Cefepime,
narrowed to CTX for CAP. Patient completed 5 day course of
azithro/CTX.
# Shock - Cardiogenic vs. distributive in setting of PNA. Low
blood pressures in the ___ initially to ___ systolic after NTG
gtt had been initiated given suspicion for MI. Contribution
from reduced preload from nitroglycerin drip. Norepi was
started, BPs improved after stopping NTG gtt, Norepi was stopped
upon arrival to MICU. Treatment for CAP as detailed above.
# Mediastinal mass - Patient with widened mediastinum on CXR,
found to have large mass continuous with thyroid on CT chest
___. FNA obtained with endobronchial biopsy, path showing
likely benign thyroid tissue, though could not rule out
malignancy. No hypo/hyperthyroidism. Tracheal silicone stent
placed ___ by IP to prevent airway collapse. She was noted to
have possible ___ edema, treated with racemic epinephrine
(in addition to PO steroids already in setting of COPD
exacerbation). Patient had some issues with
desaturation/difficulty clearing secretions after stent
placement, though decision was made to leave stent in until
outpatient surgery with endocrine surgery. Patient was treated
with guaifenesin and NAC/albuterol nebs after stent placement
for management of secretions and to prevent plugging.
Cardiology was consulted for presurgical workup given likely cor
pulmonale and troponinemia on admission. TTE x2 showed
pulmonary artery hypertension and tricuspid regurgitation. A
pharmacologic stress test was normal ___ prior to discharge.
# Myocardial Infarction - Troponin to .08 on admission. EKG at
OSH showed ?STE(T wave inversions inferiorly with ST depressions
inferiorly with ST elevations in V2 and V3), EKG at ___ with
no ST changes. Patient denied chest pain, troponinemia most
likely demand in setting of COPD exacerbation/infection. TTE
with TR/pulm artery HTN as above, normal pharm stress test ___.
# R-sided-CHF/Pulmonary HTN - pro BNP > 15000. Most likely R
sided pathology in setting of chronic pulmonary disease. No
prior known history as patient had no regular medical care.
Initial Echo ___ showed normal LV wall thickness, cavity
size and regional/global systolic function (LVEF >55%) and
mildly dilated RV cavity.
Repeat TTE ___ as above.
# Transaminitis: ALT > AST. Hepatitis viral serologies
negative. Possibly congestive hepatopathy in setting of
elevated R sided pressures. Downtrended ___, no further
LFTs drawn.
TRANSITIONAL ISSUES
===================
[] Will need to follow up with endocrine surgery to come up with
surgery date/ schedule.
[ ] 1.8 cm echogenic lesion in the right hepatic lobe
demonstrates posterior attenuation likely representing a
lipomatous or fibrotic lesion. Recommend comparison with prior
imaging or further characterization with MR liver.
[ ] Round 5 mm pulmonary nodule in the right upper lobe requires
follow-up imaging (for high risk patients, initial follow-up CT
at ___ months and then at ___ months if no change)
[ ] will need outpatient PFTs, and likely uptitration of COPD
meds
[ ] TTE with diastolic dysfunction, pulmonary HTN; once patient
is set to go to OR, anesthesia should be made aware
[ ] full code
[ ] HCP: ___ Relationship: Husband Phone number:
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
Discharge Medications:
1. Acetylcysteine 20% ___ mL NEB Q6H
RX *acetylcysteine 200 mg/mL (20 %) 4 mL every 6 hours Disp #*30
Vial Refills:*2
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, shortness
of breath
Give this medication 10 minutes prior to each ___ nebulizer
(Mucomyst) dose.
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb inhaled every
6 hours Disp #*120 Vial Refills:*0
3. GuaiFENesin ER 1200 mg PO Q12H
RX *guaifenesin 1,200 mg 1 tablet(s) by mouth every 12 hours
Disp #*60 Tablet Refills:*2
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
capsule inhaled daily Disp #*30 Capsule Refills:*2
6.Oxygen therapy
Please provide the patient with Oxygen tanks for home O2 and for
portability with goal for continuous 2 L O2 therapy.
Length of need: lifetime
7.nebulizer
Nebulizer
Indication: For use with Albuterol and Acetylcysteine nebs
Length of need: lifetime
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Community acquired pneumonia
COPD exacerbation
thyroid mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You were recently admitted with difficulty
breathing and were found to have a pneumonia. You were treated
with antibiotics, steroids, and breathing treatments, and
improved. During your stay, you were found to have a thyroid
mass which was concerning for airway compromise. You had a stent
placed to protect your airway by Interventional Pulmonology. You
were evaluated by the Cardiologists (heart doctors) and
underwent a nuclear stress test which was normal. You were also
evaluated by the Thoracic and Endocrine Surgery teams. You will
follow up with the Endocrine Surgery teams as an outpatient for
your surgery after you have recovered from this recent
pneumonia. When you meet with them they will schedule a time for
your surgery. You will also follow up with the interventional
pulmonologists who are taking care of your stent.
YOU MUST NOT SMOKE WHILE USING YOUR OXYGEN.
Please continue to take your new medications as prescribed and
keep all of your follow-up appointments.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19762081-DS-14
| 19,762,081 | 28,469,114 |
DS
| 14 |
2130-11-07 00:00:00
|
2130-11-07 22:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tetracycline
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
___: Bronchoscopy with removal of tracheal stent.
___: Partial thyroidectomy (left hemithyroidectomy) for
retrosternal large goiter, cervical approach. Parathyroid
autotransplantation.
___: trach placement ___ prlonged edema and failure to
wean from vent
History of Present Illness:
___ yo woman with significant smoking history and COPD on 2L NC
at home presents with hypoxia and SOB. She was recently admitted
from ___ for dyspnea and increasing "congestion" and
found to have a pneumonia and paratracheal mass compressing her
airway. IP placed a silicone stent and she was treated for her
PNA and sent home with scheduled surgery for mass on ___.
Returns after 1 week with hypoxia, found to be in low ___ on her
home O2. Feels like she is unable to bring up secretions, and
notices noisy breathing. She was not compliant with her flutter
valve at home but states compliance with nebulizers. Denies
cough, chest pain, fever, chills, neck stiffness, difficulty
swallowing or drooling, headache, abdominal pain, n/v/d/c.
In the ED, initial vitals: 98.1, 106, 118/54, 30, 81% Nasal
Cannula
Her labs were notable for the following venous blood gas:
pH = 7.26, pCO2 = 84, pO2 = 27, HCO3 = 39, BaseXS = 6
She was placed on a non-rebreather and given:
17:08 Sodium Chloride 3% Inhalation Soln 15 mL NEB Q2H:PRN
16:29 Ipratropium Bromide Neb 1 Neb IH ONCE MR2
16:29 Albuterol 0.083% Neb Soln 1 Neb IH ONCE MR2
IP was consulted and recommended conservative management of
mucous and ICU admission for airway observation.
On arrival to the MICU, she states that her breathing is much
better than when she first come to the ED.
Past Medical History:
- COPD
- paratracheal mass
Social History:
___
Family History:
Mother: cataracts and thyroid disorder (hyperthyroid?)
Father: early CAD (first heart attack before age ___
No family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T:97.9, BP:128/55, P:88, R:19, O2:98% nonrebreather
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: diffuse rhonchi and upper airway breath sounds, mild
inspiratory stridor on deep inhalation.
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, trace edema at bilateral
ankles
SKIN: no rash or concerning lesions
NEURO: CN II-XII grossly intact
DISCHARGE PHYSICAL EXAM
=======================
PHYSICAL EXAM:
Vital Signs: 97.7 PO 96 / 58 86 18 92 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD. Trach mask in place.
Trach- (Cuffed Portex 8.0 mm). Surrounding area without
erythema or drainage.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bilateral rhonci in all lung fields most consistent with
upper airway transmission in setting of trach mask
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, s/p PEG- area w/ out
erythema
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Left foot with scaling pruritic rash on foot and ext to
medial ankle
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
ADMISSION LABS
==============
___ 04:31PM BLOOD WBC-7.9 RBC-4.33 Hgb-13.0 Hct-43.7
MCV-101* MCH-30.0 MCHC-29.7* RDW-13.4 RDWSD-50.3* Plt ___
___ 04:31PM BLOOD Neuts-80.1* Lymphs-8.7* Monos-9.0 Eos-1.1
Baso-0.6 Im ___ AbsNeut-6.31* AbsLymp-0.69* AbsMono-0.71
AbsEos-0.09 AbsBaso-0.05
___ 04:31PM BLOOD ___ PTT-29.0 ___
___ 04:31PM BLOOD Glucose-263* UreaN-11 Creat-0.6 Na-141
K-3.8 Cl-97 HCO3-32 AnGap-16
___ 04:11AM BLOOD Calcium-8.7 Phos-3.3 Mg-1.9
___ 04:53PM BLOOD ___ pO2-27* pCO2-84* pH-7.26*
calTCO2-39* Base XS-6 Intubat-NOT INTUBA
DISCHARGE LABS
==============
___ 06:21AM BLOOD WBC-4.0 RBC-3.64* Hgb-11.3 Hct-35.9
MCV-99* MCH-31.0 MCHC-31.5* RDW-13.3 RDWSD-47.8* Plt ___
___ 06:21AM BLOOD Glucose-92 UreaN-6 Creat-0.4 Na-140 K-4.4
Cl-100 HCO3-33* AnGap-11
___ 06:21AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.9
URINE STUDIES
=============
___ 12:56PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:56PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:56PM URINE RBC-3* WBC-3 Bacteri-NONE Yeast-NONE
Epi-0
___ 12:56PM URINE CastHy-11*
MICROBIOLOGY
============
___ 12:47 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 CFU/mL Commensal Respiratory Flora.
___: BLOOD CULTURE: NEGATIVE
___: BLOOD CULTURE: NEGATIVE
___: URINE CULTURE: NEGATIVE
___: URINE CULTURE: NEGATIVE
IMAGING
=======
___: CHEST X-RAY (PORTABLE AP)
FINDINGS:
AP portable upright view of the chest. Lungs are hyperinflated
and clear. Overlying EKG leads are present. No large effusion
or pneumothorax. The heart appears mildly enlarged. The
mediastinal contour is unchanged with atherosclerotic
calcifications along the thoracic aorta. The hila are mildly
prominent and unchanged. Bony structures are intact.
___: CHEST X-RAY (PORTABLE AP)
IMPRESSION:
There is again seen a large multinodular thyroid goiter which is
better
assessed on the prior chest CT. This causes prominence of the
upper
mediastinum. Cardiac border is within normal limits. There is
mild
hyperinflation. There is likely a small left-sided pleural
effusion and there is some atelectasis versus early infiltrate
at the left retrocardiac region. There are no pneumothoraces.
___:
IMPRESSION:
Left basilar consolidation, with mildly worsened lingular
opacity, consider pneumonitis, aspiration, with probable
component of basilar atelectasis. Endotracheal tube tip is just
above carina, should be pulled back.
CT NECK ___:
Patient is status post partial left thyroidectomy, and compared
with ___, the patient has undergone interval tracheostomy.
There has been interval decrease in size of a postsurgical fluid
collection in the left thyroid bed, measuring approximately 4.5
cm x 3.3 x 2.3 cm, compared with 6.7 cm x 3.3 x 3.0 cm
previously, with interval decrease in associated mass effect on
the airway (2:80), and decreased extent of air bubbles within
fluid collection. There is symmetric mild mucosa thickening of
base of the epiglottis, aryepiglottic folds, extending into the
true and false vocal cords, with resultant significant narrowing
of the glottis series 2, image 65, making evaluation of vocal
cord paralysis difficult. There is no definite asymmetry at the
level of the true vocal cords. There is no definite medial
dislocation of the arytenoid cartilage. There is stable
heterogeneous appearance of the right thyroid lobe.
There is no lymphadenopathy by CT criteria.
An enteric tube is present in the esophagus, the distal tip of
which is notvisualized. There are mild tracheal, mainstem
bronchi secretions, and minimal mucous plugging in bilateral
upper lobe distal bronchi. . There is moderate centrilobular
emphysema. Previously seen biapical lung nodules have improved.
There is extensive calcification of the aortic arch. There are
multilevel degenerative changes in the cervical spine. There
are no suspicious osseous lesions.
PATH
====
___
Thyroid, left, partial thyroidectomy:
- Multinodular goiter with degenerative and biopsy-site changes.
- There is no evidence of malignancy.
Brief Hospital Course:
___ yo woman with significant smoking history and COPD who
presented with hypoxemia and SOB.
# s/p hemithyroidectomy c/b ___ edema
# Trach (Cuffed Portex 8.0 mm)
She was recently admitted from ___ for dyspnea and
increasing "congestion" and found to have a pneumonia and
multinodular goiter with airway compression. IP placed a
tracheal silicone stent and she was treated for her PNA and sent
home with scheduled surgery for mass on ___. Unfortunately
she represented to ___ with ___ with increased
secretions and was found to be hypoxemic to the ___.
She was admitted to the Medical ICU for close observation and
started on albuterol nebulizers, mucomist, mucinex, hypertonic
saline, and flutter valve in order relieve mucus plugging. While
in the ICU, patient continued to have deasturations into the ___
on face-tent.
Due to concern for unresolving mucus plugging of the tracheal
stent, ___ performed bronchoscopy on ___ to clear out the
stent. During bronchoscopy, the tracheal stent was noted to have
migrated. Patient was urgently taken to the operating room for
rigid/flexible bronchoscopy/ stent removal, and intubation (for
airway protection given the paratracheal mass compressing on the
trachea). During the procedure, thick secretions were noted and
patient was started on vancomycin/cefepime for empiric coverage.
On ___, patient underwent left hemithyroidectomy with
auto-transplantation of left lower parathyroid gland. The
procedure was uncomplicated and there was no need for
sternotomy. Due to pre-op laryngoscopy that had shown
dysfunction of left vocal cord a total thyroidectomy was not
attempted.
Following the procedure, patient was transferred to the Surgical
Intensive Care Unit. The patient's post-op course was
complicated by airway edema ___ edema) and failure to wean
from the vent. This was determined to be due to airway edema.
She was given several days of dexamethasone without improvement
in her edema and thus in consultation with ICU, anesthesia,
pulmonology, and the patient's family the decision was made to
perform tracheostomy on ___.
# Benign Multinodular Goiter Patient noted to have normal
thyroid synthetic function post-operatively. TSH:4.0 T4: 6.1 T3:
54. Patient was monitored for sx/signs of hypocalcemia
(numbness, muscle spasms, seizures, confusion, or cardiac
arrest) iso hemithyroidectomy. Patient does not need to follow
up with endocrine surgery team and was seen for post-op follow
up while in the hospital.
# Asymptomatic Hypotension/bradycardia: Patient has hemodynamic
sensitivity to sedative medications throughout her hospital
course. Hypotension was fluids response. Infectious process r/o
w/ UCx, BCx. Trp neg and EKG wnl throughout course. Patient
initially started on midodrine in the ICU, but tapered off on
the floor.
# Nutrition: PEG tube placed ___ w/ Jevity 1.5 to goal of 50
cc/hr. FWW 150 ml Q4H to account for free water needs. Patient
will need ongoing speech and swallow evaluation at rehab with
likely video speech and swallow.
--------------
CHRONIC ISSUES:
---------------
# COPD: Patient is known to have COPD without home O2
requirement. Continued nebs and supplemental O2 throughout
course. Patient did have elevated bicarb and elevated CO2 c/w
hypercarbia. Recommend PFTs as outpatient.
# GERD: Continued PPI.
TRANSITIONAL ISSUES:
====================
# NEW MEDICATIONS: Acetaminophen (Liquid) 650 mg PO/NG Q6H:PRN
Pain - Mild, Clotrimazole Cream 1 Appl TP BID
left foot, ankle, Docusate Sodium 100 mg PO/NG BID,
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID,
Ipratropium-Albuterol Neb 1 NEB NEB Q6H, Mirtazapine 15 mg PO/NG
QHS:PRN insomnia, Pantoprazole (Granules for ___ ___ 40
mg PO/NG DAILY, Senna 8.6 mg PO/NG BID:PRN constipation,
TraMADol 50 mg PO Q6H:PRN Pain (for s/p PEG tube pain- very
short course)
# STOPPED MEDICATIONS: Acetylcysteine 20% ___ mL NEB Q6H,
Omeprazole 40 mg PO DAILY, Tiotropium Bromide 1 CAP IH DAILY
[] Consider outpatient PFTs as patient was noted to have
hypercarbia indicative of chronic COPD
[] 1.8 cm echogenic lesion in the right hepatic lobe
demonstrates posterior attenuation likely representing a
lipomatous or fibrotic lesion.
[] Round 5 mm pulmonary nodule in the right upper lobe requires
follow-up imaging (for high risk patients, initial follow-up CT
at ___ months and then at ___ months if no change)
[] S/S recommend waiting for passy muir valve until trach is
downsize vs. ___. Of note, trach will managed by IP team
at ___. Patient has follow-up appointment for ___.
[] PEG tube placed ___ w/ Jevity 1.5 to goal of 50 cc/hr. FWW
150 ml Q4H to account for free water needs. Patient will need
ongoing speech and swallow evaluation at rehab with likely video
speech and swallow.
[] PEG tube positioning at time of discharge: 3 cm. GI recs
pulling bumper back if against skin. GI will call and arrange
for adjustment of bumper.
[] For future providers: patient will become hypotensive w/
sedatives. Use w/ caution.
#CONTACTS:
Proxy name: ___
Relationship: Husband Phone: ___
___ - ___ - ___ ___ - daughter -
___ ___ - daughter - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetylcysteine 20% ___ mL NEB Q6H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, shortness
of breath
3. GuaiFENesin ER 1200 mg PO Q12H
4. Omeprazole 40 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze, shortness
of breath
3. Clotrimazole Cream 1 Appl TP BID
4. Docusate Sodium 100 mg PO BID
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. GuaiFENesin ER 1200 mg PO Q12H
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H When off vent
8. Mirtazapine 15 mg PO QHS:PRN insomnia
9. Pantoprazole (Granules for ___ ___ 40 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth Q8H:PRN Disp #*9 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Multinodular Goiter
___ edema
SECONDARY DIAGNOSIS:
Anxiety
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ were in the hospital because ___ had part of your thyroid
removed because it was pressing on your airway. After the
procedure, ___ had swelling, which prevented ___ from breathing
on your own. A special tube was placed in your neck to help ___
breath.
Because of the swelling in your airway, ___ had issues with your
swallowing. Due to this, a special tube was placed in your
stomach to help ___ get nutrition until your swallowing function
returns.
___ had airyway specialists involved in your care. ___ will
follow-up with ENT and interventional pulmonology as an
outpatient. These appointments have been scheduled for ___.
We wish ___ the best!
Your ___ Team
Followup Instructions:
___
|
19763019-DS-7
| 19,763,019 | 22,597,860 |
DS
| 7 |
2151-07-05 00:00:00
|
2151-07-10 20:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Epigastric and RUQ pain
Elevated LFTs
Cholelithiasis
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
Ms. ___ is a healthy ___ year old lady who presented to the
___ ED as a transfer from an OSH with right upper quadrant and
epigastric pain, elevated LFTs, and a RUQ US showing
cholelithiasis.
She was in her usual state of health until about 2 months prior
to admission when she began to experience intermittent
epigastric pain. The pain came mostly at night and was not
associated with food or eating. She did get some nausea and
sweats with the pain, but no fevers or chills. Her PCP treated
her for GERD with antacids without effect. It was bad for a few
weeks, then abated, and she began to think less of it. Then, the
night prior to admission around 11PM, she experienced worsening
epigastric and RUQ pain. It was non-radiating and had no
modifying factors. It increased in severity until 4AM when she
began to also experience nausea with vomiting. She vomited again
around 9AM. She at that time decided to go to the OSH ED.
OSH RUQ US showed cholelithiasis and a purportedly distended
bile duct, though I cannot find the report for review. After
evaluation in the ___ ED, she was admitted to the medical
service for an ERCP.
ROS: Complete 10 point ROS completed and negative except as
above.
Past Medical History:
Septorhinoplasty
Microdiscectomy x2
Social History:
___
Family History:
Her father had an MI at age ___.
Physical Exam:
Vitals: Temp 97.9, HR 104, BP 123/76, RR 18, SpO2 99% on room
air
Gen: Pleasant lady in no acute distress, alert and oriented
CV: Regular rate and rhythm
Lungs: Clear to auscultation bilaterally
Abd: Soft, mildly distended, appropriately tender to palpation
incisionally.
Wound: Lap incisions covered with clean gauze and tegaderm, no
surrounding erythema or induration.
Ext: Warm and well-perfused without edema
Pertinent Results:
MRCP (___):
Cholelithiasis without evidence of cholecystitis. No
choledocholithiasis. Mild intra and extrahepatic bile duct
dilation with periductal edema and hyperemia, particularly
involving the right lobe ducts. Appearance is suggestive of
cholangitis. No associated parenchymal abscess is identified.
Brief Hospital Course:
Ms. ___ was admitted to the medical service on ___ for
management of her intermittent right upper quadrant pain. She
had an MRCP performed on ___ which showed cholelithiasis
without evidence of cholecystitis or choledocholithiasis. She
was transferred to the acute care surgery service on ___
and was taken to the operating room on ___ for a
laparoscopic cholecystectomy. Please see operative report for
details of this procedure. She tolerated the procedure well and
was extubated upon completion. She was subsequently taken to the
PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced to regular, which
she tolerated without abdominal pain, nausea, or vomiting. She
was voiding adequate amounts of urine without difficulty. She
was encouraged to mobilize out of bed and ambulate as tolerated,
which she was able to do independently. Her pain level was
routinely assessed and well controlled at discharge with an oral
regimen as needed.
On ___, she was discharged home with scheduled follow up in
___ clinic on ___. She will complete a total 10 day course
of antibiotics (was discharged on Augmentin).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Seasonique (L norgest&E estradiol-E estrad) 0.15 mg-30 mcg
(84)/10 mcg (7) oral DAILY
Discharge Medications:
1. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
You may not drive while taking Vicodin pain medication.
RX *hydrocodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every four hours Disp #*30 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 6 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
twice a day Disp #*12 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Hold for loose stools
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Seasonique (L norgest&E estradiol-E estrad) 0.15 mg-30 mcg
(84)/10 mcg (7) oral DAILY
5. Ondansetron 4 mg PO Q8H:PRN nausea,vomiting
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cholelithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted with abdominal pain and were found to have
stones in your gallbladder. You also likely had a stone in your
common bile duct that passed. You underwent an MRCP which showed
cholelithiasis without evidence of cholecystitis, no
choledocholithiasis, mild intra- and extrahepatic bile duct
dilation with periductal edema and hyperemia, particularly
involving the right lobe ducts with an appearance suggestive of
cholangitis. On ___, we removed your gallbladder
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.
Best wishes,
Your ___ surgical team
Followup Instructions:
___
|
19763024-DS-14
| 19,763,024 | 29,662,218 |
DS
| 14 |
2160-04-10 00:00:00
|
2160-04-20 11:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
UTI
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with a pmh of COPD, A fib, Type 1 DM with frequent
episodes of hypoglycemia, frequent falls attributed to
hypoglycemia with last fall in ___ with type 2 dens fracture
managed nonoperatively and prostate cancer who was transferred
to
the ER from radiology appointment after a fall.
Pt was at radiology appointment and had a mechanical fall with
headstrike, he was unable to articulate the exact events as to
why he fell however he does state that he recalls the entire
event and did not syncopize. He was not lightheaded. He did not
feel as if his blood sugars were low. His sugars in the ___ were
in the 200s. He was noted to be tachycardic with HRs in the
130s-160s immediately after the fall. He thinks that he forgot
to
take his metoprolol this AM. His HRs were controlled with 5mg IV
metop in the ___.
He reports that he has felt subjectively weaker over the past
couple of days. He also notes hematuria for 3 days in the past
week. No dysuria, no increased urinary frequency. No fevers,
chills or sweats.
On ROS he notes a good appetite, no cough, no dyspnea at rest or
with exertion. ROS otherwise negative.
Mr. ___ was hospitalized in ___ ___omplicated by
type 2 dens fracture managed nonoperatively. His falls have been
attributed to hypoglycemia in the past however during that
admission it was thought possible to afib with rvr i/s/o
palpitations. That hospitalization was also complicated by
hyperglycemia and afib with rvr.
- In the ___, initial vitals were:
T 97.8, HR 127, BP 85/44, RR 18 RA
Last vitals recorded HR 110 BP 132/79, RR 27, ___ NC
- Exam was notable for:
No prostate tenderness on rectal exam, good rectal tone
- Labs were notable for:
CBC: hgb 12.5, WBC 8.7
BMP: Na 132, K 4.6, Cl 93 HCO3 20, BUN 21 Cr 1.2
trop 0.03 CK MB 4
Urine: Large leuk, moderate blood, Glucose 1000, ketones 40, WBC
> 182
- Studies were notable for:
CT head no acute intracranial abnormality
CT Spine w/o contrast:
1. Redemonstration of type 2 dens fracture. Compared to prior,
the fracture is
slightly more pronounced and distracted.
2. Redemonstration of right C1 anterior ring and lateral mass
fractures,
similar to prior. Partially visualized T2 vertebral body
fracture
with
retropulsion, similar to prior.
3. No new fractures or alignment change.
CXR:
Severe emphysema but no definite superimposed acute process.
- The patient was given:
Metop tartrate 5mg IV
-3L LR
- Ceftriaxone @ 1500
- Spine were consulted re worsening of dens fracture:
Spine: Completed ___ 19:20
___ male with fall with worsening of dens fracture.
Patient is neurovascularly intact on exam. He also endorses
being
non compliant with c-collar. It is unlikely that worsening of
dens fracture was from acute fall rather than just progression
due to noncompliance with collar. No indication for surgical
intervention.
- Agree with admission to medicine
- Keep ___ J collar on at all times
On arrival to the floor, pt confirmed the above history. he was
without additional complaints
Past Medical History:
- type 1 Diabetes, following at ___, last a1c 7.0. Frequent
episodes of hypoglycemia discussing with ___ re a continuous
glucose monitor.
-Atrial Fibrillation: Zio patch done in ___ and had some
episodes of atrial fibrillation. He has been evaluated by
Cardiology and a left atrial appendage occlusion device was
suggested, but he was reluctant to do this. He was remained on
apixaban accepting risk for an intracranial bleed with another
fall
-Hyperlipidemia
-COPD ___ smoking and alpha one antitrypsin deficiency, has
oxygen at home but has not needed to use it in the past month
-Rib Fracture
-frequent falls attributed to hypoglycemia with fall in ___
with type 2 dens fracture managed nonoperatively
- prostate CA s/p XRT/adjuvant hormonal therapy; type 1 DM;
recurrent hypoglycemia with frequent falls;
PSHx:
TURP
Port-a-Cath placement
Social History:
___
Family History:
Family Hx: mother deceased from ovarian CA; sister deceased from
"liver or kidney failure"; no FHx of prostate CA
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: t 98.0 BP 140 / 73 HR 102 RR 22 ___
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. 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: 98.9F 137 / 71 HR 68 RR 18 95 Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Heart
sounds difficult to appreciate. Port site on R, dressing
clean/dry/intact.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. 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.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:26AM BLOOD WBC-9.1 RBC-4.46* Hgb-13.9 Hct-42.0
MCV-94 MCH-31.2 MCHC-33.1 RDW-13.8 RDWSD-48.3* Plt ___
___ 11:28AM BLOOD Neuts-79.8* Lymphs-9.8* Monos-9.1
Eos-0.1* Baso-0.7 Im ___ AbsNeut-6.95* AbsLymp-0.85*
AbsMono-0.79 AbsEos-0.01* AbsBaso-0.06
___ 11:28AM BLOOD ___ PTT-29.4 ___
___ 09:26AM BLOOD Plt ___
___ 11:28AM BLOOD Glucose-328* UreaN-21* Creat-1.2 Na-132*
K-4.6 Cl-93* HCO3-20* AnGap-19*
___ 03:48PM BLOOD cTropnT-0.03*
___ 11:28AM BLOOD cTropnT-0.03*
___ 11:28AM BLOOD CK-MB-4
___ 11:28AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.9
___ 09:26AM BLOOD PSA-<0.03
___ 01:23PM BLOOD ___ pO2-40* pCO2-42 pH-7.35
calTCO2-24 Base XS--2
___ 01:23PM BLOOD O2 Sat-65
___ 02:03PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 02:03PM URINE Blood-MOD* Nitrite-NEG Protein-30*
Glucose-1000* Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.0
Leuks-LG*
___ 02:03PM URINE RBC-16* WBC->182* Bacteri-FEW* Yeast-NONE
Epi-0
___ 02:03PM URINE CastHy-27*
___ 02:03PM URINE WBC Clm-FEW* Mucous-RARE*
DISCHARGE LABS:
===============
___ 05:30AM BLOOD WBC-7.6 RBC-3.69* Hgb-11.5* Hct-34.8*
MCV-94 MCH-31.2 MCHC-33.0 RDW-14.0 RDWSD-48.0* Plt ___
___ 05:30AM BLOOD Glucose-333* UreaN-27* Creat-0.8 Na-134*
K-4.5 Cl-97 HCO3-25 AnGap-12
___ 05:30AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.5
___ 10:17AM URINE Color-Straw Appear-Clear Sp ___
___ 10:17AM URINE Blood-SM* Nitrite-NEG Protein-TR*
Glucose-1000* Ketone-40* Bilirub-NEG Urobiln-NEG pH-5.5
Leuks-LG*
___ 10:17AM URINE RBC-3* WBC-56* Bacteri-FEW* Yeast-NONE
Epi-0
___ 10:17AM URINE CastHy-2*
___ 10:17AM URINE Mucous-RARE*
Brief Hospital Course:
SUMMARY:
========
___ yo male with PMH of COPD, A fib, Type 1 DM with frequent
episodes of hypoglycemia, prostate cancer s/p prostatectomy ___
years prior and frequent falls attributed to hypoglycemia with
last fall in ___ with type 2 dens fracture managed
nonoperatively who presents after a mechanical fall found to be
in AF w/ RVR, now resolved on home metoprolol. Found to also
have UTI, discharged with ciprofloxacin 500 mg BID for course
completion on ___.
ACUTE/ACTIVE ISSUES:
====================
# UTI:
Patient w/ several days of increased urinary frequency iso
positive UA with large leuks, >100 WBCs, and positive RBCs. He
reported 3 episodes of hematuria this week, most likely due to
his UTI, though he does have a significant smoking history that
could be suggestive of bladder malignancy if hematuria persists.
He was treated with ceftriaxone in the ___, and transitioned to
ciprofloxacin 500 mg BID on discharge, for course completion on
___. Should get repeat UA to monitor for resolution of hematuria
and consider cystoscopy if persistent given risk factors.
# A. fib with RVR: resolved
RVR in ___ controlled with 5mg IV metop. He was restarted on his
home metoprolol succinate 50 mg dose on the floor and continued
on home apixaban 5 mg BID.
# Dens Fracture:
Spine evaluated in ___ and suggested likely worsening imaging
findings i/s/o non-compliance to cervical collar. Advised to
Keep ___ collar on at all times. Evaluated by ___ during
admission
# Hypoxemic Respiratory failure/COPD secondary to
alpha-1-antitrypsin deficiency:
Patient became tachypnic to mid ___ in the ER and was placed on
3L NC s/p 3L IVF repletion. Lungs clear on auscultation without
wheezes or crackles. He was weaned off his O2 requirement to his
baseline. He was due for an ___ infusion for his
alpha-1-antitrypsin deficiency, which was deferred several days
because of his admission. His outpatient pulmonologist was
notified.
# Mechanical Fall:
Pt with frequent history of falls with previous triggers thought
to be hypoglycemia. His glucose levels were in the 200s in the
___ however, and the more likely cause is multifactorial iso
weakness/dehydration from UTI, AF w/ RVR due to a missed AM
metoprolol dose.
CHRONIC/STABLE ISSUES:
======================
# Depression:
Continued on home Seroquel 25 mg PO QHS.
# DM1:
Started home glargine 6U QAM, 3U QPM with 5U w/ meals. Discussed
regimen with outpatient ___ attending given concern that low
sugars may have contributed to falls. This is less likely given
FSG 200s in ___ provider recommended keeping insulin at
home dosing and she will see him in 1 week in follow up.
TRANSITIONAL ISSUES:
===================
[ ] Completion of ciprofloxacin 500 mg BID on ___
[ ] Patient to follow up at ___ in 1 week, consider
transitioning lantus to QAM dosing fully
[ ] Patient needs to make up ___ dose
[ ] Needs outpatient ___ follow-up
[ ] Per cardiologist, consider placement ___
occlusion device (watchman)
[ ] Pt is due for repeat colonoscopy
[ ] Repeat UA after resolution of UTI. Consider cystoscopy if
hematuria persists
[ ] Ensure pt has DexCom for real time CGM and ALARMS
[ ] Follow up urine culture, adjust antibiotics pending
sensitivities
[ ] Full out HCP form with patient
Code Status: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Flovent HFA (fluticasone) 220 mcg/actuation inhalation ___
puffs BID:PRN for worsening symptoms
3. Gabapentin 200 mg PO QAM
4. Gabapentin 300 mg PO QHS
5. Lisinopril 10 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. QUEtiapine Fumarate 25 mg PO QHS
8. Simvastatin 40 mg PO QPM
9. Tiotropium Bromide 2 CAP IH DAILY
10. Apixaban 5 mg PO BID
11. Alendronate Sodium 70 mg PO QMON
12. ___ NP (alpha-1 proteinase inhib.(hum)) 1,000 mg
injection 1X/WEEK
13. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY
14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs Q4-6H:PRN
15. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation 2 PUFFS BID
16. Metoprolol Succinate XL 50 mg PO DAILY
17. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
18. Orapred ODT (prednisoLONE sodium phosphate) 10 mg oral
DAILY:PRN
19. Glargine 6 Units Breakfast
Glargine 3 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 1 Day
last day ___
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*2 Tablet Refills:*0
2. Glargine 6 Units Breakfast
Glargine 3 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
4. Alendronate Sodium 70 mg PO QMON
5. Apixaban 5 mg PO BID
6. ___ NP (alpha-1 proteinase inhib.(hum)) 1,000 mg
injection 1X/WEEK
7. Flovent HFA (fluticasone) 220 mcg/actuation inhalation ___
puffs BID:PRN for worsening symptoms
8. Gabapentin 200 mg PO QAM
9. Gabapentin 300 mg PO QHS
10. Lisinopril 10 mg PO DAILY
11. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Orapred ODT (prednisoLONE sodium phosphate) 10 mg oral
DAILY:PRN
15. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
2 puffs Q4-6H:PRN
17. QUEtiapine Fumarate 25 mg PO QHS
18. Simvastatin 40 mg PO QPM
19. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation 2 PUFFS BID
20. Tiotropium Bromide 2 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
=======
Urinary tract infection
SECONDARY:
==========
Type 2 dens fracture
Emphysema
Atrial fibrillation
Type 1 Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital for a urinary tract infection and a
fall.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Because you had a fall, you received a picture of your head
called a non-contrast CT, which was reassuring against any
bleeding in your head. You also received a picture of your spine
to assess the fracture you had in ___. This demonstrated
worsening of your fracture. As a result, you were seen by the
orthopedic surgeons, who recommended that you wear your neck
brace at all times for the next ___ weeks. You were seen by the
physical therapist, who recommended ***.
- You were found to have a urinary tract infection and were
given antibiotics to treat the infection. You were discharged on
an oral antibiotic regimen, which you should finish on ___.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- You can arrange outpatient ___ through your orthopedic surgeon,
Dr. ___.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19763024-DS-15
| 19,763,024 | 25,770,656 |
DS
| 15 |
2160-04-15 00:00:00
|
2160-04-15 13:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
positive blood cultures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with T1DM, COPD, A fib, presents after being informed to
return to the ED because of blood cultures turning positive.
Admission notes from ___ reviewed and summarized as follows:
Presented initially to ED d/t a fall while at a radiology appt
without apparent syncope. Numerous falls prior, including one
resulting in a dens Fx for which pt following with ortho and
currently in a C-collar. Did have several days of feeling weaker
at that time. Admitted x24h getting a CTX dose in the ED and
then
being Dc'd on cipro.
Subsequently, his UCx grew 100k of Enterococcus, sensi to vanc.
Also flipped one bottle positive for Viridans strep (no sensi
run)
Since DC on ___ pt reports feeling well.
Re urinary Sx: reports his baseline frequency but no dysuria,
hematuria, flank pain, n/v
Re falls: no LH, falls, loss of consciousness, confusion. Still
wearing hard C-collar per ___ (ortho) and has appt
established
for ___. No pain; no longer on oxycodone
Re hyperglycemia, takes sliding scale at home and generally well
controlled. Denies missing doses. Follows at ___
Pt denies recent dental procedures; has dentures. No heart
value,
prior Hx endocarditis
Past Medical History:
PMHx:
prostate CA s/p XRT/adjuvant hormonal therapy; type 1 DM;
recurrent hypoglycemia with frequent falls;
emphysema/bronchiectasis due to alpha-1 antitrypsin deficiency;
depression; s/p cataract/IOL OD ___ s/p ___ ___ admit for syncope ___ s/p L clavicular Fx ___
hypercholesterolemia; community-acquired PNA ___ and RHM
PSHx:
TURP
Port-a-Cath placement
Social History:
___
Family History:
Family Hx: mother deceased from ovarian CA; sister deceased from
"liver or kidney failure"; no FHx of prostate CA
Physical Exam:
GENERAL: Alert and in no apparent distress; C-collar in place
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. No ___ edema
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No CVA tenderness
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 01:05PM BLOOD WBC-4.1 RBC-4.02* Hgb-12.6* Hct-36.9*
MCV-92 MCH-31.3 MCHC-34.1 RDW-13.8 RDWSD-46.6* Plt ___
___ 06:03AM BLOOD WBC-3.9* RBC-3.75* Hgb-11.7* Hct-34.9*
MCV-93 MCH-31.2 MCHC-33.5 RDW-13.5 RDWSD-46.1 Plt ___
___ 06:13AM BLOOD WBC-4.0 RBC-3.70* Hgb-11.5* Hct-34.9*
MCV-94 MCH-31.1 MCHC-33.0 RDW-13.9 RDWSD-48.0* Plt ___
___ 05:21AM BLOOD WBC-4.7 RBC-3.93* Hgb-12.2* Hct-36.9*
MCV-94 MCH-31.0 MCHC-33.1 RDW-13.7 RDWSD-47.0* Plt ___
___ 01:05PM BLOOD Glucose-254* UreaN-13 Creat-0.9 Na-132*
K-7.3* Cl-98 HCO3-22 AnGap-12
___ 06:03AM BLOOD Glucose-201* UreaN-10 Creat-0.6 Na-140
K-4.2 Cl-101 HCO3-28 AnGap-11
___ 06:13AM BLOOD Glucose-69* UreaN-15 Creat-0.7 Na-139
K-4.0 Cl-102 HCO3-31 AnGap-6*
___ 05:21AM BLOOD Glucose-210* UreaN-24* Creat-0.8 Na-137
K-4.7 Cl-99 HCO3-30 AnGap-8*
Brief Hospital Course:
#Enterococcal UTI: Asymptomatic in this regard. Received Cipro
from ER visit and Amoxicillin here x 3 days, stopped now with
repeat culture negative.
#strep viridans bacteremia: ___ bottles growing viridans strep.
No prosthetic valve or other ortho devices. No recent dental
procedure.
-received Ceftriaxone here which was stopped today
-seen by ID, TTE with no endocarditis, ID recommended stopping
antibiotics and bacteremia felt likely contamination at this
point
-present of port (used for antitrypsin infusions at ___ is
concerning, and ID recommends repeat blood cultures (from port
and peripheral) in a week from now when he has been off
antibiotics and following them
-patient to return to ER with any fever, chills or rigor.
#dens fracture: cont C-collar; has outpatient apt ___, will
need
collar until then.
- was seen by Ortho spine here on ___ after his fall, no
surgical management recommend, conservative management with
collar for now, was instructed to be worn at all times
- cont home gabapentin
#type 1 DM
#hyperglycemia:
-continue home regimen
#HTN:
- cont home meds, as above
CHRONIC/STABLE PROBLEMS:
#afib: cont home metop XL + apixaban
#CV: cont home statin
#COPD: cont home meds
#psych: cont home quetiapine QHS
Plan discussed with patient and he is agreeable with discharge
today.
Time spent on the discharge process is greater than 30 mins, in
counseling patient and discharge coordination.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Apixaban 5 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
5. QUEtiapine Fumarate 25 mg PO QHS
6. Simvastatin 40 mg PO QPM
7. Tiotropium Bromide 2 CAP IH DAILY
8. Alendronate Sodium 70 mg PO QMON
___ NP (alpha-1 proteinase inhib.(hum)) 1,000 mg
injection 1X/WEEK
10. Flovent HFA (fluticasone) 220 mcg/actuation inhalation ___
puffs BID:PRN for worsening symptoms
11. Gabapentin 200 mg PO QAM
12. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY
13. Metoprolol Succinate XL 50 mg PO DAILY
14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation 2
puffs Q4-6H:PRN
15. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation 2 PUFFS BID
16. Gabapentin 300 mg PO QHS
17. Lisinopril 10 mg PO DAILY
18. Orapred ODT (prednisoLONE sodium phosphate) 10 mg oral
DAILY:PRN
19. Ciprofloxacin HCl 500 mg PO Q12H
20. Glargine 6 Units Breakfast
Glargine 3 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Discharge Medications:
1. Glargine 6 Units Breakfast
Glargine 3 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
3. Alendronate Sodium 70 mg PO QMON
4. Apixaban 5 mg PO BID
5. ___ NP (alpha-1 proteinase inhib.(hum)) 1,000 mg
injection 1X/WEEK
6. Flovent HFA (fluticasone) 220 mcg/actuation inhalation ___
puffs BID:PRN for worsening symptoms
7. Gabapentin 200 mg PO QAM
8. Gabapentin 300 mg PO QHS
9. Lisinopril 10 mg PO DAILY
10. Lumigan (bimatoprost) 0.01 % ophthalmic (eye) DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Orapred ODT (prednisoLONE sodium phosphate) 10 mg oral
DAILY:PRN
14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
2 puffs Q4-6H:PRN
16. QUEtiapine Fumarate 25 mg PO QHS
17. Simvastatin 40 mg PO QPM
18. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation 2 PUFFS BID
19. Tiotropium Bromide 2 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Strep viridans bacteremia
Enterococcal UTI
Dens fracture of neck
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were called to come in to the hospital for positive blood
culture drawn from your recent ER visit. Repeat cultures drawn
here have stayed negative. You were also evaluated by the
Infectious disease team here. You are feeling well and medically
stable for discharge home today. It is felt the positive blood
culture from ER was likely contamination but the presence of a
port in your case is concerning. For this reason, it is
recommend that you get repeat blood cultures drawn at the
___ in a week (when you would be off antibiotics)
and making sure that they don't turn positive.
When you are home and you develop any fever, chills, rigors then
come back to ER immediately to get re-evaluated.
We wish you all the best!
Followup Instructions:
___
|
19763095-DS-7
| 19,763,095 | 26,519,518 |
DS
| 7 |
2138-10-24 00:00:00
|
2138-10-25 17:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Globus sensation
Major Surgical or Invasive Procedure:
___ coronary angiography with left heart catheterization,
right radial access
History of Present Illness:
Mr. ___ is a ___ year old ___ with ___ of
HTN, HLD, BPH, AAA s/p repair with stenting who is transferred
from ___ to ___ ED with concern for NSTEMI.
He presented to ___ due to concern of sensation of food
stuck in throat which occurred shortly after eating shoulder
pork
at 1500. He reports intermittent heart burn at the time which
is
not unusual for him. He experienced no shortness of breath. No
chest pain. No n/v. No radiation. On arrival to ___
patient was reportedly tachycardic in 120s. Troponin 0.14. EKG
reportedly with no ischemia, unavailable for review.
A CTA of chest was obtained and negative for PE. A CT of soft
tissue neck was negative.
He was given 1L NS, Aspirin 325 mg and a dose of lovenox at ___
and transferred to ___ ED.
Mr. ___ is a ___ yo M with history of HTN, high cholesterol,
AAA repair with stents who presents with a sensation of food
being lodged in his throat since this morning. He was referred
from ___ for elevated trop (0.14) and NSTEMI. OSH gave 1L
NS, Lovenox SQ, and ASA 325 mg. He endorses some new
lightheadedness/dizziness that started after he reported to OSH.
Denies chest pain/pressure, arm pain, SOB with exertion or at
rest, N/V, diaphoresis. Denies recent illness, fever/chills,
cough, changes in bowel/bladder habits, abd pain,
diarrhea/constipation.
Additional PMH/PSH significant only for colonic polyp and
ventral
hernia in addition to above.
In the ED, he reported some new vertigiousness that occurred
during CT scan at OSH. Denies chest pain/pressure, arm pain, SOB
with exertion or at rest, N/V, diaphoresis. Denies recent
illness, fever/chills, cough, changes in bowel/bladder habits,
abd pain, diarrhea/constipation.
- Initial vitals:
96.8 |67| 156/102| 18| 96% RA
- EKG: Sinus rhythm. Prolonged PR interval. Right bundle branch
block
- Labs/studies notable for:
___ 11:35PM BLOOD WBC: 8.8 RBC: 5.09 Hgb: 14.7 Hct: 45.4
MCV: 89 MCH: 28.9 MCHC: 32.4 RDW: 15.0 RDWSD: 48.9* Plt Ct: 182
___ 11:35PM BLOOD Neuts: 58.7 Lymphs: ___ Monos: 7.8 Eos:
4.3 Baso: 0.8 Im ___: 0.5 AbsNeut: 5.17 AbsLymp: 2.46 AbsMono:
0.69 AbsEos: 0.38 AbsBaso: 0.07
___ 11:35PM BLOOD ___: 12.0 PTT: 40.1* ___: 1.1
___ 11:35PM BLOOD Glucose: 122* UreaN: 31* Creat: 1.1 Na:
141 K: 4.6 Cl: 106 HCO3: 20* AnGap: 15
___ 11:35PM BLOOD CK(CPK): 266
___ 11:35PM BLOOD cTropnT: 0.16*
___ 11:35PM BLOOD CK-MB: 8
Patient was given no medications in ___ ED.
- Vitals on transfer:
97 |69| 111/62| 17| 96% RA
On the floor, patient reports history as above. He developed
sensation of food stuck in his throat after eating prompting
presentation to OSH. He has had episodes of substernal chest
pain
in the past (last a month ago). He denies any current chest
pain.
His globus sensation has now resolved. He reported
vertigiousness
that started during CT scan at OSH and has now resolved. He
denies SOB, DOE, cough. He has no abdominal pain. No nausea or
vomiting.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies any prior history of
stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies exertional buttock or calf pain.
Denies recent fevers, chills or rigors. All of the other review
of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- BPH
- AAA s/p repair with stent
- Gout
Social History:
___
Family History:
States a family history of heart disease in his parents when
they
were elderly.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
___ 0407 Temp: 97.6 PO BP: 159/85 L Sitting HR: 76 RR:
20
O2 sat: 93% O2 delivery: RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: Normoactive bowel sounds. Abdomen soft, nondistended,
nontender in all quadrants, no rebound/guarding, no
hepatosplenomegaly. Ventral hernia.
EXTREMITIES: No cyanosis, clubbing, there is trace peripheral
edema b/l to shins.
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric.
DERM: Skin type III. Warm and well perfused, no excoriations or
lesions, no rashes.
DISCHARGE PHYSICAL EXAM
=========================
VS: ___ 1156 Temp: 97.8 PO BP: 130/86 HR: 68 RR: 20 O2 sat:
96% O2 delivery: RA
Fluid Balance (last updated ___ @ 1337)
Last 8 hours Total cumulative -210ml
IN: Total 540ml, PO Amt 540ml
OUT: Total 750ml, Urine Amt 750ml
Last 24 hours Total cumulative -1350ml
IN: Total 1800ml, PO Amt 900ml, IV Amt Infused 900ml
OUT: Total 3150ml, Urine Amt 3150ml
GENERAL: NAD
NECK: JVP not elevated.
CV: RRR. S1, S2. No MGR.
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: +BS. Soft, non-distended, non-tender to palpation. Ventral
hernia.
EXTREMITIES: No cyanosis, clubbing, there is trace peripheral
edema b/l to shins. R radial access site c/d/I with no bruit
auscultated and no hematoma.
PULSES: +2 radial pulses b/l.
Pertinent Results:
ADMISSION LABS
===============
___ 11:35PM BLOOD WBC-8.8 RBC-5.09 Hgb-14.7 Hct-45.4 MCV-89
MCH-28.9 MCHC-32.4 RDW-15.0 RDWSD-48.9* Plt ___
___ 11:35PM BLOOD Neuts-58.7 ___ Monos-7.8 Eos-4.3
Baso-0.8 Im ___ AbsNeut-5.17 AbsLymp-2.46 AbsMono-0.69
AbsEos-0.38 AbsBaso-0.07
___ 11:35PM BLOOD ___ PTT-40.1* ___
___ 11:35PM BLOOD Glucose-122* UreaN-31* Creat-1.1 Na-141
K-4.6 Cl-106 HCO3-20* AnGap-15
___ 11:35PM BLOOD CK(CPK)-266
___ 11:35PM BLOOD CK-MB-8
___ 11:35PM BLOOD cTropnT-0.16*
___ 07:45AM BLOOD CK-MB-7 cTropnT-0.18* proBNP-414
___ 03:05PM BLOOD CK-MB-6 cTropnT-0.14*
___ 07:45AM BLOOD Albumin-4.0 Calcium-9.8 Phos-2.4* Mg-2.0
PERTINENT INTERVAL LABS
========================
___ 07:39AM BLOOD %HbA1c-6.8* eAG-148*
___ 07:39AM BLOOD Triglyc-277* HDL-32* CHOL/HD-4.6
LDLcalc-60
DISCHARGE LABS
===============
___ 06:34AM BLOOD WBC-8.1 RBC-5.20 Hgb-14.6 Hct-46.0 MCV-89
MCH-28.1 MCHC-31.7* RDW-15.0 RDWSD-48.4* Plt ___
___ 06:34AM BLOOD Glucose-146* UreaN-23* Creat-1.1 Na-142
K-4.8 Cl-104 HCO3-27 AnGap-11
IMAGING
=========
TTE (___)
--------------
CONCLUSION: The left atrial volume index is normal. There is
mild symmetric left ventricular hypertrophy with a normal cavity
size. There is suboptimal image quality to assess regional left
ventricular function. Quantitative biplane left ventricular
ejection fraction is 67 %. 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) are mildly thickened. There is no aortic valve
stenosis. There is no aortic regurgitation. The mitral valve
leaflets appear structurally normal with no mitral valve
prolapse. There is trivial mitral regurgitation. The pulmonic
valve leaflets are normal. 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.
CXR (___)
--------------
IMPRESSION:
No evidence of acute cardiopulmonary process
MICROBIOLOGY
=============
None
Brief Hospital Course:
SUMMARY OF HOSPITALIZATION
============================
Mr. ___ is a ___ year old man with ___ of HTN, HLD, BPH
presenting with intermittent chest discomfort for several weeks
and several hours of globus sensation and found to have NSTEMI.
Echo without focal wall motion abnormalities or significant
valvular dysfunction. Coronary angiogram demonstrated
significant LAD and PDA disease, LAD was intervened upon with
DES. He was discharged with improved medical regimen.
ACUTE ISSUES
=============
#NSTEMI
Patient presented to OSH with globus sensation and heartburn
after weeks of intermittent CP, found to have elevated troponin
0.14, peaked at 0.18 without EKG changes, though evidence of old
inferior/posterior MI. Prior myocardial perfusion scan at ___
___ showed LV is mildly dilated both at stress and rest, old
inferior wall infarct. TTE ___ with LVEF 67%, no focal WMA
without valvular dysfunction. A1c 6.8, mildly elevated TGAs, low
HDL. Unclear if globus sensation may have represented anginal
equivalent or was related to post-meal GERD. Patient received
heparin drip, metoprolol 12.5mg q6h, increased home atorvastatin
20mg to 80mg, continued ASA 81mg. Coronary angiography with left
heart cath ___ demonstrated two-vessel coronary disease;
drug-eluting stent was deployed to the LAD.
#Globus sensation
Presented with sensation of food stuck in throat x hours after
eating pork. Unclear if anginal equivalent, and self resolved.
___ have been esophageal dysmotility or spasm.
#Dyspnea
Patient became mildly dyspneic after ticagrelor load during
coronary angiogram. CXR was normal, did not show volume overload
or intra-pulmonary process. Thought to potentially be related to
his high blood pressure. Patient was switched to Plavix (loaded
with Plavix then switched to daily maintenance dose), and he was
started on a nitro gtt. We increased his amlodipine to 10 mg QD.
The nitro gtt was stopped. The patient was not dyspneic on
discharge.
CHRONIC ISSUES
===============
#HTN: Continued hydrochlorothiazide, losartan, and metoprolol.
#HLD: Atorvastatin 80mg
#BPH: home Tamsulosin, finasteride
#Gout: home allopurinol
TRANSITIONAL ISSUES
===================
[ ] Dyspnea - Continue to monitor for recurrence; think likely
related to ticagrelor vs. hypertension, so could uptitrate his
blood pressure medications if recurs.
[ ] Would recommend referral to Cardiac Rehabilitation as an
outpatient.
*New medications
Plavix 75 daily
Amlodipine 10 mg QD
*Changed meds
Atorvastatin 80mg
# CODE: Full, confirmed
# CONTACT: HCP: ___, wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Tamsulosin 0.4 mg PO QHS
3. Finasteride 5 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Allopurinol ___ mg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Meclizine 12.5 mg PO QHS:PRN dizziness
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
2. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*38
Tablet Refills:*0
4. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
5. Allopurinol ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. Meclizine 12.5 mg PO QHS:PRN dizziness
11. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Non-ST elevation myocardial infarction
==================
Secondary diagnoses:
===================
Hypertension, hyperlipidemia, benign prostatic hypertrophy, gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had throat pain and were found to have had a heart attack.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- We looked at the blood vessels of your heart (with a
coronary angiography") and placed a stent to open up a blockage
in your artery.
- Your medications were changed and a new medication was added
to keep the stent open and keep your heart as healthy as
possible.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- If you have a recurrence of chest pain, please contact our
___ Heartline at ___.
We wish you the best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19763129-DS-18
| 19,763,129 | 26,964,023 |
DS
| 18 |
2167-07-13 00:00:00
|
2167-07-13 14:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Tetracycline
Attending: ___.
Chief Complaint:
LUQ mass, leukocytosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP: ___ (___)
HISTORY OF PRESENT ILLNESS:
___ yoM with h/o TMJ who presents from PCP office with
leukocytosis to 173K and LUQ mass.
He reports ___ days of LUQ discomfort. He then noticed a
palpable mass and therefore called his PCP. He was seen today
for an urgent visit and labs were drawn which revealed an
elevated WBC to 180K and he was referred to the ED. Last CBC
drawn ___ showed WBC 14.6. Denies any recent fevers or
chills, no bleeding or bruising. Has occasional night sweats.
Also endorses some groin fullness that has resolved.
In the ED, initial vitals were 98 100 143/76 14 100%. He had a
CT abdomen/pelvis which showed splenomegaly to 21cm and pelvic
lymphadenopathy. Heme/onc was consulted and he was admitted to
medicine.
Heme/onc reviewed the smear which was c/w CLL (more likely) vs
hairy cell leukemia.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, 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:
Migraines
Allergic rhinitis
Aphthous stomatitis
Temporomandibular joint syndrome
Myofascial pain syndrome
Social History:
___
Family History:
Father had CVA, heart disease. Mother died of ___. No
FH of leukemia, lymphoma or other cancers.
Physical Exam:
Vitals: 97.8 134/86 82 16 99%RA 188.9 lbs
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, very large and firm spleen palpable, mild
discomfort with palpation of LUQ, +BS, no rebound
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. LLE with some dilated veins which patient reports is
chronic
Lymph: Shotty lymphadenopathy in cervical, pelvic, and axillary
regions
Pertinent Results:
___ 06:30PM WBC-173.3* RBC-4.30* HGB-12.5* HCT-37.7*
MCV-88 MCH-29.2 MCHC-33.3 RDW-14.6
___ 06:30PM NEUTS-10* BANDS-0 LYMPHS-85* MONOS-3 EOS-0
BASOS-0 ATYPS-1* ___ MYELOS-0 OTHER-1*
___ 06:30PM HYPOCHROM-OCCASIONAL ANISOCYT-1+
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
SPHEROCYT-1+
___ 06:30PM PLT SMR-NORMAL PLT COUNT-232
___ 06:30PM ___ PTT-31.6 ___
___ 06:30PM ALBUMIN-4.5 CALCIUM-9.2 PHOSPHATE-2.8
MAGNESIUM-2.2 URIC ACID-5.1
___ 06:30PM LIPASE-32
___ 06:30PM ALT(SGPT)-31 AST(SGOT)-37 LD(LDH)-230 ALK
PHOS-88 TOT BILI-0.4
___ 06:30PM GLUCOSE-110* UREA N-20 CREAT-0.8 SODIUM-143
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-17
CT abd/pelvis ___: splenomegaly measuring 21cm, pelvic
lymphadenopathy, findings may represent lymphoma.
Brief Hospital Course:
___ yoM with h/o TMJ who presents with leukocytosis to 173K,
splenomegaly, and pelvic adenopathy.
# Leukocytosis: Most likely CLL given constellation of
leukocytosis that is lymphocyte-predominant, splenomegaly and
adenopathy. Heme/onc reviewed peripheral smear and is c/w this.
Other potential diagnoses are hairy cell leukemia, mantle cell
lymphoma, lymphoplasmacytic lymphoma. No current signs of
leukostasis or tumor lysis. ___ have aggressive disease given
likely short doubling time given near normal CBC ___ year ago.
Uric acid, LDH, LFTs normal. SPEP and flow cytometry pending.
___ heme/onc was consulted and recommended sending DAT, HCV and
HBV serologies, peripheral cytogenetics and FISH, and HIV. If
diagnosis is uncertain as ___ be considered for bone
marrow biopsy.
# TM: Home Vicodin, gabapentin
# FEN: No IVF, replete electrolytes, regular diet
# PPX: Subcutaneous heparin, senna/colace, pain meds
# ACCESS: Peripherals
# CODE: Full code
# CONTACT: ___ is friend ___ in ___ ___
# DISPO: Home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain
2. Gabapentin 100 mg PO BID
Discharge Medications:
1. Gabapentin 100 mg PO BID
2. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q6H:PRN pain
3. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Possible CLL
Splenomegaly
Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have been admitted with an enlarged spleen and increased
white blood count that could be chronic lymphocytic leukemia.
You have been seen by an oncologist who has recommended further
testing that will be followed up as an outpatient. You will be
contacted by ___ oncology for a follow-up appointment this
week.
Followup Instructions:
___
|
19763129-DS-25
| 19,763,129 | 27,588,683 |
DS
| 25 |
2168-04-15 00:00:00
|
2168-04-17 21:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin / Quinolones / cefepime
Attending: ___.
Chief Complaint:
fever and malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with mantle cell lymphoma s/p
allo SCT 29 days ago who presents with a fever, malaise and
dyspepsia. He initially noted dyspepsia and constipation 5 days
ago which progressively became worse to include vomiting 2 days
ago and fevers/chills yesterday. He denies any other
accompanying symptoms other than intermittent urinary urgency.
He denies sick contacts, recent travel, or exotic food intake.
Initial labs 101.2 101 139/68 18 97%. CXR notable for 2 rounded
opacities over R chest. Labs were notable for baseline anemia.
Mild leukopenia to 3.9 with normal neutrophil count. Elevated
INR of 1.5 (baseline). UA with 3 WBC and no bacteria. He was
given 80mg IV enoxaparin, 20mg oxycontin, 1000mg of aztreonam,
1gm of vancomycin, and 325mg of tylenol.
Past Medical History:
PAST ONCOLOGIC HISTORY:
** evaluated by PCP ___ ___ in the urgent care clinic for
___ weeks of LUQ discomfort and new ? palpable abnormality in
this area. He had a CBC and found to have profound leukocytosis
of 173k (Last CBC drawn prior to this presentation was in
___ which revealed a
WBC of 14.6). He had no other systemic symptoms at the time- no
fevers, chills, drenching night sweats, weight loss, abnormal
bleeding/bruising, LD. Notes maybe appetite not quite at
baseline and not feeling himself for a few weeks. CT
abdomen/pelvis showed splenomegaly to 21cm and pelvic
lymphadenopathy. Ultimately did have a CT chest on ___ to
complete work up that showed bilateral axillary adenopathy and
prevascular nodes. There was a right
axillary node deep into the pectoralis minor muscle measuring
24x
12 mm. ?vetebral hemangioma at T6. Flow cytometry: CD5+CD23+ B
cell lymphoproliferative process, consistent with CLL. He was
started by local oncologist on FC. Received 2 days of this
treatment and more testing came back on the cytogenetics with
CCND1-IGH (Cyclin D1) which is more consistent with a Mantle
Cell Lymphoma. Day 3 was subsequently held (last dose was on
___. ** referred to Dr. ___ second opinion and
establish care. The recommendation was to do ___
alternating with HIDAC for a total of 6 cycles followed by
consolidation with an autologous stem cell transplant. This is
based on Nordic trial with recent article in ___ Journal of
Haematology. "Nordic MCL2trial update: six-year follow-up after
intensive immunochemotherapy for untreted mantle cell lymphoma
followed by BEAM or BEAC + auto stem cell support: still very
long survival but late relapses do occur" ** started on first
cycle of CHOP chemotherapy (Rituxan held with first cycle) on
___ ___omplicated by diarrhea, hemorrhoids and
general irritation in perirectal area. Was r/o for C. difficile.
- ___ MaxiCHOP
- ___ HD-ARA-C
- ___ rituximab
- ___ MaxiCHOP
- ___ Rituxan
- ___ Admit for HD-ARA-C
PAST MEDICAL/SURGICAL HISTORY:
Migraines: no episodes for many years
Allergic rhinitis
Aphthous stomatitis
Temporomandibular joint syndrome: R side, controlled with
vicodin
Myofascial pain syndrome
Social History:
___
Family History:
(per OMR, confirmed with patient) No FH of leukemia, lymphoma or
other cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS - 98.2 83 128/76 16 97% RA
General: chronically ill thin appearing gentleman, NAD
HEENT: dry MM,
Neck: supple neck
CV: RRR no m/r/g
Lungs: CTAB no w/r/r
Abdomen: soft/nt/nd +BS
GU: no CVA tenderness
Ext: non-edematous
Neuro: CNII-XII grossly intact, gait normal, affect appropriate
DISCHARGE PHYSICAL EXAM:
VITALS Tmax 98.1 Tc: 98 HR 68 BP 112/70 RR 18 SaO2 98%RA
i/os: +447cc, formed BM x4
General: Thin, lying down, restricted affect
HEENT: Alopecia present, sclera anicteric, dry MM, clear
oropharynx, no oral lesions
CV: regular rate and rhythm, normal S1/S2, no m/r/g
Lungs: CTAB, no crackles, wheeze, rhonchi
Abdomen: Soft, nondistended, non-tender, spleen edge 3cm below
left costal margin
GU: No foley, no suprapubic tenderness
Ext: warm and well-perfused, no peripheral edema
Neuro: Alert and oriented x3, depressed affect, CNII-XII intact,
___ strength in UE and ___ bilaterally, no focal deficits
Skin: Palmar erythema (improved) and small petechial rash along
wrists and forearms bilaterally (improved). Erythema on soles of
feet as well (improved). Line sites look clean.
Pertinent Results:
ADMISSION LABS:
___ 06:01PM BLOOD Lactate-0.8
___ 12:00AM BLOOD Albumin-3.4* Calcium-7.8* Phos-2.9 Mg-1.6
___ 08:30AM BLOOD ALT-12 AST-15 LD(LDH)-386* AlkPhos-63
TotBili-0.5
___ 05:50PM BLOOD Glucose-98 UreaN-6 Creat-0.5 Na-136 K-4.1
Cl-101 HCO3-24 AnGap-15
___ 05:50PM BLOOD ___ PTT-39.4* ___
___ 05:50PM BLOOD WBC-3.9* RBC-3.37* Hgb-10.1* Hct-31.6*
MCV-94 MCH-29.9 MCHC-31.9 RDW-17.1* Plt ___
___ 05:50PM BLOOD Neuts-71* Bands-4 Lymphs-16* Monos-8
Eos-0 Baso-0 ___ Metas-1* Myelos-0
___ 06:05PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:05PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-80 Bilirub-SM Urobiln-4* pH-6.0 Leuks-NEG
___ 06:05PM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
DISCHARGE & PERTINENT LABS:
___ 08:30AM BLOOD WBC-4.8 RBC-3.70* Hgb-10.6* Hct-34.4*
MCV-93 MCH-28.6 MCHC-30.8* RDW-17.2* Plt ___
___ 05:50PM BLOOD WBC-3.9* RBC-3.37* Hgb-10.1* Hct-31.6*
MCV-94 MCH-29.9 MCHC-31.9 RDW-17.1* Plt ___
___ 12:00AM BLOOD WBC-3.4* RBC-3.28* Hgb-9.7* Hct-31.5*
MCV-96 MCH-29.5 MCHC-30.8* RDW-17.5* Plt Ct-93*
___ 01:08AM BLOOD WBC-3.6* RBC-3.29* Hgb-9.5* Hct-31.0*
MCV-94 MCH-28.8 MCHC-30.6* RDW-17.1* Plt ___
___ 01:40AM BLOOD WBC-4.1 RBC-3.38* Hgb-10.2* Hct-32.1*
MCV-95 MCH-30.2 MCHC-31.9 RDW-17.2* Plt Ct-95*
___ 12:00AM BLOOD WBC-2.8* RBC-3.22* Hgb-9.5* Hct-30.4*
MCV-95 MCH-29.5 MCHC-31.2 RDW-17.0* Plt Ct-85*
___ 11:42PM BLOOD WBC-2.0* RBC-3.13* Hgb-9.2* Hct-29.6*
MCV-95 MCH-29.5 MCHC-31.3 RDW-17.1* Plt Ct-80*
___ 11:51PM BLOOD WBC-1.7* RBC-3.17* Hgb-9.2* Hct-29.6*
MCV-93 MCH-28.9 MCHC-31.0 RDW-16.9* Plt Ct-72*
___ 12:03AM BLOOD WBC-2.2* RBC-3.41* Hgb-9.8* Hct-31.5*
MCV-92 MCH-28.7 MCHC-31.1 RDW-16.8* Plt ___
___ 12:00AM BLOOD WBC-2.1* RBC-3.46* Hgb-10.0* Hct-31.8*
MCV-92 MCH-28.9 MCHC-31.4 RDW-16.9* Plt ___
___ 12:20AM BLOOD WBC-2.0* RBC-3.62* Hgb-10.7* Hct-33.7*
MCV-93 MCH-29.6 MCHC-31.7 RDW-16.8* Plt ___
___ 11:36PM BLOOD WBC-1.4* RBC-3.46* Hgb-9.9* Hct-31.7*
MCV-92 MCH-28.7 MCHC-31.3 RDW-16.7* Plt ___
___ 06:53AM BLOOD WBC-1.6* RBC-3.39* Hgb-10.0* Hct-32.2*
MCV-95 MCH-29.6 MCHC-31.2 RDW-16.8* Plt ___
___ 12:10AM BLOOD WBC-1.6* RBC-3.58* Hgb-10.2* Hct-33.3*
MCV-93 MCH-28.6 MCHC-30.7* RDW-16.4* Plt ___
___ 12:00AM BLOOD WBC-1.5* RBC-3.78* Hgb-10.9* Hct-35.2*
MCV-93 MCH-28.8 MCHC-31.0 RDW-16.3* Plt ___
___ 12:04AM BLOOD WBC-1.9* RBC-3.93* Hgb-11.5* Hct-36.8*
MCV-94 MCH-29.3 MCHC-31.3 RDW-16.4* Plt ___
___ 12:00AM BLOOD WBC-1.2* RBC-3.48* Hgb-10.1* Hct-32.6*
MCV-94 MCH-29.1 MCHC-31.1 RDW-16.5* Plt ___
___ 12:04AM BLOOD WBC-1.3* RBC-3.36* Hgb-10.1* Hct-31.6*
MCV-94 MCH-30.0 MCHC-31.9 RDW-16.6* Plt ___
___ 12:05AM BLOOD WBC-1.4* RBC-3.75* Hgb-11.0* Hct-35.0*
MCV-94 MCH-29.4 MCHC-31.4 RDW-16.2* Plt ___
___ 12:00AM BLOOD WBC-1.2* RBC-3.43* Hgb-10.3* Hct-32.2*
MCV-94 MCH-29.9 MCHC-31.9 RDW-16.4* Plt ___
___ 12:13AM BLOOD WBC-1.5* RBC-3.71* Hgb-11.0* Hct-34.4*
MCV-93 MCH-29.6 MCHC-31.9 RDW-16.0* Plt ___
___ 12:22AM BLOOD WBC-1.4* RBC-3.38* Hgb-10.2* Hct-32.1*
MCV-95 MCH-30.3 MCHC-31.9 RDW-16.2* Plt Ct-88*
___ 12:06AM BLOOD WBC-1.0* RBC-3.14* Hgb-9.3* Hct-29.2*
MCV-93 MCH-29.7 MCHC-31.9 RDW-15.9* Plt Ct-82*
___ 12:00AM BLOOD WBC-1.0* RBC-3.08* Hgb-9.2* Hct-28.9*
MCV-94 MCH-29.9 MCHC-31.8 RDW-16.2* Plt Ct-74*
___ 12:30AM BLOOD WBC-1.0* RBC-2.88* Hgb-9.0* Hct-26.9*
MCV-93 MCH-31.2 MCHC-33.4 RDW-15.9* Plt Ct-65*
___ 12:24AM BLOOD WBC-3.0*# RBC-3.25* Hgb-10.0* Hct-31.0*
MCV-95 MCH-30.7 MCHC-32.2 RDW-16.4* Plt Ct-69*
___ 12:24AM BLOOD Neuts-81.5* Lymphs-11.5* Monos-5.1
Eos-1.8 Baso-0
___ 12:30AM BLOOD Neuts-68.8 ___ Monos-10.7 Eos-1.8
Baso-0
___ 12:24AM BLOOD ___ PTT-35.3 ___
___ 12:24AM BLOOD Glucose-87 UreaN-10 Creat-0.5 Na-140
K-4.1 Cl-108 HCO3-27 AnGap-9
___ 12:24AM BLOOD ALT-27 AST-27 LD(LDH)-228 AlkPhos-33*
TotBili-0.5
___ 12:24AM BLOOD Albumin-2.9* Calcium-7.9* Phos-2.3*
Mg-1.5* UricAcd-3.1*
___ 12:03AM BLOOD VitB12-GREATER TH
___ 12:03AM BLOOD TSH-2.7
___ 07:11AM BLOOD Cortsol-14.1
___ 12:00AM BLOOD PSA-1.4
___ 12:13AM BLOOD IgG-594*
___ 10:08AM BLOOD Cyclspr-148
___ 12:22AM BLOOD HERPES 6 DNA PCR, QUANTITATIVE-Test Name
___ 12:22AM BLOOD EBV PCR, QUANTITATIVE, WHOLE BLOOD-Test
___ 12:05AM BLOOD B-GLUCAN-Test
CMV Viral Load (Final ___:
207 IU/mL.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
Reported to and read back by ___ 4:35PM ___.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
MICRO:
___ CMV VL Pending
___ Ucx pending
___ Bcx x2 pending
___ Bcx x2 pending
___ 03:50PM CEREBROSPINAL FLUID (CSF) WBC-14 RBC-0 Polys-0
___ ___ 03:50PM CEREBROSPINAL FLUID (CSF) WBC-10 RBC-1* Polys-0
___ ___ 03:50PM CEREBROSPINAL FLUID (CSF) TotProt-72*
Glucose-53 LD(LDH)-26
___ 03:50PM CEREBROSPINAL FLUID (CSF) ADENOVIRUS PCR-Test
Name
___ 03:50PM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY
PCR-Test Name
___ 03:50PM CEREBROSPINAL FLUID (CSF) ___ VIRUS (JCV) DNA
QUANTITATIVE PCR-Test Name
___ 03:50PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Name
___ 03:50PM CEREBROSPINAL FLUID (CSF) HERPES 6 PCR-Test
Name
___ 03:50PM CEREBROSPINAL FLUID (CSF) ___ VIRUS,
QUAL TO QUANT, PCR-Test Name
IMAGING:
___ CXR 1700
IMPRESSION: Two rounded densities projecting over the right
chest, one seen previously in the anterior lateral right third
rib. An additional one projecting over the anterior right sixth
rib, unclear whether external to the patient, osseous, or
pulmonary in nature. Suggest repeat with nipple markers for
further evaluation.
___ CXR 2200
FINDINGS: As compared to the previous radiograph, a repeat
radiograph is
performed with nipple markers. The previously seen opacities
correspond to the nipples. No change in appearance of the lung
and of the cardiac
silhouette. Known calcified granuloma in the right upper lobe.
___ CHEST CT:
IMPRESSION:
1. No localized areas of consolidation within the lungs to
suggest a
pulmonary source of infection.
2. Moderate pericardial effusion, increased from ___. Bronchial wall thickening and interlobular septal
thickening. This likely
represents mild hydrostatic edema particularly in the setting of
new trace
pleural effusions.
4. Similar appearance of axillary lymph nodes to prior CT.
___ CT ABDOMEN/PELVIS:
IMPRESSION:
1. No acute intra-abdominal process or infectious focus.
2. Small-to-moderate simple pericardial effusion. For details
regarding the
chest please see dedicated chest CT report.
3. Unchanged splenomegaly.
4. Mild hepatic steatosis.
___ MRI HEAD:
IMPRESSION:
No evidence of acute intracranial process or abnormal
enhancement identified within the confines of this motion
limited examination.
___ HEAD CT
IMPRESSION: No acute intracranial process.
___ CXR:
IMPRESSION:
New left lower lobe opacification concerning for developing
pneumonia.
ECHO ___:
Overall left ventricular systolic function is normal (LVEF>55%).
RV with normal free wall contractility. There is a moderate
sized pericardial effusion. The effusion appears
circumferential. No right ventricular diastolic collapse is
seen. There is brief right atrial diastolic collapse c/w
elevated intrapericardial pressure without overt tamponade.
Compared with the prior study (images reviewed) of ___,
no clear change.
Brief Hospital Course:
___ yo M w/ hx of mantle cell lymphoma s/p allo-SCT, admitted on
Day +27, who p/w malaise, constipation, emesis, and fever now
with resolving diarrhea, found to have increasing pericardial
effusion.
#Fever/malaise: Unclear etiology., may be related to developing
PNA with new LLL opacity identified on CXR on ___ although
patient denied SOB, cough, sputum production. Other differential
diagnoses to consider include viral illness such as CMV,
viral/bacterial gastroenteritis, medication side effect,
contamination from indwelling CVL. CMV VL previously
undetectable, but patient had low levels of CMV viremia during
hospital course: <137 on ___ and increasing to 257 on
___, 207 on ___. Patient was started on ganciclovir was was
discontinued on ___ due to wrosening leukopenia. Valganciclovir
was restarted on ___ at 450 mg PO Q12H due to continued CMV
viremia. Initially constipated but then diarrhoea, abd exam
benign, small stool with mucus and blood streaks raises concern
for inflammatory process such as CMV colitis though CT abd/pelv
showed no sign of infection or inflammation. C. diff negative,
stool cx negative. MRI read with no evidence of abnormal
enhancement such as in toxoplasmosis. Increasing pericardial
effusion may represent viral pericarditis. LP indicative of
aseptic meningitis; all CSF infectious studies were negative.
Urine BK virus was negative. EBV and HHV6 negative. Fungal
markers negative. Bcx negative, last fever ___ at 100.6. Patient
completed a course of vancomycin (which was discontinued on ___
and meropenem (which was discontinued on ___. Patient
remained afebrile. Patient received IVIG x2 on ___ and ___.
Patient's IgG remained low at 594 on ___ and he received
another infusion of IVIG and a banana bag.
#Pericardial effusion: On transplant workup, pt was found to
have low EF on TTE with confirmed EF 48% on cardiac MRI. Known
pericardial effusion but CT Chest showed moderate effusion, TTE
shows increase in effusion with evidence of R-sided collapse but
no change in LV function, likely due to underfilling not
tamponade especially with no dyspnea or hypotension. LVEF 75%
and actually hyperdynamic likely due to underfilling from
hypovolemia vs sepsis. Effusion ddx includes viral infection,
third spacing from poor nutrition like less likely without other
edema and Alb in mid 3s, and lymphoma though less likely in the
setting of recent transplant. Continued on IVF, carvedilol BID.
Pulsus paradoxus remained stable at ___. Cardiology consult
recommended fluids, monitoring vital signs for evidence of
tamponade, and repeat TTE which remained stable from prior
studies throughout hospital stay. Patient will follow-up with
cardiology in the outpatient setting.
#RASH: New rash started on ___. Palmar and sole erythema with
petechial involvement of forearms and ankles. DDx include drug
rash vs GVHD. Vanc and ___ dc'd on ___ and ___ respectively
but needed to be restarted on ___ due to fever and possible
developing pneumonia. Derm biopsy showed drug reaction but
cannot exclude acute GVHD. Patient was started on solumedrol 2
mg/kg IV and solumedrol was tapered and patient was transitioned
to predisone with rapid improvement. Vanco dc'ed on ___.
Meropenem dc'ed on ___. Patient was discharged on 15 mg PO
prednisone with plan to taper to 10 mg on ___.
#Diarrhea: Patient developed loose bowel movements during
hospital stay. ___ be related to increased PO intake,
antibiotics, GVHD or infection. Cdiff was negative. Patient had
low levels of CMV viremia (as high as 257 during hospital stay)
and valganciclovir was started on ___ at 450 mg PO Q12H. Vanco
and ___ were discontinued on ___ and ___ respectively.
Patient was on steroid taper as above. Patient was placed on
phase 3 GVHD diet and bowel movements became more formed.
#Leukopenia: Patient developed worsening leukopenia during
hospital stay with ___ ct as low as 1. Unclear etiology, may be
related to medication effect, or failure of graft/relapse or
infection. Ganciclovir dc'ed on ___. Repeat bone marrow biopsy
was performed on ___ and results were pending on discharge.
Bactrim was held and atovaquone was started for PCP ___.
Patient received neupogen on ___ and ___ increased to 3 prior
to discharge.
#Hypotension: Patient had an episode of hypotension with BP
76/42 in the context of sitting up in the chair for the first
time on ___, most likely due to orthostasis given poor PO
intake, deconditioning, and that hypotension responded to 1L
fluid bolus. Differential diagnosis also includes adrenal
insufficiency given steroids were being tapered quickly.AM
cortisol wnl at 14.1. Patient received IVF and BP returned to
normal.
# Dyspepsia/nausea/diarrhea: Patient has long-standing
indigestion/nausea exacerbated by medication intake managed
previously with lorazepam and pantoprazole and recently
prescribed compazine by ___ NP. Sx well-controlled at
discharge on prior admission until about two days after
discharge at which point patient became constipated and noted
worsening of "burning" in stomach. DDx includes viral
gastroenteritis, CMV colitis, GVHD, peptic ulcer disease.
Amylase and lipase wnl making pancreatitis unlikely.
Constipation resolved after admission and patient had stool
streaked with mucus and blood then began having diarrhea raising
concern for inflammatory process such as colitis or GVHD though
CT shows no evidence of colitis/inflammation and FOBT negative.
Diarrhea resolved after one day with some continued intermittent
abd discomfort. GI consult recommended stool studies as above,
BID pantoprazole, and deferral of EGD/flex sig for now pending
further evidence of CMV colitis or GVHD. Continued on lorazepam,
pantoprazole, sucralfate and maalox for dyspepsia as well as
ondansetron, prochlorperazine for nausea. Mirtazapine 15 mg PO
QHS was added for poor appetite and depression and viscous
lidocaine was also added prior to meals to held patient's
stomach upset. Patient was placed on phase 3 GVHD diet and
stomach upset improved.
#AMS: New started on ___. No new recent changes to meds. Neuro
and ID evaluated and thought to be aseptic meningitis. MRI head
and CT head showed no intracranial process. Electrolytes wnl
except for being chronically hyponatremic. LP showed 72 protein
and 14 WBC, CSF infectious studies negative. Pt's ativan and
oxycodone doses decreased in order to limit sedating meds.
Oxycodone dc'ed (pt continues on oxycontin) and decreased
lorazepam to 0.5 mg Q12H on ___. Patient's mental status
significantly improved with limitation of sedating meds.
#Nutrition: Patient had not been taking good PO. TPN was
considered but was not started. Patient's stomach upset was
treated as above. He was started on mirtazapine and viscous
lidocaine as well as the phase 3 GVHD diet and his PO intake
improved significantly. He was encouraged to add white meat
chicken, egg whites for more protein prior to discharge. He
received a banana bag on ___. He remained on folate and a
multivitamin.
#Coagulopathy: INR rising slowly since ___ from 1.3 to 1.7
with baseline around 1.1 on ___, stable today despite PO vit K
___. Patient is on enoxaparin but should not have this much of
a rise in INR. Albumin 3.3, no evidence or known causes of liver
injury so likely not related to overall protein synthesis.
Coagulopathy likely a result of nutritional depletion of vitamin
K given poor PO intake. INR dropped to 1.4 after 1mg IV Vit K on
___. Enoxaparin was held ___ for LP procedure. INR was 1.1
prior to discharge.
#Hyponatremia: Found to have low sodium, unclear etiology. DDx
includes SIADH ___ pain/nausea as patient vs hypovolemia.
Decreased after stopping fluids so could be hypovolemic,
especially given underfilling on TTE. Urine lytes show urine Na
of 110 and Urine osm of 494 vs serum osm of 263. Na 130 on
___.
#Mantle cell lymphoma s/p allo-SCT: High risk cytogenetics
(t(11:14), 17p) s/p treatment with nordic regimen ___ and
rituximab) and now s/p MUD allo-SCT with reduced intensity
flu/bu/ATG conditioning. Patient had rash and diarrhea possibly
due to GVHD treated with steroids and GVHD diet as above. He was
continued on CSA and acyclovir, voriconazole, ursodiol and
atovaquone prophylaxis. Given low IgG levels, IVIG was
administered x3 on ___ and ___. A repeat bone marrow
biopsy was performed on ___ due to dropping blood counts, the
results were pending on discharge.
#Depression: Patient has a restricted affect and notes
long-standing dysthymic mood. He was started on sertraline
during last admission which was continued during this admission.
#DVT in Lt UE: Patient had DVT in LUE discovered on previous
admission ___ likely associated with venous access.
Enoxaparin held given coagulopathy and LP on ___ and treatment
was discontinued as patient has no further sx or evidence of
continued clot.
#TMJ: Long history of ear/neck/shoulder pain ___ TMJ.
CT-head/neck was negative for mastoiditis in ___ during
prior admission. Stable on home oxycontin 20mg Q12hr. Lorazepam
and oxycodone were weaned down as above.
TRANSITIONAL ISSUES:
-Please ensure patient has outpatient cardiology follow-up for
pericardial effusion (scheduled an appt with cardiology for
patient on ___
-Please follow-up bone marrow biopsy, FISH and cytogenetics from
___
-Please follow cyclosporine levels closely; patient is being
discharged on 175 mg PO Q12H and last CSP level was 148 on ___
-Please continue to monitor CBC with diff closely
-Please continue to address nutrition issues and stomach upset
with patient; patient is being discharged on a low fat,
lactose-restricted, low fiber diet and is being encouraged to
add protein (chicken, pork, fish, egg whites)
-Please continue to monitor CMV VL; patient is being discharged
on valganciclovir 450 mg PO Q12H due to persistent low levels of
CMV viremia
-Please continue to taper prednisone (patient is being
discharged on 15 mg PO daily and will taper down to 10 mg PO
daily on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Carvedilol 3.125 mg PO BID
3. Enoxaparin Sodium 70 mg SC Q12H
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Lorazepam 0.5 mg PO Q4H:PRN nausea, insomnia, anxiety
6. CycloSPORINE (Neoral) MODIFIED 150 mg PO Q12H
7. Fluconazole 200 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
11. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
12. Pantoprazole 40 mg PO Q24H
13. Sertraline 25 mg PO DAILY
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. Ursodiol 300 mg PO BID
16. Sucralfate 1 gm PO QID
17. Docusate Sodium 100 mg PO BID
18. Senna 1 TAB PO BID:PRN constipation
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Capsule Refills:*0
2. Carvedilol 3.125 mg PO BID
RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*60 Capsule
Refills:*0
5. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*90 Tablet Refills:*0
6. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone [OxyContin] 20 mg 1 tablet extended release 12
hr(s) by mouth every twelve (12) hours Disp #*60 Tablet
Refills:*0
7. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Capsule Refills:*0
8. Sertraline 25 mg PO DAILY
RX *sertraline 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Ursodiol 300 mg PO BID
RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*60
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. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth
daily Disp #*30 Packet Refills:*0
12. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
heartburn
RX *alum-mag hydroxide-simeth [Maalox Advanced] 200 mg-200 mg-20
mg/5 mL 15 mL by mouth four times a day Disp #*1 Bottle
Refills:*1
13. Clobetasol Propionate 0.05% Cream 1 Appl TP BID rash
RX *clobetasol 0.05 % apply small amount twice a day Disp #*1
Tube Refills:*0
14. Mirtazapine 15 mg PO HS
RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
15. Voriconazole 200 mg PO Q12H
RX *voriconazole 200 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*1
16. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet,delayed release (___) by
mouth every twelve (12) hours Disp #*60 Tablet Refills:*1
17. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone [Mepron] 750 mg/5 mL 10 mL by mouth daily Disp
#*30 Unit Refills:*1
18. CycloSPORINE (Neoral) MODIFIED 175 mg PO Q12H
Please take seven 25 mg pills twice per day
RX *cyclosporine modified 25 mg 7 capsule(s) by mouth every
twelve (12) hours Disp #*210 Capsule Refills:*0
19. 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
20. Lorazepam 0.5 mg PO BID:PRN nausea, insomnia, anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth twice a day Disp #*30
Tablet Refills:*0
21. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
22. Lidocaine Viscous 2% 20 mL PO TID
RX *lidocaine HCl 20 mg/mL 20 mL by mouth three times a day Disp
#*1 Bottle Refills:*2
23. PredniSONE 15 mg PO DAILY
Go down to 10 mg daily on ___
RX *prednisone 5 mg 3 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
24. ValGANCIclovir 450 mg PO Q12H
Please discuss the ongoing need for this medication with Dr.
___.
RX *valganciclovir [Valcyte] 450 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: graft versus host disease, mantle cell lymphoma status
post allogeneic hematopoietic stem cell transplant
Secondary: Chronic temporomandibular joint pain, deep venous
thrombosis, depression
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
fever, nausea, constipation, and abdominal discomfort. You were
tested for numerous infections. You were treated with antibiotic
and antiviral medications to which you responded well.
Infectious disease and gastroenterology specialists were called
to help determine the cause of your symptoms and develop a plan
for treatment. Your symptoms were managed with acid-blocking
medication and antinausea medication. You also developed a rash
which was treated with steroids. You also had a repeat bone
marrow biopsy performed on ___, the results of which are
pending.
Please follow a lactose-restricted, low fat (<20 grams per day),
low fiber white diet (white rice, white pasta, potato) and make
sure to eat white meat chicken (without skin), pork (without
fat) and white fish as well as egg whites for protein. Please
take 15 mg prednisone (three 5 mg pills) daily and go down to 10
mg (two 5 mg pills) on ___. Please discuss
further changes in medications with Dr. ___.
You should follow up in the clinic and with Dr. ___ at the
appointments below.
It has been a pleasure caring for you. We wish you the best,
Your ___ team
Followup Instructions:
___
|
19763428-DS-8
| 19,763,428 | 29,905,139 |
DS
| 8 |
2135-07-01 00:00:00
|
2135-07-01 17:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Concern for stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is ___ speaking ___ yo man with a very complex
medical history including CLL, malignant melanoma s/p resection,
prostate cancer, hypertension and dyslipidemia who came in with
an episode of dizziness. Per Mr. ___ and his son, he was in
his
usual state of health until this morning when his wife noticed
he
was leaning to the right when walking. He was otherwise feeling
well and went to the grocery store this afternoon. On his way
home, he developed a sudden feeling of dizziness which he
describes as feeling off balance as opposed to vertiginous and
had difficulty walking due to the dizziness. His neighbor helped
him home and he then came to the ED for evaluation. This event
of
dizziness lasted about 30 min and currently he denies any
complaints. He has not been ill recently, nor has he had any
changes in medications, or new medications. He has had one event
called a "micro stroke" back in about ___ in the ___ during
which he apparently fainted but no further details were
elicited.
Currently, he appears comfortable and aside from his walking,
his
son says he seems like himself.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Does
admit to 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:
Coronary artery disease status post stent in ___.
-Hypertension.
-Basal and squamous cell skin cancers.
-Prostate cancer, on Lupron, managed by urology.
-Melanoma of R leg
-Osteoporosis.
-History of blepharitis.
Social History:
___
Family History:
nc
Physical Exam:
Vitals: T:98.6 P:38-70 R: 16 ___ SaO2: 99RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx,
Neck: Supple, No nuchal rigidity, very large L neck mass
(~6x6cm), has been present ___ years, per son has been workup
and
found to be benign
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
___ Stroke Scale score was 0:
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
-Mental Status: Per son who was interpreting: Alert, oriented x
3. Able to relate history without difficulty. Attentive, able
to name ___ backward without difficulty. Language is fluent
with
intact repetition and comprehension. Normal prosody. There
were
no paraphasic errors. Pt. was able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
both midline and appendicular commands. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
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.
mild fine postural tremor. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4+ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
proprioception throughout. No extinction to DSS. Graphasethesia
intact b/l
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: some unsteadiness when rising to standing, leaning to
right side from waist up, taking small, hesitant, narrowbased
steps but this in the setting of many wires and small ED room
At the time of discharge:
Pertinent Results:
___ 05:10AM BLOOD WBC-25.0* RBC-4.01* Hgb-11.7* Hct-35.4*
MCV-88 MCH-29.3 MCHC-33.2 RDW-14.0 Plt ___
___ 05:30PM BLOOD WBC-27.1* RBC-4.00* Hgb-11.8* Hct-35.8*
MCV-89 MCH-29.5 MCHC-33.0 RDW-14.2 Plt ___
___ 05:30PM BLOOD Neuts-12* Bands-0 Lymphs-88* Monos-0
Eos-0 Baso-0 ___ Myelos-0
___ 05:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 05:30PM BLOOD ___ PTT-28.3 ___
___ 05:30PM BLOOD Plt Smr-NORMAL Plt ___
___ 05:10AM BLOOD Glucose-102* UreaN-17 Creat-0.9 Na-138
K-3.9 Cl-103 HCO3-28 AnGap-11
___ 05:30PM BLOOD ALT-10 AST-24 AlkPhos-57 TotBili-0.3
___ 05:10AM BLOOD ALT-8 AST-13 AlkPhos-58 TotBili-0.5
___ 05:10AM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.7 Mg-1.9
Cholest-144
___ 05:30PM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.9 Mg-2.0
___ 05:10AM BLOOD VitB12-903*
___ 05:10AM BLOOD %HbA1c-PND
___ 05:10AM BLOOD Triglyc-50 HDL-58 CHOL/HD-2.5 LDLcalc-76
___ 02:33AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 02:33AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Brief Hospital Course:
Mr. ___ is an ___ year old man with history of multiple
malignancies, coronary artery disease and hypertension who
presented due to an episode of lightheadedness
as well as abnormal gait. A workup had been relatively
unremarkable but a head CT obtained today showed a large area of
encephalomalacia as well as area in the right parietal lobe felt
to be concerning for acute/subacute infarct. Since resolution
of
his dizziness which lasted about 30 min, Mr. ___ does not have
any complaints but his son does admit he is still walking
abnormally.
His neurologic exam was remarkable only for mild left IP
weakness as well as an abnormal gait with him leaning to the
right from the waist with small, hesitant steps. Given his
history of prior infarct and episode today, admission for workup
of possible stroke was done. An MRI of the head was performed
for evaluation of anatomy and age of prior infarcts. There was
no acute infarct but there were chronic infarcts in the right
parietal lobe and the left frontal lobe. We checked fasting
lipid panel (LDL 76) and HBA1c (5.7). Aspirin 81 mg daily was
continued. CTA brain and neck vessel imaging was unrevealing for
significant atherosclerosis. Cardiac echo demonstrated that the
left atrium was normal in size. No thrombus/mass was seen in the
body of the left atrium. No atrial septal defect was seen by 2D
or color Doppler. Left ventricular wall thicknesses are normal.
Therefore no cardiac source could be identified.
Since MRI brain was negative for any acute ischemia, the
dizziness was thought to be related to symptomatic bradycardia.
We stopped his metoprolol as he was having bradycardia to 30.
We checked cardiac enzyme and the result came back negative for
MI. He was monitored by telemetry. BP allowed to autoregulate
with goal SBP < 180 (goal SBP 140-180s). He was restarted on
his blood pressure meds with an increase in the amlodipine
secondary to hypertension and the discontinuation of the
metoprolol. He should follow up with his cardiologist regarding
further management of his cardiac issues.
ENDO
- He was started on ISS with finger sticks QID with a goal of
normoglycemia
FEN
- He recieved fluids at 50 cc/hr to help keep down serum
viscosity given hx of CLL
TOX/METAB:
- We checked LFTs which were WNL. Urine and serum tox screens
result came back negative
.
ID
the patient did not develop fever or leukocytosis, chest xray
was clear and UA did not show any infection.
PPX:
- He recieved senna and colace for constipation prevention and
started on sub q heparin for DVT prevention
Disposition:
-Mr. ___ was evaluated by physical therapy the family did not
want him to be placed into a rehab facility as they already have
___ services and prefered home physical therapy.
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
ALENDRONATE - alendronate 70 mg tablet. 1 Tablet(s) by mouth
weekly - (Prescribed by Other Provider)
AMLODIPINE - amlodipine 5 mg tablet. 1 Tablet(s) by mouth daily
-
(Prescribed by Other Provider)
DOXAZOSIN - doxazosin 2 mg tablet. 1 Tablet(s) by mouth daily -
(Prescribed by Other Provider)
IMIQUIMOD - imiquimod 5 % Topical Cream Packet. Apply to
affected
areas on lower back and right scalp five times per week for 6
weeks only
LEUPROLIDE (3 MONTH) [LUPRON DEPOT (3 MONTH)] - Lupron Depot (3
Month) 22.5 mg IM Syringe Kit. 1 injection every 3 months -
(Prescribed by Other Provider)
METOPROLOL SUCCINATE - metoprolol succinate ER 50 mg
tablet,extended release 24 hr. 1 Tablet(s) by mouth daily -
(Prescribed by Other Provider)
MUPIROCIN - mupirocin 2 % Ointment. Apply to wound daily
OXYCODONE-ACETAMINOPHEN - oxycodone-acetaminophen 5 mg-325 mg
tablet. 1 Tablet(s) by mouth every 6 hours as needed for pain DO
NOT DRIVE WHILE TAKING THIS MEDICATION
SIMVASTATIN - simvastatin 40 mg tablet. 1 Tablet(s) by mouth at
bedtime - (Prescribed by Other Provider)
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 Tablet(s) by
mouth daily - (Prescribed by Other Provider)
SENNOSIDES-DOCUSATE SODIUM - sennosides-docusate sodium 8.6
mg-50
mg tablet. Two Tablet(s) by mouth daily for constipation
SILK OF CORN - Dosage uncertain - (OTC
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
RX *amlodipine 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Doxazosin 2 mg PO HS
5. Senna 2 TAB PO HS
6. Alendronate Sodium 70 mg PO 1X/WEEK (WE)
7. imiquimod *NF* 5 % Topical 5 x per week
8. Leuprolide Acetate 22.5 mg IM ONCE EVERY 3 MONTHS Duration: 1
Doses
9. Simvastatin 40 mg PO DAILY
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
11. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Outpatient Lab Work
Labs:Sodium; Potassium; Chloride; Bicarbonate; Glucose; BUN;
Creatinine; Calcium; Phosphate; Magnesium
Reason: Hypertension.
Send results to: Name: ___
Location: ___ OFFICE
Address: ___, ___
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
symptomatic bradycardia
chronic old strokes
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 hospitalized due to symptoms of dizziness. These were
thought to be a result of your low heart rate and therefore you
were discontinued on your metoprolol. Your head CT and MRI were
negative for acute stroke but did demonstrate old strokes.
Ischemic strokes, is 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 by keeping your cholesterol low and blood pressure
undercontrol. We also preformed an echocardiogram which was
unrevealing for a source. You should follow up with your
primary care doctor regarding the changes to your medications.
<>
We are changing your medications as follows:
stopped metoprolol and increased your Amlodipine and started
Lisinopril for blood pressure control.
**This new medication of Lisinopril can cause some difficulties
with your sodium and potassium and therefore have your
electrolytes check in 1 week and follow up with Dr. ___.
<>
Please take your other medications as ___
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these ___
- 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 ___
- sudden drooping of one side of the ___
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of
___
- sudden blurring or doubling of ___
- sudden onset of vertigo (sensation of your environment
spinning around ___
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
19763428-DS-9
| 19,763,428 | 25,223,632 |
DS
| 9 |
2136-09-20 00:00:00
|
2136-09-22 17:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ man with CAD s/p PCI with chronic
anginal symptoms, symptomatic bradycardia status post pacer
placement at ___ several months prior, malignant
melanoma and other skin cancers s/p multiple resections and CLL
here for evaluation of atraumatic lower back pain. Patient
reports he awoke 2 days prior with mid back pain that has been
worsening in severity and is now radiating to his right flank.
The pain is exacerbated with movement. He does report
intermittent anginal symptoms over this time however he does
have
these at baseline, and was recently started on isosorbide
dinitrate (he also uses SL nitro occasionally in the evening).
He
denies dysuria, leg weakness/numbness/tingling, urinary fecal
incontinence, fevers, chills, night sweats, abdominal pain,
nausea, vomiting, diarrhea. He uses a cane at baseline, and is
independent in his ADLs except for the past few days as he was
limited by pain. Denies any skin rash or history of zoster.
Past Medical History:
--CLL: He is RAI stage I on the basis of his lymphadenopathy,
without hepatosplenomegaly. His Binet staging is unclear given
the unknown extent of lymphadenopathy. His WBC is overall
stable. His hemoglobin, platelet count are stable and his
symptoms remain unchanged during ___ ___ onc evaluation
--numerous, nonmelanoma skin cancers, as well as a melanoma
on the right shin, 0.4 mm, no mitoses and nonulcerated (___)
s/p multiple surgeries for removal of skin cancers
PMH/PSH:
1. Coronary artery disease status post stent in ___.
2. Hypertension.
3. Basal and squamous cell skin cancers.
4. Prostate cancer, previously on Lupron, managed by urology.
5. Osteoporosis.
6. History of blepharitis.
- Malignant melanoma
- CLL as above
- TMJ left-sided mass (likely benign salivary tumor, previously
followed at ___
- Bilateral cataract repair
- ? stroke vs TIA (head MRI ___ without any e/o acute
infarct)
Social History:
___
Family History:
No known family history of cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
98.2, 125/53, 61, 18, 95%RA
GEN: NAD
HEENT: PER and minimally reactive (2mm b/l), EOMI, MMM,
oropharynx clear, no cervical ___. L jaw nodular mass not TTP
Resp: slight bibasilar crackles, no wheezes or rhonchi
CV: RRR without m/r/g, nl S1 S2. JVP<7cm
Chest: left upper chest wall with well healed incision from PPM
placement.
ABD: normal bowel sounds, non-tender, not distended
EXTR: Warm, well perfused. No edema. 2+ pulses.
NEURO: alert and orientedx3, CN ___ grossly intact, ___ motor
grossly intact. Downgoing babinski's bilaterally. patellar
reflexes 1+ equal b/l.
Back: +TTP of thoracic/ upper lumbar spine. No paraspinal
tenderness. No CVA tenderness.
DISCHARGE PHYSICAL EXAM:
VS: 98 97.7 113-132/53-70 60-66 ___ 95/RA
GEN: NAD, sleeping in bed
HEENT: L jaw nodular mass not TTP and mobile, no JVD
Resp: CTAB, no wheezes or rhonchi
CV: RRR with ___ SEM throughout pericordium, no r/g, nl S1 S2.
Chest: left upper chest wall with well healed incision from PPM
placement.
ABD: normal bowel sounds, non-tender, not distended
EXTR: Warm, well perfused. No edema. 2+ pulses.
NEURO: ___ and ___ motor grossly intact.
Back: Dark red papules diffuse across his back with underlying
erythema. pain with palpation at T11 region. No paraspinal
tenderness. No CVA tenderness.
Pertinent Results:
ADMISSION LABS:
___ 03:48PM BLOOD WBC-21.5* RBC-3.82* Hgb-11.5* Hct-35.5*
MCV-93 MCH-30.1 MCHC-32.4 RDW-14.0 Plt ___
___ 03:48PM BLOOD Neuts-33* Bands-0 Lymphs-63* Monos-3
Eos-0 Baso-1 ___ Myelos-0
___ 03:48PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:25AM BLOOD ___ PTT-28.8 ___
___ 03:48PM BLOOD Glucose-108* UreaN-24* Creat-1.0 Na-135
K-4.1 Cl-102 HCO3-25 AnGap-12
___ 07:25AM BLOOD ALT-13 AST-57* LD(LDH)-216 CK(CPK)-604*
AlkPhos-47 TotBili-0.5
TROPONINS:
___ 04:48AM BLOOD CK-MB-6 cTropnT-2.19*
___ 03:37AM BLOOD CK-MB-30* MB Indx-7.2* cTropnT-1.04*
___ 01:20PM BLOOD CK-MB-56* MB Indx-9.3* cTropnT-1.06*
___ 05:50PM BLOOD cTropnT-0.18*
___ 03:48PM BLOOD cTropnT-0.18*
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-18.5* RBC-3.40* Hgb-10.4* Hct-30.8*
MCV-91 MCH-30.7 MCHC-33.8 RDW-13.8 Plt ___
___ 07:00AM BLOOD ___ PTT-59.6* ___
___ 05:25AM BLOOD Glucose-97 UreaN-17 Creat-0.7 Na-135
K-3.8 Cl-100 HCO3-24 AnGap-15
BONE SCAN Study Date of ___
INTERPRETATION: Whole body images of the skeleton obtained in
anterior and posterior projections show intense, linear tracer
uptake at the T11 vertebral body compatible with compression
fracture. Incidental note is made of focal tracer uptake at the
left 3rd rib end anteriorly compatible with prior trauma. There
is residual tracer in the bowel from a sestamibi cardiac
perfusion study the day before.
The kidneys and urinary bladder are visualized, the normal route
of tracer excretion.
IMPRESSION: Intense linear tracer uptake at T11 vertebral body
compatible with compression fracture.
CARDIAC PERFUSION PHARM Study Date of ___
INTERPRETATION:
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 a fixed, moderate
reduction in photon counts involving the distal anterior wall,
distal septum, distal inferior wall and the apex. There is also
a fixed, severe reduction in photon counts involving the distal
lateral wall and the mid and distal inferior and inferolateral
walls.
Gated images reveal akinesis of the apex, distal lateral wall
and the mid
inferior and inferolateral walls. There is hypokinesis of the
distal anterior wall, distal septum, distal inferior wall, and
the basal inferior and inferolateral walls The calculated left
ventricular ejection fraction is 38% with an EDV of 147 ml.
IMPRESSION:
1. Fixed, medium sized, moderate severity perfusion defect
involving the LAD territory.
2. Fixed, large, severe perfusion defect involving the LCx
territory.
3. Increased left ventricular cavity size. Moderate systolic
dysfunction with multiple wall motion abnormalities as described
above.
Stress Study Date of ___
INTERPRETATION: This ___ year old man with h/o HTN, HLD, sCHF,
AS,
and stable angina; s/p MI ___, PPM in ___, and possible
PCI in
___ was referred to the lab for CAD evaluation. The patient was
admininstered 0.142 mg/kg/min of Persantine over four minutes.
The
patient presented with low/mid back discomfort constant over the
last
week. No other chest, neck, back, or arm discomforts were
reported by
the patient throughout the study. In the presence of baseline
ventricular pacing, the ST segments are uninterpretable for
ischemia.
The rhythm was intermittent A-V paced and sinus with ventricular
pacing.
Several, isolated APBs, one VPB, and an 11 beat run of atrial
tachycardia was noted after aminophylline. Appropriate
hemodynamic
response to the infusion. Post-MIBI, the Persantine was reversed
with 125 mg of Aminophylline IV. IMPRESSION: Non-anginal type
symptoms. Uninterpretable ST segments for ischemic in the
presence of ventricular pacing. Rhythm as noted. Nuclear report
sent separately.
ECG Study Date of ___ 4:56:32 ___
Atrial and ventricular sequential pacing. Compared to the
previous tracing of ___ there is no significant change.
Portable TTE (Complete) Done ___ at 3:50:06 ___
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with infero-lateral, apical and distal septal
hypokinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) 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. There is no mitral valve prolapse. Mild to moderate
(___) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the LVEF has decreased and regional LV systolic dysfunction is
much more extensive
ECG Study Date of ___ 10:41:08 AM
Probable A-V sequentially paced rhythm. Atrial spikes are
difficult to
discern. Compared to the previous tracing of ___ pacemaker
rhythm is
unchanged. However, T waves are now inverted in the
anterolateral precordial leads, although difficult to interpret.
Cannot rule out underlying myocardial ischemia. Clinical
correlation is suggested.
CHEST (PA & LAT) Study Date of ___ 5:18 ___
FINDINGS: Dual-lead pacer is unchanged. The heart remains
mildly enlarged. Since the CT torso, there has been no
significant change with mild bibasilar atelectasis again noted.
Gaseous distention of bowel in the upper abdomen noted without
signs of free air.
CTA CHEST W&W/O C&RECONS, NON-CORONARY, CTA Abd&Pelv Study Date
of ___ 5:02 ___
IMPRESSION:
1. No acute aortic abnormality or pulmonary embolus.
2. A 3.2 x 2.3 cm anterior mediastinal mass with internal
calcifications the upper portion of which was partially
visualized on prior CTA neck.
Differential includes lymphoma, thymoma, thyroid lesion or germ
cell tumor. Scattered prominent but nonenlarged mediastinal
lymph nodes.
3. 1-cm left lower lobe nodule and 6-mm right lower lobe
nodule. Given size, short-term followup is recommended as these
lesions are suspicious for metastases.
4. 1 cm intermediate density lesion in the right interpolar
kidney which may represent a cyst or solid lesion. Consider
ultrasound to further
characterize.
5. Top normal caliber of large bowel with air-fluid levels
without wall
thickening or pericolonic fat stranding is nonspecific, it could
be suggestive of a mild enteritis.
6. Trace ascites.
7. Small-to-moderate hiatal hernia.
8. Enlarged prostate.
9. Cholelithiasis without evidence for cholecystitis.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION:
___ year old male with CAD s/p PCI with chronic anginal symptoms,
symptomatic bradycardia s/p PPM, malignant melanoma and other
skin cancers s/p multiple resections and CLL with mid thoracic
back pain, found to have no osseous lesions but with CT scan
revealing new mediastinal mass as well as pulmonary nodules.
ACTIVE ISSUES:
# Elevated troponins: The patient presented with rising
troponins to 2.19 with Ck-MB downtrending but was chest free
throughout his hospital stay. He had a rest and stress perfusion
images reveal a fixed, moderate reduction in photon counts
involving the distal anterior wall, distal septum, distal
inferior wall and the apex. There was also a fixed, severe
reduction in photon counts involving the distal lateral wall and
the mid and distal inferior and inferolateral walls. He was
continued on metoprolol, aspirin and his statin.
#Back pain: The patient's chief complaint was back pain. He had
no signs of symtpoms of cord compromise but he did have point
tenderness at the T11 region. . Review of his CT suggested loss
of disc height. He could not have an MRI given his pacemaker.
Given his history of multiple malignancies, he underwent bone
scan that showed T11 compression fracture but no signs of
lesions. His pain improved prior to discharge but he may benefit
from TLSO brace with ambulation for comfort.
# Back rash: Prior to discharge, the patient developed a diffuse
dark red papular rash with underlying erythema. This was felt
likely related to sweating and lying on the mat on his bed. It
will be important that his skin is kept dry and protected.
# Incidental nodules/masses: The patient was found to have a
3.2x2.3cm anterior mediastinal mass on CT. Differential includes
lymphoma, thymoma, thyroid lesion or germ cell tumor. He also
has a 1cm left lower lobe lung nodule and 6mm right lower lobe
nodule suspicious for metastases, he should have short term
follow-up. He also had a 1cm intermediate density lesion in the
R interpolar kidney which may represent a cyst or solid lesion.
He should have an ultrasound to futher characterize.
CHRONIC ISSUES:
#CLL: He has never required treatment. He does have
lymphadenopathy and lymphocytosis. No splenomegaly on CT ___.
No thrombocytopenia. He does have some mild anemia compared to
baseline. He should follow-up with his outpatient
hematologist/oncologist for ___ care.
# Hyperlipidemia: Continued on home statin
# H/o CAD s/p PCI: As per above, continued on home medications.
# Osteoporosis: Stable. No longer on alendronate.
# Hypertension: Normotensive. Continued on his home amlodipine
and lisinopril.
# BPH: Stable. Continued on home doxazosin
# H/o prostate cancer: No longer receiving treatment
TRANSITIONAL ISSUES:
- He has a 3.2 x 2.3 cm anterior mediastinal mass with internal
calcifications the
upper portion of which was partially visualized on prior CTA
neck. Differential includes lymphoma, thymoma, thyroid lesion
or germ cell tumor.
Scattered prominent but nonenlarged mediastinal lymph nodes.
- The patient has a 1-cm left lower lobe nodule and 6-mm right
lower lobe nodule. Given size, short-term followup is
recommended as these lesions are suspicious for
metastases.
- He also has 1 cm intermediate density lesion in the right
interpolar kidney which may represent a cyst or solid lesion.
Consider ultrasound to further characterize.
- He has a T11 compression fracture. If this continues to bother
him, he may benefit from TLSO brace with ambulation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Doxazosin 8 mg PO HS
3. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
4. Simvastatin 40 mg PO QPM
5. Senna 8.6 mg PO BID:PRN constipation
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Dipyridamole-Aspirin 1 CAP PO BID
8. Lisinopril 40 mg PO DAILY
9. Isosorbide Dinitrate 30 mg PO DAILY
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Dipyridamole-Aspirin 1 CAP PO BID
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
4. Doxazosin 8 mg PO HS
5. Isosorbide Dinitrate 30 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. Acetaminophen 650 mg PO TID
9. Atorvastatin 80 mg PO DAILY
10. Bisacodyl ___AILY:PRN constipation
11. Lidocaine 5% Patch 1 PTCH TD QPM
12. Metoprolol Tartrate 6.25 mg PO BID
13. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four
(4) hours Disp #*10 Tablet Refills:*0
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
15. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary diagnoses:
- NSTEMI
- T11 compression fracture
- Mediastinal mass
Secondary diagnoses:
- Lung nodules, kidney nodule
- CLL
- Hypertension
- Coronary artery disease
- Prostate cancer
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 participating in your care here at ___.
You were admitted on ___ with back pain and found to have
damage to your heart based on your lab work, despite not having
any chest pain. You underwent testing called a stress test that
showed you would not likely benefit from another cardiac
catheterization.
You also had imaging of your chest and abdomen. This imaging
showed you had nodules in your lungs and kidney as well as a
mass in your chest that may be a cancer. You will have follow-up
with thoracic surgery and may need to have a biopsy. You will
also likely need to have further imaging as an outpatient.
Your main concern was back pain. You had a special study called
a bone scan that showed you had a fracture in one of your
vertebrae. If you have worsening back pain, you may benefit from
wearing a special brace when you walk.
If you have chest pain, worsening back pain, shortness of
breath, or any other concerning symptoms, please let your doctor
know right away.
Again, it was our pleasure participating in your care.
We wish you the very best,
-- Your ___ Medicine Team --
Followup Instructions:
___
|
19763430-DS-22
| 19,763,430 | 27,271,255 |
DS
| 22 |
2176-04-14 00:00:00
|
2176-04-15 07:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Abilify / Phenergan Plain / Benzodiazepines / Opioids-Morphine &
Related
Attending: ___.
Chief Complaint:
Traumatic Neck Injury
Major Surgical or Invasive Procedure:
Surgical Neck Exploration
Percutaneous Endoscopic Gastrostomy Tube
History of Present Illness:
Mr. ___ is a ___ year-old male with h/o dementia (suspected
___ c/b neuroapthy/retinopathy/CRI, and a large
goiter who was at his PCP's office ___ when he fell off an exam
table and injured his neck by landing on his cane.
The patient presented to the ED where he was seen by ACS and
taken for exploratory surgery of his right neck wound. Injury to
the platysma and possible injury to the salivary gland was
found. A drain was left in place. The patient did well following
surgery however has become increasingly delirious over his
hospital stay. Seen by geriatrics who felt the patient might be
appropriate for a medicine team. No active surgical issues.
Transferred to medicine for management of delirium.
On transfer, patient's VS were 98.2, 112/69, 82, 96%RA. The
patient reports feeling well. No presently agitated.
ROS: (+) as per HPI. Patient is a poor historian but a 12-point
ROS is otherwise negative.
Past Medical History:
Past Medical History:
1. Diabetes mellitus type 2.
2. Autonomic neuropathy.
3. Renal insufficiency.
4. Diabetes retinopathy.
5. Diverticulosis.
6. Depression.
7. Goiter.
8. ___ syndrome
Social History:
___
Family History:
Mother w/ ___, colon CA
Father ___/ ___, ___
Physical Exam:
Admission PE:
VS - 98.2, 112/69, 82, 96%RA
General: Obese male, awake and alert, minimally verbal
HEENT: NCAT, anicteric sclera, clear oropharynx
Neck: Large mass on R with drain placed
Cardiac: RRR
Pulm: Good air entry b/l
Abd: +BS, slightly distended and diffusely minimally tender
without guarding; no peritoneal sign
Ext: No ___ edema; peripheral pulses intact; warm extremities;
smooth waxy feet with no hair; no foot ulcer noted
Neuro: Awkae and alert. Oriented to person and place. Moving all
extremities.
Psych: Flat affect, responds well to family
Discharge PE:
VS: Tm 98.9 Tc 98.1 119/44 (119-146/44-60) 74 (72-84) 18 97-99%
RA
FSG range yesterday 149-313, range 2 days ago 176-298
General: Obese male, awake, alert
Neck: Large R neck mass, no tenderness to palpation with no
erythema or drainage, significant amount of swelling, with no
fluctuance noted.
CV: RRR, S1, S2
lungs: clear to auscultation anteriorly
Abd: soft, nontender, +abdominal binder
GU: Good rectal tone, prostate enlarged ~60gm, non-tender,
minimally boggy.
Ext: warm, well perfused, no ___ edema, 2+ DP pulses
Neuro: awake, alert, conversant, pleasant,
Pertinent Results:
Laboratory Studies:
Admission labs:
___ 01:30PM BLOOD WBC-9.4 RBC-3.94* Hgb-12.3* Hct-36.9*
MCV-94 MCH-31.2 MCHC-33.3 RDW-12.4 Plt ___
___ 01:30PM BLOOD Neuts-76.5* Lymphs-14.0* Monos-5.4
Eos-3.6 Baso-0.4
___ 02:17PM BLOOD ___ PTT-25.0 ___
___ 01:30PM BLOOD Glucose-190* UreaN-32* Creat-1.5* Na-138
K-4.8 Cl-105 HCO3-25 AnGap-13
___ 06:45AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.9
___ 07:35AM BLOOD TSH-0.20*
___ 01:42PM BLOOD Lactate-1.2
___ 06:35AM BLOOD PREALBUMIN-Test
Imaging:
CT head: ___
CONCLUSION: No evidence of hemorrhage, mass effect, or acute
infarction.
Carotid series: ___
Impression: Right ICA less than 40% stenosis.
Left ICA less than 40% stenosis.
Discharge labs:
___ 07:20AM BLOOD WBC-8.3 RBC-3.43* Hgb-10.6* Hct-32.4*
MCV-95 MCH-30.9 MCHC-32.7 RDW-13.2 Plt ___
___ 07:35AM BLOOD UreaN-34* Creat-1.5*
___ 07:20AM BLOOD Glucose-306* UreaN-29* Creat-1.4* Na-140
K-4.4 Cl-105 HCO3-28 AnGap-11
___ 07:20AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1
Brief Hospital Course:
Mr. ___ is a ___ year-old man with dementia (suspected
___ complicated by neuroapthy/retinopathy/CRI, and
a large goiter who sustained traumatic injury to his right
platysma after falling on his cane.
ACTIVE ISSUES
-------------
#. Right Platysma Injury - The patient was admitted to the acute
care surgery service on ___ after suffering a fall at his
PCP's office resulting in a stab wound to the neck with his
walking cane. He was taken to the OR for neck exploration with
tracheoscopy, EGD and drain placement. For full details of the
procedure please see the operative report. There was no evidence
of esophageal, tracheal or vascular injury. He was extubated and
taken to the PACU for recovery in stable condition prior to
being taken back to the floor. Overnight he was noted to have
some dysuria with urinary retention. A foley catheter was
placed. UA was negative. His diet was advanced to clears, he was
started on PO pain meds and SSI. He was noted to have some
coughing with feedings so he was made NPO and on HD 2 he failed
a speech and swallow evaluation with recommendations that he
remain NPO. The patient was then transferred to the Medicine
service for management of his delirium.
On the medicine service, the patient was continued on his NPO
status with IVF. A dobhoff was placed however was not tolerated
by the patient and he self-dc'd the tube. The patient's neck
drain was removed after it was determined that there was no
penetrating injury to the salivary gland. He was continued on
IVF until ___ when a PEG tube was placed by surgery. The
patient tolerated the procedure well and was started on tube
feeds on ___. The patient tolerated his tube feeds well.
Re-evalauation by speech and swallow cleared him for nectar
thick liquids and pureed solids, as well as continuing on tube
feeds. He was discharged on this diet as well as continued tube
feeds. He had a cough productive of thick mucous during his
hospitalization with no evidence of pneumonia. He received chest
___ for to clear secretions.
#. Dementia - The patient has a history of dementia and is
oriented x1-2 at baseline. In the hospital he suffered from
intermittent delirium and hallucinations that were managed well
with olanzapine as needed. His home Seroquel was held because of
over-sedation, and his mental status improved somewhat, though
remains worse than his baseline before this hospitalization. We
will hold his home Seroquel upon discharge. Olanzapine was then
discontinued (because of sedation) in favor of PRN ativan for
agitation.
# altered mental status/delirium: The patient has baseline
dementia, as discussed above. He was transferred to medicine
for management of his delirium. Non pharmacologic delirium
treatments including orientation to day night cycle, adequate
pain control, ensuring good BMs, etc was started. His sedating
medications, including Seroquel was also stopped. Infectious
work up was negative. Carotid duplex found <40% stenosis
bilaterally, CT of the head was unremarkable. He would not
cooperate with EEG. The patient was found to have a dirty UA,
with Uculture growing out E.coli, and was briefly started on
Bactrim; later switched to ciprofloxacin 500mg PO BID for a 10
day course (to end ___.
Upon discharge the patient's mental status cleard significantly.
#. Urinary Retention - The patient had a foley placed during his
initial neck exploration that was removed on transfer to
medicine. Following this, the patient had intermittent urinary
retention requiring straight catheterization. He was started on
flomax which some mild benefit. He has a large bladder volume
and usually will not void until he reaches ___ on bladder
scan. As per his daughter ___, the patient has outpatient
Urology follow scheduled.
# UTI: The patient was also found to have an Ecoli UTI on
straight cath urine specimen. He was started on PO Cipro and
was discharged to rehab with the instructions to complete a 10
day total course.
#. Diabetes - The patient has ___ managed at home with insulin,
sulfonylurea and metformin. In the hospital, the patient was
maintained on regular ISS with good control. After the PEG tube
placement and initation of tube feeds, the patient's sugars
increased to the mid ___. His morning dose of lantus was
increased to 24 and his regular insulin sliding scale was
uptitrated as necessary. The patient was discharged on a regular
insulin sliding scale and morning lantus. The patient's oral
hypoglycemics were stopped. On discharge his glucose was in
better control but with a few episodes of hyperglycemia such
that his insulin sliding scale should be uptitrated by rehab.
TRANSITIONAL ISSUES
-------------------
#. Speech and Swallow Re-evaluation
#. Physical and Occupational therapy
#. TUBE FEEDING ORDERS: Pulmocare full strenght at 60cc/hr with
q4hr 50cc water flushes.
# Diet: nectar-thick liquids, pureed solids and continue
nutritional support with feeds through PEG tube
# Urinary retention: sometimes will not void until bladder
volume is ~700cc on bladder scan. If still does not void above
this, requires intermittent straight catheterization. As per
his daughter, ___, the patient has follow up with Urology
as an outpatient next week.
# Uptitrate basal insulin and sliding scale as necessary
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. bimatoprost *NF* 0.01 % ___ HS
2. FoLIC Acid 1 mg PO DAILY
3. GlipiZIDE 15 mg PO BID
Take at lunch and dinner
4. Glargine 12 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. MetFORMIN (Glucophage) 500 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Quetiapine Fumarate 25 mg PO HS
8. Simvastatin 40 mg PO HS
9. sitaGLIPtin *NF* 100 mg Oral DAILY
10. Acetaminophen 325 mg PO Q6H:PRN Pain
11. Aspirin 81 mg PO DAILY
12. Calcium Carbonate 500 mg PO DAILY
13. Vitamin D 400 UNIT PO DAILY
14. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Glargine 24 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Bisacodyl ___AILY
Hold for loose stools
4. Tamsulosin 0.4 mg PO HS
5. Aspirin 81 mg PO DAILY
6. bimatoprost *NF* 0.01 % ___ HS
7. Calcium Carbonate 500 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Simvastatin 40 mg PO HS
12. Vitamin D 400 UNIT PO DAILY
13. Acetaminophen IV 1000 mg IV Q 8H pain
please do not exceed 3 grams daily
14. Pulmocare *NF* (nut.tx.pulm.disord.soy,lacfree) 240 ml Oral
Q4H
RX *nut.tx.pulm.disord.soy,lacfree [Pulmocare] 1 can PGT every
four (4) hours Disp #*48 Bottle Refills:*0
15. Ciprofloxacin HCl 500 mg PO Q12H Duration: 9 Days
Please give via g-tube; END DATE ___
16. Lorazepam 0.5 mg PO Q6H:PRN agitation
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every 6 hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Traumatic Neck Injury
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you at ___!
You were admitted due to a neck injury. In the hospital you
underwent surgery to determine that there was no major injury to
your mouth or digestive tract. Following the procedure, you were
evaluated by the speech and swallow team who felt you could not
eat safely without food going down to your lungs (aspiration).
You had a feeding tube placed in your stomach and tolerated the
procedure well. Since then you were re-evaluated by the speech
and swallow team who said that you are able to eat thick liquids
and pureed solid food. You are now ready for discharge to an
extended care facility.
See below for instructions regarding follow-up care:
Followup Instructions:
___
|
19763430-DS-23
| 19,763,430 | 29,298,016 |
DS
| 23 |
2176-04-22 00:00:00
|
2176-04-22 19:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Abilify / Phenergan Plain / Benzodiazepines / Opioids-Morphine &
Related
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
Placement of a "PICC" line
History of Present Illness:
___ year old male discharged from ___ ___ after
admission for L platysmal injury s/p surgical repair presents
from rehab with fever to 101, productive cough, and elevated
white count. Patient has a complex PMH including dementia, DM cb
CRI/neuropathy/retinopathy, but most recently was hospitalized
following a traumatic penetrating neck wound, which was explored
without evidence of esophageal or tracheal penetration. A G-tube
was placed and tube feeds were begun. Speech and swallow
evaluated him and cleared him for pureed solids and nectar thick
liquids but on transfer to nursing home he was made NPO until
re-evaluation could take place. He is a high aspiration risk. He
also has BPH c/b urinary retentition and most recently was
treated for e. coli/klebsiella UTI with 10 day course of cipro,
3 days completed thus far. Cough is productive of thick yellow
sputum. Denies any pain.
Per care providers at the nursing home, patient was doing well
on ___ and ___, somewhat lethargic but generally
arousable and awake. He had not received deroquel or zyprexa for
agitation, and only required ativan once. ___ night and
___ morning he was noticed to be subjectively warm with
chills and an oral temp was 100.7. Out of concern for infection
he was sent to the ___ ED. Of note, he had been using a
condom cathether and required intermittent straight
catherization but did not have an indwelling foley. No
diarrhea. He was constipated and received a fleet enema the
morning before admission with good results.
Initial VS in the ED: 98.6 83 117/52 20 98% Labs notable for
pyuria and leukocytosis as well as Cr 1.7 (from 1.2 ___. CXR
without sign of acute process. Patient was given Ceftriaxone for
presumed UTI. Surgery evaluted surgical site and felt unlikely
contributing to presentation. CT of neck showed no abscess.
Patient also received 7.5 mg of zyprexa for agitation. VS prior
to transfer: 100 °F (37.8 °C) (Rectal), Pulse: 86, RR: 16, BP:
126/59, O2Sat: 97, O2Flow: (Room Air), Pain: 0.
On the floor, patient is somewhat lethargic but arousable. He is
unable to provide any history. The above history was obtained
from ED documentation and records as well as conversation with
providers at nursing home
Past Medical History:
Past Medical History:
1. Diabetes mellitus type 2.
2. Autonomic neuropathy.
3. Renal insufficiency.
4. Diabetes retinopathy.
5. Diverticulosis.
6. Depression.
7. Goiter.
8. ___ syndrome
Social History:
___
Family History:
Mother w/ ___, colon CA
Father w/ ___, MI
Physical Exam:
Admission PE:
Vitals: 98.1 102/40 70 18 100%RA
General: lethargic but arousable to voice and follows basic
commands
HEENT: Sclera anicteric, dry MM
Neck: large neck mass/goiter, non-tender, no fluctuance,
incisions C/D/I, no erythema
Lungs: Coarse breath sounds throughout
CV: Regular rate and rhythm, normal S1 + S2
Abdomen: soft, non-tender, non-distended, bowel sounds present.
G-tube site w/o signs of infection
Ext: Warm, well perfused, no edema
Foley: draining clear yellow urine
Discharge PE:
Vitals: 98.1 141/58 78 20 95% RA, FS327
General: Awake, alert, pleasant and NAD
Neck: large neck mass/goiter, non-tender, no fluctuance,
incisions C/D/I, no erythema
Lungs: Coarse breath sounds throughout without obvious
consolidation
CV: Regular rate and rhythm, normal S1 + S2
Abdomen: soft, non-tender, non-distended, bowel sounds present.
G-tube site w/o signs of infection
Ext: Warm, well perfused, no edema
Pertinent Results:
Admission Labs:
___ 05:58PM WBC-28.1*# RBC-3.87* HGB-12.1* HCT-36.5*
MCV-94 MCH-31.3 MCHC-33.2 RDW-13.1
___ 05:58PM NEUTS-90.7* LYMPHS-4.1* MONOS-4.6 EOS-0.5
BASOS-0.1
___ 05:58PM GLUCOSE-176* UREA N-42* CREAT-1.7* SODIUM-139
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
___ 06:01PM LACTATE-2.0 K+-4.7
___ 05:58PM ___ PTT-25.6 ___
___ 09:05PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-LG
___ 09:05PM URINE RBC-1 WBC-17* BACTERIA-FEW YEAST-NONE
EPI-0
___ 09:05PM URINE HYALINE-3*
___ 09:05PM URINE MUCOUS-OCC
Discharge Labs:
___ 03:31AM BLOOD WBC-10.0 RBC-3.08* Hgb-9.9* Hct-29.1*
MCV-95 MCH-32.2* MCHC-34.1 RDW-12.7 Plt ___
___ 03:31AM BLOOD Glucose-238* UreaN-26* Creat-1.0 Na-139
K-4.6 Cl-106 HCO3-24 AnGap-14
___ 03:31AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.8
CXR:
IMPRESSION:
1. New left midzone and worsening bibasilar patchy opacities.
2. Tip of new PICC line tip overlies the proximalmost SVC,
near the
confluence of the brachiocephalic and subclavian veins. No
pneumothorax
detected.
Please note that an initial wet reading suggested that the tip
of the PICC
line overlay the distal SVC. It is now thought that the cortical
edge of the
spine may have mimicked the appearance of the PICC line. A
revised wet
reading, concordant with this report, will be provided to the
___ line
clinician by radiology resident, Dr. ___ on the afternoon
of this exam.
G-tube study:
IMPRESSION: Satisfactory position of PEG tube, no leak.
CT neck:
IMPRESSION:
1. Status post right anterolateral neck incision. No
underlying collection or abscess.
2. Stranding along the anterolateral aspect of a massive right
thyroid goiter likely represents sequela of prior trauma. No
active extravasation of contrast or abscess formation.
3. Enlarged right superior paratracheal lymph node, now 2.6 x
2.1 cm.
Brief Hospital Course:
___ year old male discharged from ___ recently s/p neck
exploratory surgery who presents with fever to 101, productive
cough, and elevated white count, found to have a pneumonia on
chest x-ray.
ACTIVE ISSUES
-------------
# Pneumonia - The patient was found to have leukocytosis and
fever on admission, and ultimately found to have PNA, given
possible infiltrate on CXR in the setting of productive cough.
Surgery was initially consulted and determined that the neck
wound was healing well. A Neck CT demonstrated no abscess or
signs of infection.
Given suspicion for PNA, the patient was started on empiric IV
Vancomycin, Cefepime, and Flagyl for an 8 day course. He
remained afebrile for the entire duration of hospitalization and
his white count trended down, returning to normal by time of
discharge. A MRSA nasal swab was done which was negative. He
will be discharged with a PICC line to complete an 8 day course
for hospital acquired pneumonia (___).
# UTI / Urinary retention - On his previous hospitalization he
was diagnosed with a UTI and given a 10 day course of cipro, of
which he completed 3 days. On admission to the ED he was given
1 dose of IV ceftriaxone. Though urine cultures obtained on
this admission were negative, his treatment for pneumonia
(vanc/cefepime/flagyl) has also covered any possibility of a
UTI. A condom catheter was placed for the duration of
hospitalization and there were no issues with urinary rentention
requiring straight catheterization. Of note, he has a large
bladder volume
and can reach ___ on bladder scan before voiding.
# ___ - On admission his creatinine was 1.7. This improved to
1.1 after IV normal saline. This creatinine bump was thought to
be pre-renal, secondary to low fluids. 250cc free water flushes
q4hrs were added to his tube feed order to provide additional
fluid. He should continue this regimen on discharge.
# Dementia - patient has a history of dementia and is oriented
x1-2 at baseline. The patient is extremely sensitive to any and
all sedating medications and seroquel, zyprexa, benzodiazepines,
and trazodone were avoided as much as possible due to
oversedation. Overall his mental status improved over time and
he was alert and conversant by time of discharge. We recommend
continuing to hold seroquel on discharge and recommend that
neuroleptic and sedating medications be avoided as much as
possible. If absolutely necessary and in extreme circumstances,
use zyprexa for agitation, and avoid benzodiazepines.
# Diabetes - The patient has ___ managed at home with insulin,
sulfonylurea and metformin, but with discharged from the
hospital previously on a regiment of AM Lantus 24 and sliding
scale insulin as needed. On this hospitalization, his sliding
scale was up-titrated as necessary and his AM lantus was
increased to 30u. As tube feeds were resumed, his sugars
increased to the mid ___, requiring an increase in his sliding
scale insulin. On discharge his glucose was in somewhat better
control but with a few episodes of hyperglycemia such that it is
imperitive that his insulin regimen should continued to be be
uptitrated and adjusted as necessary by rehab.
#Fungal Rash - on the day of discharge a localized, raised,
erythematous rash was noted in the patient's inguinal area,
consistent with a fungal rash. Miconazole powder was applied
topically to this area four times a day. This powder should
continue to be applied to the area until the rash clears.
# Right neck injury s/p wound exploration/drain placement on
___ - evaluated by surgery, thought to be doing fine, no
issues during hospitalization. The patient has outpatient
follow up with Surgery scheduled.
TRANSITIONAL ISSUES
-------------------
# Completion of IV Vanc/Cefepime/Flagyl through and including
___
#. Speech and Swallow Re-evaluation
#. Physical and Occupational therapy
#. TUBE FEEDING ORDERS: Pulmocare full strenght at 60cc/hr with
q4hr 250cc water flushes.
# Diet: nectar-thick liquids, pureed solids and continue
nutritional support with feeds through PEG tube
# Urinary retention: sometimes will not void until bladder
volume is ~700cc on bladder scan. If still does not void above
this, requires intermittent straight catheterization. Patient
will need to reschedule Urology outpatient appointment
# He will require uptitration in basal insulin and sliding scale
at rehab facility.
# please note, the patient is VERY sensitive to antipsychotic
medications and benzodiazepines. Please try to avoid using
these medications.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from records.
1. Tamsulosin 0.4 mg PO HS
2. Lumigan *NF* (bimatoprost) 0.01 % ___ HS
3. Aspirin 81 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Simvastatin 40 mg PO HS
6. Acetaminophen IV 1000 mg IV Q8H:PRN pain, fever
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
8. Calcium Carbonate 500 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q8H:PRN pain, fever
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Simvastatin 40 mg PO HS
8. Vitamin D 400 UNIT PO DAILY
9. CefePIME 1 g IV Q24H Duration: 2 Days
D1 = ___
RX *cefepime 1 gram 1 gram daily Disp #*2 Bag Refills:*0
10. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Duration: 2 Days
D1 = ___
11. Vancomycin 1000 mg IV Q 12H Duration: 2 Days
D1 = ___
12. Lumigan *NF* (bimatoprost) 0.01 % ___ HS
13. Multivitamins 1 TAB PO DAILY
14. Tamsulosin 0.4 mg PO HS
15. Glargine 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
16. Miconazole Powder 2% 1 Appl TP QID
17. Bisacodyl 10 mg PR HS
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Hospital-acquired pneumonia
Discharge Condition:
Condition: stable
Mental Status: Alert, awake, pleasant, conversant. Oriented to
himself
Ambulatory Status: non-ambulatory
Discharge Instructions:
It was a pleasure taking care of you at the ___!
You were admitted because of a fever. In the hospital we
determined that you had pneumonia. You were started on treatment
with intravenous antibiotics which you will need to finish after
you leave the hospital. You are now ready for discharge back to
the nursing facility.
Please see below for information regarding follow up
appointments
Followup Instructions:
___
|
19763430-DS-24
| 19,763,430 | 24,098,430 |
DS
| 24 |
2176-09-01 00:00:00
|
2176-09-01 12:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Abilify / Phenergan Plain / Benzodiazepines / Opioids-Morphine &
Related
Attending: ___.
Chief Complaint:
Lethargy and Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
___
Time: ___
________________________________________________________________
PCP:
Name: ___
Location: ___- MEDICAL CARE CTR
___
Address: ___
Phone: ___
Fax: ___
Email: ___
_
________________________________________________________________
HPI: ___ with history of PNA and recurrent UTIs presenting from
nursing home with altered mental status, fever, cough and
elevated WBC. Daughter reports increased confusion over the past
month which is his typical presentation for UTI. Had temperature
to 104 at NH today. Desated to 80% on RA at ___. Given IM
ceftriaxone prior to transfer for eval. Of note, patient has had
multiple falls over the past few weeks. Was recently seen at
___ ___ weeks ago for fall and found to have a UTI s/p 10
day course of levaquin with some improvement but then became
confused again over the past two weeks after completing the
course of abx.
He (separately) of continued sacral pain to his daughter.
Since his fall he has been having urinary retention up to 800
cc. He has had 6 falls for the past year.
He self d/c'ed his foley one week ago and is s/p traumatic foley
catheter placement today.
In ER: (Triage Vitals:unable) 98.7 93 111/54 20 97% ra )
Meds Given:
Today 16:24 Lidocaine Jelly 2% (Urojet) 5mL Urojet 1 ___,
___
___ 18:14 Vancomycin 1g Frozen Bag 1 ___
___ 18:44 Acetaminophen IV 1000 mg / 100 mL Vial 1 from
Pharmacy
Today 18:45 Azithromycin 500 mg in 5% Dextrose 1 from Pharmacy
Today 19:24 Azithromycin 500mg Vial 1 ___
Fluids given: 1L NS
Radiology Studies: L/S spine X ray and CXR
consults called: UROLOGY - for torn urethral meatus when foley
catheter placed
.
PAIN SCALE: unable to attain since pt is soundly asleep and
pt's family states that this is his baseline. ROS obtained from
family and from NH records.
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ +] Fever [ ] Chills [ ] Sweats [+ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[ +] _10____ lbs. weight loss over __6___ months
Eyes [X]
Legally blind x ___ years with ___ syndrome.
ENT
high aspiration risk
RESPIRATORY: [X] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ ] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: Cannot assess
GI: [] All Normal
[ +] Nausea [+] Vomiting [] Abd pain [] Abdominal swelling
[ ] Diarrhea [ +] Constipation- but ? cdiff secondary to
fever and new leukocytosis [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [] All Normal
[ ] Dysuria [+] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [] All Normal
[ ] Rash [ ] Pruritus [+] decubitus
MS: [] All Normal
[ +] Joint pain- coccyx [ ] Jt swelling [ ] Back pain [ ]
Bony pain
NEURO: [] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change
[+]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [] All Normal
[++ ] agitation but pt with h/o anxiety and depression[]Suicidal
Ideation [ ] Other:
ALLERGY:
[+ ]Medication allergies [ ] Seasonal allergies
Abilify Rash
Components responsible for reaction(s): Aripiprazole
Level of Certainty: Moderately Certain History
Benzodiazepines Confusion/delirium History
Opioids-Morphine & Related Confusion/delirium History
Phenergan Plain hallucination and EPS per dtr
Components responsible for reaction(s): Promethazine Hcl
Level of Certainty: Moderately Certain
Confirmed with dtr.
[X]all other systems negative except as noted above
Past Medical History:
Past Medical History:
1. Diabetes mellitus type 2.
2. Autonomic neuropathy.
3. Renal insufficiency.
4. Diabetes retinopathy.
5. Diverticulosis.
6. Depression.
7. Goiter.
8. ___ syndrome
9. Dementia- diagnosed in ___ when he developed delirium after
cataract surgery. Then ___ - diagnosed with probabe Lew Body
Dementia.
10. MRSA bacteremia - ___
Social History:
He was originally from ___ and moved ___ in ___. He was living
at ___ and was able to walk to the dining room until ___ after he was admitted s/p fall.
Lives in ___ - ___ since d/c on ___
penetrating injury to neck. He first went to ___ NH- Per
OT eval in ___ he has a fluctuating ability to
participate in ADL and mobility due to his short term memory
deficits and is alert and oriented x 1 at baseline.
Former dentist. Quit smoking ___ years ago but prior to that had
a 40 pack year history.
Remote history heavy drinking but quit ? > ___ years ago.
Next of kin: wife ___ and dtr ___, dtr cp ___- ___. He also has a son and dtr thus 3
children.
___ - ___ -back up
Retired ___ ___ thus gets benefits through the ___.
He is now wheelchair bound but was walking with 2 assist with a
wheelchair.
Family History:
Confirmed with dtr.
Mother w/ colon CA
Father w/ ___, ___
Physical Exam:
PHYSICAL EXAM:
PAIN SCORE: could not be obtained given patient's mental status.
1. VS T 100.2 axillary P 80 BP 107/62 RR 18 O2Sat on _96% on
RA _
GENERAL: Elderly male, laying in bed. He is deeply somnolent.
He only wakes up when I do his prostate exam and confirms that
it hurts when I press.
Nourishment: good
Grooming:good
Mentation: soundly asleep.
2. Eyes: [] WNL
Both pupils do not react to light. EOM- could not be tested
Conjunctiva: clear
in OP
3. ENT [] WNL
Enlarged goiter noted.
Well healed surgical scar from neck exploratory surgery.
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[X] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [?] Systolic Murmur
___, Location:LUSB
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema b/l trace b/l edema s/p toe amputation
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [ ]
Very distant breath sounds but lungs sound clear
6. Gastrointestinal [ ] WNL
Soft, nt, no rebound. PEG site c/d/i and non-tender
Rectum: filled with soft brown stool. Disempacted.
7. Musculoskeletal-Extremities [] WNL
+ cogwheeling in b/l upper extremities.
He is very rigid in both upper and lower extremities.
8. Neurological [] WNL
Could not be assessed. Only when turned did he respond to his
dtr calling his name. His CN appear symmetrical.
9. Integument [] WNL
[X] Warm [] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [X] Moist [] Mottled [X] Ulcer: decubitus- sacral
-stage I per RN
10. Psychiatric [] WNL
[] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated
[] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
12. Genitourinary [] WNL
+ penile tear which is tender to palpation. + fresh and dried
blood present at the meatus.
[ +] Catheter present [] Normal genitalia [ ] Other:
40 gram prostate which is tender to palpation.
TRACH: []present [X]none
PEG:[]present []none [X ]site C/D/I
COLOSTOMY: :[]present [X]none [ ]site C/D/I
Discharge physical exam:
Pertinent Results:
.
___ 07:30AM BLOOD WBC-6.8 RBC-3.34* Hgb-10.2* Hct-30.6*
MCV-92 MCH-30.5 MCHC-33.3 RDW-13.7 Plt ___
___ 07:20AM BLOOD WBC-6.6 RBC-3.21* Hgb-10.0* Hct-29.7*
MCV-93 MCH-31.2 MCHC-33.7 RDW-13.2 Plt ___
___ 08:30AM BLOOD WBC-5.5 RBC-3.21* Hgb-10.0* Hct-30.0*
MCV-93 MCH-31.1 MCHC-33.3 RDW-13.2 Plt ___
___ 07:30AM BLOOD WBC-7.3 RBC-3.37* Hgb-10.6* Hct-31.7*
MCV-94 MCH-31.4 MCHC-33.4 RDW-13.4 Plt ___
___ 07:40AM BLOOD WBC-7.3# RBC-3.12* Hgb-9.8* Hct-29.4*
MCV-94 MCH-31.5 MCHC-33.5 RDW-13.7 Plt ___
___ 04:04PM BLOOD WBC-17.4*# RBC-3.70* Hgb-11.5* Hct-34.8*
MCV-94 MCH-31.2 MCHC-33.2 RDW-13.3 Plt ___
___ 07:40AM BLOOD Neuts-83.5* Lymphs-10.1* Monos-5.0
Eos-1.2 Baso-0.2
___ 04:04PM BLOOD Neuts-92.3* Lymphs-4.6* Monos-2.9 Eos-0.1
Baso-0.1
___ 07:40AM BLOOD ___ PTT-25.7 ___
___ 04:04PM BLOOD ___ PTT-29.5 ___
___ 07:30AM BLOOD Glucose-135* UreaN-16 Creat-1.0 Na-137
K-4.3 Cl-105 HCO3-24 AnGap-12
___ 12:50PM BLOOD Glucose-272* UreaN-16 Creat-1.1 Na-135
K-5.4* Cl-105 HCO3-21* AnGap-14
___ 08:30AM BLOOD Glucose-203* UreaN-18 Creat-1.0 Na-138
K-4.4 Cl-106 HCO3-26 AnGap-10
___ 07:30AM BLOOD Glucose-182* UreaN-21* Creat-1.0 Na-140
K-4.2 Cl-104 HCO3-25 AnGap-15
___ 07:40AM BLOOD Glucose-161* UreaN-32* Creat-1.3* Na-141
K-4.4 Cl-108 HCO3-25 AnGap-12
___ 04:04PM BLOOD Glucose-174* UreaN-35* Creat-1.5* Na-141
K-4.8 Cl-104 HCO3-28 AnGap-14
___ 09:00PM BLOOD CK(CPK)-27*
___ 12:50PM BLOOD ALT-15 AST-22 CK(CPK)-37* AlkPhos-79
TotBili-0.2
___ 04:04PM BLOOD ALT-13 AST-17 AlkPhos-101 TotBili-0.4
___ 04:04PM BLOOD Lipase-11
___ 09:00PM BLOOD CK-MB-2 cTropnT-0.03*
___ 12:50PM BLOOD CK-MB-2 cTropnT-0.04*
___ 07:30AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.8
___ 12:50PM BLOOD Calcium-8.4 Phos-2.7 Mg-1.7
___ 08:30AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.6
___ 07:30AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.7
___ 07:40AM BLOOD Calcium-8.4 Phos-3.0 Mg-1.7
___ 04:04PM BLOOD Albumin-3.6 Calcium-9.4 Phos-4.1 Mg-1.9
Iron-11*
___ 04:04PM BLOOD calTIBC-241* VitB12-689 TRF-185*
___ 04:04PM BLOOD TSH-0.34
___ 04:04PM BLOOD T4-7.5 T3-83
___ 04:04PM BLOOD PSA-2.6
___ 10:30PM BLOOD Type-ART pO2-109* pCO2-36 pH-7.45
calTCO2-26 Base XS-1
___ 11:58PM URINE Color-Straw Appear-Clear Sp ___
___ 05:05PM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:58PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:05PM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5* Leuks-LG
___ 11:58PM URINE RBC-12* WBC-4 Bacteri-NONE Yeast-NONE
Epi-0
___ 05:05PM URINE RBC-156* WBC-175* Bacteri-MANY Yeast-NONE
Epi-0
.
___ CXR:
IMPRESSION: Limited, negative.
.
___ lumbosacral films:
IMPRESSION: Degenerative changes without definite sign of acute
fracture or malalignment. If strong clinical concern,
cross-sectional imaging may be performed to further assess.
.
EKG:
Sinus rhythm. A-V conduction delay. Possible prior anteroseptal
myocardial infarction. Left axis deviation. Compared to the
previous tracing of ___ no diagnostic interim change.
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 ___ 56 -33 75
.
___ EEG:
IMPRESSION: This was an abnormal routine EEG in the awake and
drowsy states due to the presence of a slightly slow and
disorganized background. This finding suggests the presence of a
mild encephalopathy which indicates diffuse cerebral dysfunction
but is non-specific as to etiology. No focal or epileptiform
features were seen.
.
CT head:
There is no evidence of an acute intracranial hemorrhage, edema,
large vessel territorial infarction, or shift of the midline
structures. The ventricles and sulci are slightly prominent in
size and configuration, likely representing age-related
involutionary changes. Mild periventricular white hypodensities
are noted likely sequela of chronic small vessel ischemic
changes. No acute fractures are identified. The visualized
mastoid air cells and paranasal sinuses are clear.
IMPRESSION:
No acute intracranial injury.
.
CXR ___: no pneumonia. no failure
.
Microbiology:
Date 6 Lab # Specimen Tests Ordered By
All ___
All BLOOD CULTURE Influenza A/B by ___ NOT PROCESSED MRSA SCREEN
Rapid Respiratory Viral Screen & Culture URINE All EMERGENCY
WARD INPATIENT -negative
___ MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
___ URINE URINE CULTURE-FINAL INPATIENT= <10,000
___ URINE URINE CULTURE-FINAL INPATIENT
=negative
___ Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-FINAL; Respiratory Viral Antigen
Screen-FINAL INPATIENT
___ Influenza A/B by ___ NOT PROCESSED
INPATIENT
___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT-no
MRSA
___ URINE URINE CULTURE-FINAL EMERGENCY
WARD=mixed genital flora
___ BLOOD CULTURE Blood Culture, Routine-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine
___ 11:23 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- <=2 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 8 R
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ 8 I
Brief Hospital Course:
Pt is a ___ y.o male with h.o presumed ___ Body dementia with
___ hallucinations, Dm2, CKD, DM2, depression, who
presented with complicated UTI, encephalopathy and recent
traumatic foley removal.
# Encephalopathy in the setting of advanced dementia (probable
___ Body), ___ syndrome and depression. Pt with
reports of weeks of worsening delerium prior to admission.
Initially during admission, pt with acute hyperactive delerium
and agitation and required antipsychotic therapy. Pt's baseline
appears to be AAox1 with tangential speech, confused, but able
to walk with a walker with assist, belt, and able to eat with
assistance. However, pt's mental status worsened on ___ with pt
with period of "unresponsiveness" at ~1150am. During this
episode, vital signs were stable, EKG unchanged from prior,
finger stick >300, no signs of asymmetry or rhythmic jerking
movements noted but did have signficant rigidity and
intermittent diffuse twitching with forceable closing of his
eyes (resisting motions to open his eyes). Neurology was called
for evaluation. EEG revealed encephalopathy but no signs of
seizure activity. CT head did not reveal any acute findings. Pt
did receive a dose of 1mg of haldol 2 days prior to this
episode. Haldol order was dc'd given history ___ Body
dementia and concern for precipitating further parkinsonian
symptoms, but it was not thought that the haldol was the
inciting cause. Of note, the patient had additional episodes of
"unresponsiveness" on ___ and ___ that did not last as long as
nor were as significant as the episode on ___. The neurology
and psychiatry teams were consulted for further management and
assistance. Both services felt that pt likely has significant
baseline dementia with superimposed delerium due to his dementia
with ___ hallucinations and due to UTI. He was
continued on his standing seroquel QHS dosing as pt does become
quite agitated without this medication. He was continued on
6.25mg BID PRN acute agitation. He continued to have
drastically waxing and waning mental status without clear
trajectory of improvement.
- The patients daughter (a nurse practitioner) confirms that her
father does best with Seroquel.
# Complicated urinary tract infection. Per report from pt's
dtr, pt with prior klesiella in the urine which was thought by
his nursing facility to be "contamination". Ucx on admission
with contaminated genital flora. He was given ceftriaxone x1 IM
prior to admission. He was continued on IV cipro therapy for
presumed complicated UTI. He recieved this medication for 5 days
when the "unresponsive episode" occurred and it was temporarily
discontinued in the event that pt was experiencing seizures. EEG
returned negative. Of note, UCX x2 repeated in the setting of
unresponsiveness revealed no growth, but subsequent culture grew
>100K pseudomonas sensitive only to cefepime and amikacin and he
was treated with cefepime. Urology was consulted as well for
traumatic foley removal with urethral bleeding and recommended
intermittent catherization if retaining urine (check PVR qshift
and straight cath if >300) rather than permanent foley given
risk for continued trauma. Pt will be following up with urology
for ongoing care. Of note, he was instructed to start cystex
therapy BID for UTI ppx after his course of cipro is complete.
- Therapy was initiated on ___ (peviously was being treated
with CTX that did not cover for the pseudomonas). Treatment to
be for 2 weeks (complete on ___ consider repeating UA/UCx
at completion.
# Initial concern for pneumonia. No hypoxia or other respiratory
symptoms. Viral screen negative. CXR negative x2.
# R.arm antecubital hematoma- area of mild erythema noted in
antecub area and surrounding in site of former IV. Initially,
site had appearance of potential fungal infection. However, the
erythema resolved and then appeared consistent with hematoma
related to prior IV. Local wound care provided
# BPH w/urethral/meatal injury ___ self-discontinuation of
Foley. See above, urology was consulted who recommended
intermittent catheterization (via coude catheter) rather than
continuous foley given risk of recurrent trauma and need for
restraints. Would check PVR qshift and cath for PVR >300. Pt was
continued on tamsulosin and finasteride. After cefepime therapy
is completed, pt should be started on cystex 1tablespoon BID for
UTI ppx.
# Acute renal failure in the setting of stage II CKD. Improved
with IVF. Felt to be prerenal.
# Recent falls with autonomic neuropathy and diabetic
retinopathy. Physical therapy was consulted who recommended
rehab.
# Normocytic anemia. Ferritin elevated. Consistent with anemia
of chronic disease. No signs of acute bleeding during admission
#HL-continued ASA, pravastatin
#Glaucoma-continued latanoprost
#IDDM type 2. Poor control, increased HISS ___
- Nectar prethickened liquids, diabetic diet, insulin regimen.
Pt's home dose of glargine 25units was initially decreased to
15units given his initial poor PO intake. This was eventually
increased back to his home dose of 25 units.
CODE: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 75 mg PO DAILY
2. Quetiapine Fumarate 6.25 mg PO BID:PRN agitation
3. CeftriaXONE 50 mg IM ONCE Duration: 1 Doses
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. Pravastatin 80 mg PO HS
6. Tamsulosin 0.8 mg PO HS
7. Lactulose 30 mL PO DAILY
8. Glargine 25 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. Aspirin 81 mg PO DAILY
10. Calcium Carbonate 1250 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Quetiapine Fumarate 25 mg PO Q 10 ___
Discharge Medications:
1. Sertraline 75 mg PO DAILY
2. Quetiapine Fumarate 6.25 mg PO BID:PRN agitation
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
4. Pravastatin 80 mg PO HS
5. Tamsulosin 0.8 mg PO HS
6. Lactulose 30 mL PO DAILY
7. Aspirin 81 mg PO DAILY
8. Calcium Carbonate 1250 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Quetiapine Fumarate 25 mg PO Q 10 ___
12. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
13. Docusate Sodium (Liquid) 100 mg PO BID
14. Finasteride 5 mg PO DAILY
15. Lidocaine Jelly 2% (Urojet) 1 Appl TP PRN straight cath
16. Senna 1 TAB PO BID
17. Cystex (methenamine & sod sal) *NF* (methenamine-sodium
salicylate) 162-162.5 mg Oral BID
for prevention of UTI. To start after cefepime therapy complete
18. CefePIME 1 g IV Q12H
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
20. Glargine 25 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Complicated urinary tract infection (Psuedomonal)
Traumatic Foley self-removal causing urethral and meatal
injuries
Delirium in the setting of probably ___ Body dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted for an evaluation of confusion. Your work up
revealed a urinary tract infection for which you were started on
antibiotic therapy with good effect. You were noted to have
periods of confusion and unresponsiveness for which you were
evaluated by the neurology and psychiatry teams. In addition,
you experienced trauma related to your foley catheter and are
getting catheterizations as needed.
Followup Instructions:
___
|
19764001-DS-12
| 19,764,001 | 23,101,422 |
DS
| 12 |
2124-01-22 00:00:00
|
2124-01-25 19:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Left patellar fracture and tendon repair with orthopedic surgery
History of Present Illness:
___ year old man with a history of CLL, pulmonary emboli,
depression, and alcohol abuse, presenting with bizarre behavior,
and concern of alcohol withdrawal and seizures.
History obtained from wife over the phone. She states that
approximately ___ years ago patient had a severe knee infection
post-operatively complicated by sepsis and near death, and since
then he has resorted to periods of heavy drinking due to loss of
previous mobility. He has progressively been drinking more over
the years.
Additionally, he struggled with prescription narcotic abuse in
the aftermath of his knee surgery, and attended a rehab facility
in ___ in ___.
Wife states that the patient is currently in a period of heavy
drinking, although the patient does not believe that he really
drinks to excess. She estimates that he drinks all day long, and
it is hard for her to tell exactly how much he drinks. She
estimates that he drinks roughly a half of a ___ of vodka per
day, plus a bottle of wine. He often doesn't appear
intoxicated, but typical noticeable features include impaired
gait, poor memory, and word finding difficulty.
She states that he has frequent "episodes" of being "totally out
of it." He has had multiple recent brief hospitalizations where
EMS will be called for agitation, aimlessness, disorientation.
He will be hospitalized for several days and then discharged.
His wife is not sure of the diagnosis during the
hospitalizations, but states that she thinks she has been told
that it is not due to alcohol withdrawal.
Patient and wife deny history of complicated withdrawal or
withdrawal seizures. Apparently patient was told by a doctor who
once witnessed a "spell" by the patient on an airplane that he
has petit mal seizures, and wife is concerned that patient has
now fixated on this explanation for his behavior.
Several days prior to this current admission, patient was awake
vomiting all night after eating out a restaurant. THe following
morning his wife left for a trip with a friend to ___. She
she left him she noted that he was tremulous, diaphoretic, and
agitated, but denying anything wrong. Over the next 2 days, she
was not able to reach him by phone, so she asked a friend to
check in on him. The friend found him down at home, with the
house in disarray (hole in the wall, blood on the bed and
walls). He was reportedly observed to have twitching concerning
for seizure. EMS was called and he was taken to ___
___.
Regarding his left knee; patient recently returned 2 weeks ago
from a trip to ___. According to his wife patient fell
at some point during this trip and fractured his patella, but
she is not able to provide any additional information.
At ___ he had a head CT that showed no acute
intracranial process. He was transferred to the ___ ED.
Initial vitals here were T 98.6, BP 123/68., HR 102, RR 18, SPO2
98% on NC. He was febrile in the ED to 103.
Labs:
--UA trace leuks, moderate blood, negative nitrites, few
bacteria
--urine tox positive for opiates, negative otherwise
-- serum tox negative (including ETOH)
-- INR 1.2
-- WBC 52 (78% lymphs), Hgb 7.7, plt 202
-- ALT 64, AST 157, Alk phos 114, lipase 12, T bili 0.7, Albumin
4.4
-- CK 5568
-- Na 141, K 5.0, CO2 25, Creat 3.0, BUN 58, AG 24
-- lactate 1.6
CT head without intracranial process. CXR negative.
He was given diazepam 10mg IV x2, 1000ml NS, ceftriaxone 1g IV,
and acetaminophen 1000mg PO.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
Arthritis
Asthma
PE Saddle Embolism
Depression
CLL
GERD
Hypertension
Peripheral Vascular disease
Cervical Spondylolysis
Recurrent cellulitis of lower extremities
DVT filter
Social History:
___
Family History:
not relevant to current hospitalization
Physical Exam:
ADMISSION EXAM:
================
Vitals: T: 98.6 BP:102/61 P:102 R: 18 O2: 96% on 2L NC
GENERAL: tremulous, diaphoretic, uncomfortable and anxious in
appearance
HEENT: Sclera anicteric, dry oral mucosa,oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rhythm, tachycardic 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 on the left lower extremity with quad tendon
deformity, and large 11x12 cm area of ecchymoses on the medial
suprapatellar side, no erythema, edema, induration
SKIN: laceration under chin, left elbow, right forearm.
Multiple echymoses bilateral thighs and shins, upper abdomen,
bilateral forearms
NEURO: awake and alert, alternating with brief periods where
patient closes eyes and stops speaking but responds promptly to
voice or light touch. Occasional twitching of arms and face.
Responds inappropriately or tangentially to questions. He is
disoriented (states date is ___, location is ___
Correctly names president as ___ Unable to initiate serial
7s or 3s. Inattentive. PERRL, EOMI, facial sensation and
movements intact/symmetric. Hearing intact. Strength ___ in
BUE/BLE (unable to fully assess LLE). Sensation intact in all
distal extremities. Tremulous.
Content of thought notable for question of visible
hallucinations (spiders on right side of vision)
DISCHARGE EXAM:
================
Vitals: 98.9 (max 99.2) 150/90 (150s-170s/80s-100s) 84 (80s-90s)
98% on RA
GENERAL: no acute distress
HEENT: Sclera anicteric, PERRLA, EOM intact, moist mucous
membranes, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: CTAB, no wheezes, rales, rhonchi
CV: Regular rate 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: Multiple echymoses bilateral thighs and shins, upper
abdomen, bilateral forearms
NEURO: alert and oriented x3, CNII-XII intact, able to name and
discuss current and past presidents, good concentration (months
of the year backward), no asterixis, no clonus, no dysmetria on
finger-nose-finger, no dysdiadochinesia
Pertinent Results:
ADMISSION:
===========
___ 10:13PM BLOOD WBC-52.0* RBC-2.77* Hgb-7.7* Hct-24.8*
MCV-90 MCH-27.8 MCHC-31.0* RDW-17.7* RDWSD-56.2* Plt ___
___ 10:13PM BLOOD Neuts-13* Bands-0 Lymphs-78* Monos-4*
Eos-0 Baso-0 ___ Metas-2* Myelos-1* NRBC-2* Plasma-2*
AbsNeut-6.76* AbsLymp-40.56* AbsMono-2.08* AbsEos-0.00*
AbsBaso-0.00*
___ 10:13PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ Burr-1+
Pencil-1+ Tear Dr-1+ Ellipto-1+
___ 10:13PM BLOOD ___ PTT-31.4 ___
___ 10:13PM BLOOD Glucose-97 UreaN-58* Creat-3.0* Na-141
K-5.0 Cl-97 HCO3-25 AnGap-24*
___ 10:13PM BLOOD ALT-64* AST-157* CK(CPK)-5568*
AlkPhos-114 TotBili-0.7
___ 10:13PM BLOOD Albumin-4.4 Calcium-8.9 Phos-6.5* Mg-2.5
PERTINENT RESULTS:
=================
___ 03:00PM BLOOD WBC-34.0* RBC-2.50* Hgb-6.9* Hct-22.6*
MCV-90 MCH-27.6 MCHC-30.5* RDW-18.1* RDWSD-58.7* Plt ___
___ 03:46AM BLOOD WBC-16.6*# RBC-2.17* Hgb-6.0* Hct-19.7*
MCV-91 MCH-27.6 MCHC-30.5* RDW-18.3* RDWSD-59.5* Plt ___
___ 03:40PM BLOOD WBC-12.6* RBC-2.47* Hgb-6.9* Hct-23.1*
MCV-94 MCH-27.9 MCHC-29.9* RDW-17.7* RDWSD-60.2* Plt ___
___ 07:31AM BLOOD WBC-8.0 RBC-2.74* Hgb-7.8* Hct-24.8*
MCV-91 MCH-28.5 MCHC-31.5* RDW-17.7* RDWSD-58.6* Plt ___
___ 10:00AM BLOOD Ret Aut-4.1* Abs Ret-0.10
___ 07:50AM BLOOD Glucose-112* UreaN-8 Creat-0.7 Na-129*
K-4.1 Cl-94* HCO3-25 AnGap-14
___ 07:53PM BLOOD ALT-50* AST-61* AlkPhos-95 TotBili-0.5
___ 03:00PM BLOOD TotProt-5.9* Calcium-8.2* Phos-3.2#
Mg-2.6
___ 07:50AM BLOOD Calcium-7.8* Phos-2.0* Mg-1.4*
___ 07:30AM BLOOD Albumin-3.2* Calcium-7.7* Phos-2.5*
Mg-2.1
___ 03:46AM BLOOD calTIBC-381 Hapto-20* Ferritn-114 TRF-293
___ 07:53PM BLOOD Osmolal-269*
___ 03:46AM BLOOD TSH-1.2
___ 03:46AM BLOOD CRP-202.0*
___ 10:00AM BLOOD PEP-ABNORMAL B IgG-888 IgA-22* IgM-74
IFE-MONOCLONAL
___ 10:38AM BLOOD ___ pO2-63* pCO2-43 pH-7.38
calTCO2-26 Base XS-0
___ 10:38AM BLOOD Lactate-0.8
Micro:
=========
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Blood Cx ___: No growth to date
___ 10:00 am TISSUE LEFT KNEE JOINT #1.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 10:02 am TISSUE LEFT KNEE JOINT #2.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 10:04 am TISSUE LEFT KNEE JOINT #3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 10:08 am TISSUE LEFT KNEE JOINT #4.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 10:13 am TISSUE LEFT KNEE JOINT #5.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
RPR: Negative
Cryptococcal Ag: Negative
Urine Cx ___: Negative
Blood Cx ___: No Growth
Imaging:
=========
NCHCT ___:
IMPRESSION:
Motion artifact degrades image quality and limits evaluation.
Within this
limitation, no acute intracranial hemorrhage or other acute
process
identified.
CXR ___:
No acute cardiopulmonary process.
CT LLE without Contrast ___:
1. Patella ___ consistent with a ruptured patellar tendon.
Additionally,
there is a fracture of the patella with multiple bony fragments
at the level of the knee joint. There is extensive hematoma
extending from the knee joint up to the left hip. There is a
hemorrhagic joint effusion. Infection cannot be excluded.
2. There is no evidence of hardware complication.
CT hip without contrast ___:
1. Stranding along the anterolateral aspect of the left thigh,
concerning for hematoma is better assessed on CT lower extremity
from the same date.
2.There is moderate wall thickening of the sigmoid colon and
rectum,
consistent with proctocolitis.
Spinal Xray ___:
Inferior vena cava filter. Moderate lumbar scoliosis with
rotational
component. Mild thoracic scoliosis. No physiologic cervical
lordosis. There is mild generalized and mostly asymmetrically
narrowing of the disc spaces, with mild to moderate spondylofite
formation. Moderate degenerative intervertebral changes. No
evidence of vertebral compression fractures.
Knee Xray ___:
In comparison with the study of ___, following tendon
repair there is
much less separation between the fragments of the Patella.
Postsurgical changes are seen in soft tissues.
CXR ___:
As compared to the previous radiograph, no relevant change is
seen. The
vasculature is mildly enlarged, suggesting the presence of mild
fluid
overload. No pleural effusions. Minimal atelectasis at the
left lung base. Mild cardiomegaly. No pneumonia.
DISCHARGE:
=========
___ 10:40AM BLOOD WBC-8.4 RBC-3.07* Hgb-8.5* Hct-27.9*
MCV-91 MCH-27.7 MCHC-30.5* RDW-16.8* RDWSD-55.7* Plt ___
___ 10:40AM BLOOD Glucose-153* UreaN-12 Creat-0.8 Na-136
K-4.0 Cl-94* HCO3-27 AnGap-19
___ 10:40AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ year old male with PMH of CLL, HTN, provoked
PE, alcohol and opioid abuse who was transferred to ___ for
altered mental status, possible alcohol-withdrawal seizures,
left patellar tendon rupture, and left patella fracture.
#Altered mental status:
Patient presented with disorientation, brief episodes of eye
closure, twitching/ tremulousness, fever, frequent falls,
inattentiveness, and diaphoresis. Given his reported heavy
drinking and transaminitis with 2:1 ratio of AST:ALT (157/64),
this cluster of symptoms was concerning for alcohol withdrawal
and possibly delirium tremens. In addition, the patient
presented after being found down with elevated CK and ___ and
therefore toxic metabolic encephalopathy may have also been
contributing to his confusion. Head CT was negative for acute
hemorrhage or other structural intracranial process. Tox screen
was positive for opiates (patient has history of prescription
narcotic abuse) but otherwise negative, and serum osmolality was
normal. One dose of ceftriaxone was administered in the ED for
possible UTI, however urine cultures were performed and were
negative. The patient was admitted to the MICU where he was
placed on the phenobarbital protocol for alcohol withdrawal.
Neurology was following and recommended continued reversal of
metabolic abnormalities, thiamine and folate supplementation, as
well as to rule-out infection as a possible source and his
symptoms. Infectious work-up including blood cx, CXR, urine cx,
knee tissue cxs, RPR, cryptococcal antigen, and MRSA screen
negative. The patient's mental status improved as his
___ improved, and he had no witnessed seizures
during his hospital stay. While it is unclear what his episodes
of agitation and abnormal movements are a result from, it is
likely that his acute presentation of confusion was in the
setting of heavy alcohol abuse/withdrawal, overuse of home
baclofen and pain medications, and the resulting
___. His symptoms continued to improve and
he was back at baseline mental status upon discharge.
#Patella fracture:
Patient found to have a comminuted fracture of his L patella and
large thigh hematoma, s/p left total knee replacement, which was
first seen in ___ but has since worsened with loss of
extensor mechanism and worsened comminution. Plain films from
OSH showed proximal quad tendon retraction. Patient's knee was
initially kept in a knee immobilizer until he was medically
stabilized. He then underwent repair of his patellar tendon and
straight casting. Intraoperative knee tissue samples were taken,
and Gram stains and cultures were negative. Patient tolerated
the procedure well, and his post-op pain was managed with
standing acetaminophen, lidocaine patches, home pregabalin,
standing tramadol, and oxycodone ___ mg PRN. Plan to follow-up
in the ___ clinic following discharge.
#Acute kidney injury:
Patient presenting with elevated creatinine of 3.0, with unknown
baseline. Likely due to rhabdo and decreased PO intake after the
patient was found down in his home. UA showed granular and
cellular casts. He was given IV fluids with improvement of Cr to
0.8 upon discharge.
# Anemia:
Patient presented with a normocytic anemia, with initial Hgb of
7.7. Hgb decreased to 6.0 morning of ___. Drop likely due to a
combination of dilution from IV fluids and continued bleeding
into thigh hematoma. He was transfused 2 units packed RBC on
___, with an appropriate increase in Hgb. Hgb on discharge 8.5.
# Rhabdomyolysis:
The patient was found down in his home with CK 5568 on
admission. This was deemed as a likely contributor to his ___
and altered mental status. He was given IVF boluses and his CK
continued to downtrend throughout his hospital stay.
# Hyponatremia:
Post-operatively the patient developed a hyposmolar hyponatremia
with Na of 129, serum Osm of 269. Patient was euvolemic on exam.
High urine osmolality and high urine Na, consistent with SIADH,
likely secondary to pain during the post-op period. Patient's
pain management was optimized and he was placed on a 800 mL/day
fluid restriction. At the time of discharge, patient's serum Na
increased to 136 and fluid restriction was 1500 mL/day . He will
have repeat labs and an appointment with his PCP the day
following discharge.
# Anxiety:
Patient developed anxiety in the post-op period, which he
attributed to post-op pain. As he was on the phenobarbital
protocol, his anxiety was managed with hydroxyzine PRN, and his
pain management was optimized.
# Thrombocytopenia:
Patient's platelet count dropped from 202 to 134 over the course
of a few days, thought to be most likely due to dilution from IV
fluids. At the time of discharge, his platelet count had
normalized to 171.
# Fever:
Patient developed a fever to 101.5 F the morning after his
surgery, which subsequently resolved that day and patient
remained afebrile for the rest of his hospital course. Fever was
thought to be due to surgery / post-op atelectasis. An
infectious workup -- with blood cultures, urinalysis and urine
culture, and CXR -- was negative.
# Diarrhea:
Patient experienced constipation and was started on lactulose.
He subsequently developed diarrhea and the lactulose was held.
He continued to have diarrhea of decreasing volume and
frequency. His symptoms were managed with loperamide PRN.
CHRONIC
#History of DVT/PE s/p IVC filter:
Patient was on Xarelto at home. As Xarelto interacts with
phenobarbital, heparin was initially substituted for Xarelto. In
coordination with his PCP, it was determined that the patient
will not be systemically anticoagulated upon discharge as he has
completed a 6 month course for his provoked PE. In addition,
given his ongoing alcohol abuse and history of frequent falls,
it was deemed safer to stop the xarelto at this time. He will be
started on a 6 week course of lovenox 40mg SubQ per protocol
after orthopedic procedure with plans to follow-up with his PCP
for further management.
#Alcoholism:
Patient has ongoing alcohol abuse and was evaluated by social
work. It is unclear whether the patient desires to stop drinking
at this time, but the risks of prolonged alcohol use were
reviewed in detail. Social work provided information for
residential addiction treatment programs through ___
as well as an intensive outpatient program in ___ -
Addiction Recovery Services.
#Depression:
Home zonisamide and venlafaxine were held in the setting of
renal failure on admission. Restarted upon discharge with
information provided by social work for continued management of
his symptoms.
#Hypertension:
Patient's home lisinopril was initially held in the setting of
___. His clonidine patch was also held. With resolution ___
with IVF, his home lisinopril was restarted and uptitrated to
40mg daily. Continued to hold clonidine upon discharge with
plans to follow-up with PCP for further management.
#Neuropathic pain:
Patient received home pregabalin. Baclofen was held in fear that
it may have been contributing to his altered mental status.
# Back Pain:
Secondary to multiple falls, with no acute fracture evident on
imaging. Patient's pain was managed with home pregabalin and
tramadol.
TRANSITIONAL ISSUES:
- Repeat CMP (sodium level) on ___ and fax results to PCP
___ at ___
- Consider referral to AA or other resources for alcohol abuse
treatment.
- Patient has a history of narcotic abuse, caution with pain
control management as an outpatient. Patient was inquiring about
holistic pain management programs.
- Upon discharge held clonidine and uptitrated lisinopril to 40
mg QD. Follow up BP's as outpatient and adjust medication as
needed.
- Given history of significant alcohol abuse and transaminitis
in the hospital setting, may repeat LFTs as outpatient and
consider possible alcoholic cirrhosis.
- Patient found to be anemic on admission in the setting of a
large left thigh hematoma. Follow up CBC as an outpatient and
consider further workup if remains below baseline.
- Appointment with ortho scheduled for ___.
- Needs neurology follow up for questionable seizures.
- Communication: HCP: ___ home ___, cell
___
- Code: Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zonisamide 25 mg PO BID
2. Pregabalin 75 mg PO DAILY
3. Pregabalin 150 mg PO QPM
4. Rivaroxaban 20 mg PO DAILY
5. alpha lipoic acid ___ mg oral BID
6. Cetirizine 10 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Thiamine 100 mg PO BID
10. Pravastatin 40 mg PO QPM
11. Venlafaxine 225 mg PO QHS
12. Lisinopril 20 mg PO DAILY
13. Baclofen 40 mg PO BID
14. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QTHUR
15. TraZODone 100 mg PO QHS:PRN insomnia
16. Fluticasone Propionate NASAL 2 SPRY NU DAILY
17. Omeprazole 40 mg PO BID
18. Norco (HYDROcodone-acetaminophen) 7.5-325 mg oral DAILY
Discharge Medications:
1. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Multivitamins 1 TAB PO DAILY
3. Pregabalin 75 mg PO DAILY
4. Pregabalin 150 mg PO QPM
5. Thiamine 100 mg PO BID
6. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
7. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subQ Daily Disp #*40 Syringe
Refills:*0
8. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. TraMADOL (Ultram) 100 mg PO Q6H
RX *tramadol 100 mg 1 capsule(s) by mouth every six (6) hours
Disp #*5 Capsule Refills:*0
10. alpha lipoic acid ___ mg oral BID
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. Omeprazole 40 mg PO BID
13. Pravastatin 40 mg PO QPM
14. TraZODone 100 mg PO QHS:PRN insomnia
15. Venlafaxine 225 mg PO QHS
16. Vitamin D ___ UNIT PO DAILY
17. Zonisamide 25 mg PO BID
18. Cetirizine 10 mg PO DAILY
19. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN severe
pain
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every six (6)
hours Disp #*10 Tablet Refills:*0
20. Outpatient Lab Work
E87.1 hyponatremia
Please check CMP and LFTs and fax to Dr. ___ at ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Toxic metabolic encephalopathy secondary to alcohol
abuse; left patellar rupture
Secondary: Chronic Lymphocytic Leukemia, Provoked Pulmonary
Embolus, Hypertension, Peripheral Vascular 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 taking care of you during your stay at ___.
You were admitted for your confusion and left knee injury. Upon
admission, there was concern that you were experiencing seizures
due to your recent heavy alcohol use. You were brought to the
medicine intensive care unit where you were given
anti-convulsants for your symptoms. Your confusion resolved and
you were transferred to the medical floor.
With the resolution of your confusion, you were taken to the OR
with the orthopedic surgery team for repair of your left
patellar tendon rupture and patella fracture. Your procedure
went well and you were given medication to help with your pain.
Please follow-up at the appointments listed below and try to
abstain from alcohol.
Best Wishes,
Your ___ Team
Followup Instructions:
___
|
19764173-DS-10
| 19,764,173 | 27,550,501 |
DS
| 10 |
2156-07-20 00:00:00
|
2156-07-21 01:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Facial pain
Left eye pain
Bilateral chest wall pain
Assault
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an ___ year old male, not on anti-coagulation, who
presented as transfer from ___ s/p assault. Patient is
an inmate at ___ and was assaulted
earlier today by another inmate. Was kicked in the head twice
and kicked in the chest twice, no LOC. He notes facial pain, L
eye pain associated with decreased visual acuity, and bilateral
upper chest wall pain. At the OSH, imaging was significant for
left 7th rib fracture and EKG with atrial fibrillation. He was
transferred here to ___ for trauma evaluation and further
care.
Past Medical History:
Atrial fibrillation (s/p cardioversion in ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam
Constitutional: Comfortable, awake, alert
Head / Eyes: ENT / Neck: Extraocular muscles intact, Pupils
equal, round and reactive to light; periorbital ecchymoses
bilaterally, no septal hematoma, dried blood in nares, normal
bite
Chest/Resp: Clear to auscultation, chest wall tenderness
bilaterally
Cardiovascular: Normal first and second heart sounds, Regular
Rate and Rhythm
GI / Abdominal: Soft, Nontender, Nondistended
Musc/Extr/Back: No cyanosis, clubbing or edema; no T or L spine
TTP
Skin: No rash, warm and dry, ecchymosis to R arm
Neuro: Speech fluent, moving all extremities
Discharge Physical Exam
General: AAO x4, resting comfortably in bed, NAD
HEENT: Bilateral periorbital edema and ecchymosis, + tenderness
to palpation; L eye conjunctival injection; + EOMI, +PERRL
bilaterally
CV: +irregular rate, normal S1/S2, no RMG
Resp: Normal WOB, +CTAB, no wheezes or crackles
GI: Abdomen soft, non-distended, non-TTP; no rebound or
guarding; +BS x 4 quadrants
Neuro: CN II-XII intact, sensation grossly intact and
bilaterally symmetrical, strength ___ in bilateral upper & lower
extremities, normal coordination
Skin: Ecchymosis to R arm
Ext: Warm, well, perfused, no peripheral edema
Pertinent Results:
___ 04:23PM LACTATE-1.7
___ 03:55PM GLUCOSE-87 UREA N-11 CREAT-0.8 SODIUM-142
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17
___ 03:55PM estGFR-Using this
___ 03:55PM LIPASE-13
___ 03:55PM WBC-9.3 RBC-4.10* HGB-13.3* HCT-40.0 MCV-98
MCH-32.4* MCHC-33.3 RDW-12.6 RDWSD-45.1
___ 03:55PM NEUTS-64.0 ___ MONOS-8.4 EOS-0.9*
BASOS-0.2 IM ___ AbsNeut-5.96 AbsLymp-2.44 AbsMono-0.78
AbsEos-0.08 AbsBaso-0.02
___ 03:55PM PLT COUNT-142*
___ 03:55PM ___ PTT-31.4 ___
___ 03:40PM URINE HOURS-RANDOM
___ 03:40PM URINE UHOLD-HOLD
___ 03:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Brief Hospital Course:
Patient is an ___ year old male, not on anti-coagulation,
presenting as a trauma transfer from OSH on ___. Patient is
an inmate at ___ and was assaulted
earlier that morning by another inmate. Kicked in the head x2,
kicked in the chest x2, no LOC. Notes facial pain, pain to L eye
associated with decreased vision, and bilateral chest wall pain.
Denies any SOB. Imaging at OSH notable for non-diplaced L ___
rib fracture and questionable nasal bone fracture, and EKG with
atrial fibrillation. Transferred for trauma evaluation and
further care.
Primary survey was intact, with negative eFAST. Secondary survey
was notable for bilateral periorbital ecchymosis and edema, L
eye conjunctival injection, bilateral upper chest wall
tenderness. CXR was obtained, which demonstrated low lung
volumes with mild left basilar atelectasis and chronic appearing
bilateral posterior rib fractures, but no acutely displaced rib
fractures appreciated. OSH imaging was reviewed, per the
official Radiology report, the nasal bone fracture was chronic
appearing. Lab work was unremarkable.
Ophthalmology was consulted for the L eye pain with decreased
visual acuity, and the patient was found to have a L
subconjunctival hemorrhage and small L corneal abrasion. They
noted his decreased visual acuity was most likely secondary to
advanced cataract. They recommended starting moxifloxacin drops
QID and erythromycin ointment BID to the L eye, and close follow
up with a local eye provider ___ 1 week of discharge.
The patient was admitted to the Acute Care Surgery Service for
monitoring and conservative management of his rib fracture. His
pain was well controlled with scheduled Tylenol and PRN
oxycodone. Overnight, patient was in atrial fibrillation with
brief asymptomatic runs of bradycardia to the ___ while asleep,
lasting a few seconds and self-resolving. Internal Medicine was
consulted for the AFib with bradycardia, and after evaluating
the patient, they reported the runs of bradycardia while asleep
were not concerning. Given the possible risks of
anti-coagulation with the patient's age and recent history of
trauma, they recommended the patient follow up with an
outpatient Internal Medicine provider ___ 2 weeks of
discharge to discuss his atrial fibrillation and possible
long-term anti-coagulation.
Tertiary survey on HD1 revealed no additional injuries, and the
patient was cleared by ___ for discharge back to his ___
facility. He was progressing well post-trauma and no longer had
acute inpatient needs, and was discharged to his ___
facility. At the time of discharge, the patient was doing well,
afebrile and hemodynamically stable. The patient was tolerating
a regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO TID Duration: 7 Days
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
2. Ciprofloxacin 0.3% Ophth Soln 1 DROP LEFT EYE QID
RX *ciprofloxacin HCl 0.3 % 1 drop to L eye four times a day
Refills:*0
3. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE BID
RX *erythromycin 5 mg/gram (0.5 %) Ointment L eye twice a day
Refills:*0
4. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate Duration: 7 Days
Do not exceed 3200 mg/day
RX *ibuprofen 800 mg 1 tab by mouth every eight (8) hours Disp
#*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left 7th rib fracture
Periorbital edema
Left eye subconjunctival hemorrhage
Left eye corneal abrasion
Atrial fibrillation
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
trauma, with injuries including a left 7th rib fracture,
periorbital edema, left eye subconjunctival hemorrhage, and
small left eye corneal abrasion. You were managed conservatively
with pain control for your rib fractures. Your left eye was
evaluated by Ophthalmology, and they recommended starting
moxifloxacin eye drops and erythromycin drops to the left eye,
with close follow up with a local eye provider ___ 1 week. You
were also seen by the Internal Medicine team for atrial
fibrillation, and they recommended following up with Internal
Medicine as an outpatient to discuss possible treatment with
blood thinners. You are recovering well and are now ready for
discharge. Please follow the instructions below to continue your
recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please 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.
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.
Rib Fractures:
* Your injury caused a left 7th rib fracture 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).
Left eye subconjunctival hemorrhage and corneal abrasion
* Follow up with local eye provider ___ 1 week
* NO contact lens use until follow-up
Atrial fibrillation
* Follow up with an outpatient Internal Medicine doctor within 2
weeks of discharge for long-term treatment of atrial
fibrillation
Warm regards, Your ___ Surgery Team
Followup Instructions:
___
|
19764344-DS-11
| 19,764,344 | 23,122,898 |
DS
| 11 |
2145-09-30 00:00:00
|
2145-09-30 14:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dysphagia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of esophageal cancer s/p neoadjuvant
chemoradiation and s/p esophagectomy ___ - ___ and
___ presents with inability to swallow PO food or
liquid. He states that starting yesterday, he started to get
symptoms of a URI and had more phlegm than usual. At the same
time, he started having difficulty swallowing, sometimes feeling
the food go all the way down to his stomach but then vomited it
up, and sometimes it got stuck in his upper chest and he brought
it back up within 5 minutes. He denies any nausea, abdominal
pain, trouble with his bowels. Up until 2 days ago, he had no
limitations to his diet and he was able to eat anything without
symptoms of dysphagia or vomiting.
Of now, his final follow-up CT torso was ___ and showed no
evidence of disease. He no longer requires follow-up CT scans
for
esophageal cancer. In addition, he had an EGD in ___ to obtain
an FNA of a suspicious lymph node (which was negative). At that
time, they incidentally found an anastomotic stricture that
required balloon dilation in order to pass the EUS probe. He was
not symptomatic at the time, and also denies any symptoms since
then. He has not required any further dilations since ___. He
reports that his weight has been stable and has not had
unintentional weight loss.
Past Medical History:
PMH: esophageal cancer s/p neoadjuvant chemoradiation, HTN,
prostate cancer s/p prostatectomy, vitamin D deficiency, gout
PSH: esophagectomy (___), prostatectomy (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
___ ___ Temp: 98.6 PO BP: 129/81 HR: 73 RR: 18 O2 sat: 93%
O2 delivery: Ra
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, No JVD
PULM: normal excursion, no respiratory distress
ABD: soft, NT, ND, no mass, no hernia
EXT: WWP
Pertinent Results:
___ upper endoscopy
Esophageal previous surgery.
Normal mucosa normal stomach.
Mucosa in the whole exam
.
Recommendations: No findings to explain regurgitation.
Follow-up in addition per inpatient GI team
___ CT abdomen pelvis with contrast
1 no abdominopelvic lymphadenopathy or metastasis
2 mild colonic diverticulosis
3 please refer to the separate chest CT dictation regarding
intrathoracic findings
___ CT chest with contrast
Interval development of 3 pulmonary nodules too small to
characterize. Short-term follow-up in 3 months is recommended
for assessment of the stability.
Unremarkable appearance of the new esophagus.
Please review CT abdomen pelvis and the corresponding report for
assessment of intra-abdominal pathology
Brief Hospital Course:
Mr. ___ was admitted to ___ the setting of dysphagia of
liquids vomiting with a past medical history of esophageal
cancer status post esophagectomy to concern for recurrence or
other obstructive pathology. He underwent an upper endoscopy on
___ which was essentially normal. On ___ underwent
a CT of his chest, abdomen, and pelvis which similarly
demonstrated no obvious obstructive pathology or evidence of
recurrent/metastatic disease. Of note the CT of his chest
demonstrated incidentally discovered pulmonary nodules which
will be left patient with a scan. His diet was advanced,
initially performed on ___, without nausea/vomiting,
and then on ___. Mechanical diet which he similarly
tolerated well without evidence of dysphagia. Outpatient
follow-up with ENT was arranged for further evaluation of his
dysphagia due to a suspected oropharyngeal component. He was
discharged home, tolerating a soft mechanical diet, ambulating,
hemodynamically stable without evidence of infection.
Medications on Admission:
HCTZ 25 QD, lisinopril 20 QD, atenolol 25 QD, sertraline 50
QAM, vitamin D3 (unknown dose)
Discharge Medications:
HCTZ 25 QD, lisinopril 20 QD, atenolol 25 QD, sertraline 50
QAM, vitamin D3 (unknown dose)
Discharge Disposition:
Home
Discharge Diagnosis:
Dysphagia
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 here at ___
___. You were admitted to our hospital for
trouble swallowing. A swallow study was normal and a CT of your
chest and abdomen demonstrated no cause for your difficulty
swallowing. We have arranged follow up with ENT as an
outpatient. You have recovered and are now ready to be
discharged to home. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
MEDICATIONS:
- Take all the medicines you were on 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.
Dear Mr. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital for
trouble swallowing. A swallow study was normal and a CT of your
chest and abdomen demonstrated no cause for your difficulty
swallowing. We have arranged follow up with ENT as an
outpatient. You have recovered and are now ready to be
discharged to home. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
MEDICATIONS:
- Take all the medicines you were on 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:
___
|
19764389-DS-13
| 19,764,389 | 21,861,444 |
DS
| 13 |
2202-01-19 00:00:00
|
2202-01-19 15:16:00
|
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:
right ankle ORIF on ___ ___
___ of Present Illness:
___ s/p slip on ice and fall, p/w R ankle pain. Denies HS/LOC.
This is her only complaint.
Past Medical History:
HYPERTENSION
DIABETES TYPE II
HYPERCHOLESTEROLEMIA
THYROID NODULE
LOW BACK PAIN
DEPRESSION
Social History:
___
Family History:
NC
Physical Exam:
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Right lower extremity in a splint. Fires ___
Right lower extremity SILT superficial peroneal, deep peroneal
and tibial distributions
Right lower extremity dorsalis pedis pulse 2+ with distal digits
warm and well perfused
Pertinent Results:
___ 05:15PM URINE HOURS-RANDOM
___ 05:15PM URINE HOURS-RANDOM
___ 05:15PM URINE UHOLD-HOLD
___ 05:15PM URINE GR HOLD-HOLD
___ 05:15PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 04:40PM GLUCOSE-148* UREA N-8 CREAT-0.7 SODIUM-133
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-26 ANION GAP-15
___ 04:40PM estGFR-Using this
___ 04:40PM WBC-9.5 RBC-4.08* HGB-11.7* HCT-33.9* MCV-83
MCH-28.7 MCHC-34.5 RDW-13.8
___ 04:40PM NEUTS-77.2* LYMPHS-17.8* MONOS-4.2 EOS-0.6
BASOS-0.1
___ 04:40PM ___ PTT-30.2 ___
___ 04:40PM ___ PTT-30.2 ___
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 trimalleolar ankle fracture 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 of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
TDWB RLE in a plaster splint (to remain on until follow up), and
will be discharged on Lovenox x 2 weeks for DVT prophylaxis. The
patient will follow up in two weeks 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:
ALCOHOL SWABS [ALCOHOL PADS] - Alcohol Pads. use as directed
daily
BLOOD SUGAR DIAGNOSTIC [ONETOUCH ULTRA TEST] - OneTouch Ultra
Test strips. use as directed daily
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 WITH VITAMIN D3] -
Calcium 600 with Vitamin D3 600 mg(1,500 mg)-400 unit chewable
tablet. 1 tablet(s) by mouth twice a day
PSYLLIUM [REGULOID, SUGAR FREE] - Reguloid, Sugar Free oral
powder. 1 tablessoonful Powder(s) by mouth once a day
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Atenolol 25 mg PO BID
3. Calcium Carbonate 500 mg PO TID
4. ClonazePAM 0.5 mg PO QHS:PRN insomnia
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC QD DVT prevention
Start: Today - ___, First Dose: Next Routine Administration
Time
7. MetFORMIN XR (Glucophage XR) 500 mg PO BID
8. Nortriptyline 20 mg PO QHS
9. Psyllium 1 PKT PO DAILY
10. Rosuvastatin Calcium 10 mg PO QPM
11. Senna 8.6 mg PO BID
12. Vitamin D 400 UNIT PO DAILY
13. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4-6H Disp #*60
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right trimalleolar ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Instructions After Orthopedic 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.
Medicines
- Resume taking your home medications unless specifically
instructed to stop by your surgeon. Please talk to your primary
care doctor within the next ___ weeks regarding this
hospitalization and any changes to your home medications that
may be necessary.
- Do not drink alcohol, drive, or operate machinery while you
are taking narcotic pain relievers (oxycodone/dilaudid).
- As your pain lessens, decrease the amount of narcotic pain
relievers you are taking. Instead, take acetaminophen (also
called tylenol). Follow all instructions on the medication
bottle and never take more than 4,000mg of tylenol in a single
day.
- If you need medication refills, call your surgeon's office
3-to-4 days before you need the refill. Your prescriptions will
be mailed to your home.
- Please take lovenox injections for 2 weeks to help prevent the
formation of blood clots.
Constipation
- Both surgery and narcotic pain relievers can cause
constipation. Please follow the advice below to help prevent
constipation.
- Drink 8 glasses of water and/or other fluids like juice, tea,
and broth to stay well hydrated.
- Eat foods that are high in fiber like fruits and vegetables.
- Please take a stool softener like docusate (also called
colace) to help prevent constipation while you are taking
narcotic pain relievers.
- You may also take a laxative such as senna (also called
Senokot) to help promote regular bowel movements.
- You can buy senna or colace over the counter. Stop taking them
if your bowel movements become loose. If your bowel movements
continue to stay loose after stopping these medications, please
call your doctor.
Incision
- Please return to the emergency department or notify your
surgeon if you experience severe pain, increased swelling,
decreased sensation, difficulty with movement, redness or
drainage at the incision site.
- You should wear your splint and ace wrap on your right leg at
all times. Do not get this wet. Cover it with a trash bag when
bathing so as not to get it wet.
- No baths or swimming for at least 4 weeks after surgery.
- Your staples/sutures will be taken out at your 2-week follow
up appointment. No dressing is needed if your wound is
non-draining.
- You may put an ice pack on your surgical site, but do not put
the ice pack directly on your skin (place a towel between your
skin and the ice pack), and do not leave it in place for more
than 20 minutes at a time.
Activity
- Your weight-bearing restrictions are: touch down weight
bearing in the right lower extremity.
- You should wear your splint at all times. You should cover
this with a waterproof cover when bathing
Physical Therapy:
TDWB in RLE. ROMAT at R knee and hip
Treatments Frequency:
Right leg in splint at all times. Splint and sutures to be
removed upon 2 week follow up
Followup Instructions:
___
|
19764408-DS-44
| 19,764,408 | 26,701,041 |
DS
| 44 |
2131-06-04 00:00:00
|
2131-06-04 15:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Depakote / Keppra / Paxil / Sulfacetamide / Zoloft / Bactrim /
Fentanyl / Morphine
Attending: ___.
Chief Complaint:
abdominal pain, vomiting, ? chronic pancreatitis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with DM2, chronic pancreatitis, bipolar d/o,
HTN, DVT/PE, multiple prior abd surgeries, h/o SBO, presenting
to ED today with multiple complaints including abdominal pain,
nausea, bilious-nonbloody vomiting x 4 days. He reports that on
___, he had acute onset of epigastric pain unlike any pain he
has had before. He also reports that he had a black bowel
movement on ___. Over the last few days, he has had worsening
sharp, epigastric pain without radiation. He does note that he
has been coughing but he describes "coughing up bilious stuff".
He does endorse some shortness of breath. He has not had a bowel
movement since ___. + passing gas. He reports sweats,
subjective fevers, chills all of which started on ___. He
also notes that his blood sugars have been running low (~30 two
days ago) despite no medication for diabetes. He notes that he
is undergoing work-up at ___ for hypoglycemia. He contacted
his gastroenterologist today who referred him into the emergency
department.
ED Course
Initial Vitals/Trigger: 98.2 ___ 16 100%, triggered upon
arrival for tachycardia, EKG: ST @ 104, NA, NI. guaiac +, trace,
no melena, dilaudid, zofran, cta chest, abdomen - negative for
acute process. The pt received:
3L NS, hydromorphone 1mg x 3, ondansetron, ASA, Magnesium
Currently, he reports ongoing abdominal pain; however, he is
very hungry and just ordered a hamburger and salad (prior to
diet order placed).
ROS: + superficial headache related to staple in his head, +
tingling, decreased sensation in left hand, left foot. no vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria. All other ROS negative.
Past Medical History:
Chronic pancreatitis, Diabetes Type II, PTSD, Bipolar
disorder with dissociative episodes, History of alcohol
abuse(sober since ___, Hypertension, Seizure disorder, LUE
DVT, PE, currently off coumadin for one year, Chronic low back
pain, Hyperlipidemia, hx of electrocution, Stabbing x multiple
times, h/o apnea on depakote requiring intubation, GERD
ERCP for pancreatitis ___ and ___, Puestow procedure with
Roux-en-Y formation ___, cholecystectomy, appendectomy,
open hernia repair with mesh ___
Social History:
___
Family History:
Mother with HTN and DM.
Father, Brother with DM.
Physical Exam:
VS: 96.8 152/90 102 20 100% RA ___ 146
GENERAL: Well-appearing man in NAD, slightly uncomfortable, poor
historian.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: Reg S1, S2, no MRG.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Abd scar. Soft, +BS, diffusely tender. + voluntary
guarding
EXTREMITIES: dry skin, no c/c/e, 1+ peripheral pulses.
SKIN: No rashes or lesions except for dry skin
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ in RLE, ___ in other extremities, sensation to light touch
decreased in R foot, R hand (lateral 3 fingers), cerebellar exam
intact.
Pertinent Results:
___ 10:30AM WBC-13.5*# RBC-5.09 HGB-15.0 HCT-47.7 MCV-94
MCH-29.5 MCHC-31.5 RDW-16.8*
___ 10:30AM NEUTS-70.6* ___ MONOS-6.2 EOS-0.4
BASOS-0.9
___ 10:30AM PLT COUNT-519*
___ 10:30AM ___ PTT-39.5* ___
___ 10:30AM GLUCOSE-141* UREA N-5* CREAT-1.2 SODIUM-139
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16
___ 10:30AM ALT(SGPT)-18 AST(SGOT)-21 ALK PHOS-78 TOT
BILI-0.3
___ 10:30AM LIPASE-8
___ 10:30AM ALBUMIN-4.9 CALCIUM-10.1 PHOSPHATE-3.0
MAGNESIUM-1.7
EKG: sinus tach, nml axis, no ischemic changes
CT TORSO:
IMPRESSION:
1. No evidence for pulmonary emboli or other acute process.
2. Coronary artery calcifications.
3. No evidence for bowel obstruction.
4. Findings consistent with chronic pancreatitis, including
widespread
pancreatic calcifications, with stable findings status post
Puestow with
Roux-en-Y.
CT HEAD:
FINDINGS: There is no evidence of intracranial hemorrhage,
edema, masses, or
mass effect. The gray-white matter differentiation is well
preserved. The
ventricles and sulci are mildly prominent, consistent with mild
involutional
changes. The basal cisterns are normal. Imaged paranasal sinuses
and mastoid
air cells are clear. The orbits are unremarkable.
IMPRESSION: No acute intracranial pathology.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ yo M with DM2, chronic pancreatitis,
bipolar d/o, HTN, DVT/PE, multiple prior abd surgeries, h/o SBO,
presenting to ED today with multiple complaints including
abdominal pain, nausea, bilious-nonbloody vomiting x 4 days.
1. Abdominal pain/chronic pancreatitis: His symptoms are most
consistent with chronic pancreatitis without elevation of
pancreatic enzymes; however, given h/o black stool and guaiac +
in ED, need to consider possibility of GI bleeding as well. He
is passing gas but could be early SBO as well. CT scan was
reassuring. He was given supportive care with pain and IVF
control. With improvement. He was given 2 days worth of
zofran/dilaudid and instructed to call his PCP on ___.
2. Acute renal failure: baseline creat 0.8. likely pre-renal.
Resolved with IVF
3. R sided weakness, decreased sensation: He report that this is
a new finding that he has never experienced in the past. He also
notes that his gait has been abnormal recently. ? possibly
related to peripheral neuropathy but atypical to be one-sided.
CT Head was negative.
4. DM2, controlled: He reports work-up for hypoglycemia ongoing
? related to poor po intake with low glycogen stores. Access to
___ notes not working through OMR. Currently glucose 146.
He was kept off insulin without any issues.
- ___ follow up
4. Bipolar disorder/PTSD: continued SSRI, lorazepam prn,
amitryptilline qhs
5. HTN: held ACEI in the setting of renal failure
Medications on Admission:
MEDICATIONS:
1. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed
Release(E.C.) PO three times a day: with meals
.
10. Medications Held
Please hold Metformin 500mg BID and Glargine 5 units at bedtime
UNTIL your blood sugars improve with food.
11. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every ___ hours
as needed for pain: avoid with alcohol or driving.
Disp:*30 Tablet(s)* Refills:*0*
12. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day: while taking opiates.
Disp:*30 packets* Refills:*1*
Discharge Medications:
1. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. lisinopril 10 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 BID (2 times a day).
7. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
9. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain fever.
10. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed
Release(E.C.) PO three times a day: with meals.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
13. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*10 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, epigastric
Acute on chronic pancreatitis
Type 2 diabetes mellitus
Bipolar/ PTSD
h/o DVT/PE
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. Blood work and CT scan
was unremarkable. The likely cause of your pain was related to
your chronic pancreatitis. With supportive care your symptoms
improved.
Please take all medications as prescribed and keep all follow up
appointments.
You were given a few pain and nausea pills to get through the
weekend. Please call your PCP on ___ for a follow up
appointment. As discussed, do NOT use your narcotic medication
with alcohol or driving as this can cause sedation and serious
injury.
Followup Instructions:
___
|
19764408-DS-45
| 19,764,408 | 24,752,931 |
DS
| 45 |
2131-07-16 00:00:00
|
2131-07-19 13:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Depakote / Keppra / Paxil / Sulfacetamide / Zoloft / Bactrim /
Fentanyl / Morphine
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old man with a history of chronic pancreatitis and
esophagitis who presents with abdominal pain. He underwent
EGD/EUS ___ which showed Grade C esophagitis in the
gastroesophageal junction, compatible with reflux esophagitis,
Erythema and petechiae in the antrum, and pancreatic parenchymal
changes compatible with chronic pancreatitis. He also received a
celiac plexus block at the time. He presents with worsening LLQ
sharp, constant abdominal pain radiating to the back improved
with dilaudid and not made worse by food or bowel movement. The
pain began 4 days ago with gradual onset. He reports pain is
similar to chronic pancreatitis pain but more severe. He has
also had nausea, and vomiting over the past week and is not able
to tolerate oral intake.
.
In the ED initial vitals were: 100.2, ___, 18, 100% RA.
Labs showed HCT 45.4, WBC 7.6, Cr 1.2 Lip: 18, ALT: 17 AP: 58
Tbili: 0.4 Alb: 4.6 AST: 41. He had a CT abdomen with showed
stable chronic pancreatitis but no findings of acute
pancreatitis or other acute findings. He vomited once. He was
given 1L NS, dilaudid 1mg IV x 3, and zofran. CXR was
unremarkable, Vitals prior to transfer were: 97.3, 100, 128/76,
18, 99% RA.
.
On arrival to the floor, he complained of ___ abdominal pain
though he appeared comfortable. He denies recent uncooked foods,
denies antibiotics.
Review of systems:
(+) Per HPI plus subjective fever and reported 20lb weight loss
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache. Denies shortness of breath, cough,
dyspnea or wheezing. Denies chest pain, chest pressure,
palpitations. Denies constipation. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
- Chronic pancreatitis
- GERD
- Diabetes Type II
- Hypertension
- Hyperlipidemia
- PTSD
- Bipolar disorder with dissociative episodes
- History of alcohol abuse (sober since ___
- Seizure disorder
- LUE DVT
- Pulmonary Embolism(currently off coumadin for one year)
- Chronic low back pain
- Hx of electrocution
- Multiple stabbings
- h/o apnea on depakote requiring intubation
- s/p ERCP for pancreatitis ___ and ___
- s/p Puestow procedure with Roux-en-Y formation ___
- s/p cholecystectomy
- s/p appendectomy
- s/p open hernia repair with mesh ___
Social History:
___
Family History:
Mother with seizure disorder, HTN and DM. Father, Brother with
DM.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: T:98.4 BP:152/92 HR:104 RR:18 02 sat:99RA
GENERAL: Middle aged male with strange affect, in NAD, awake and
alert
HEENT: EOMI, PERRLA, anicteric sclera, pink conjunctiva, mucous
___
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: CTAB, no rales wheezes or rhonchi,
ABDOMEN: +BS, voluntary guarding diffusely ___. Diffusely
tender on distracted exam. No rebound.
EXT: no edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII symmetric and intact tested and intact,
strength ___ throughout,
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE:
GENERAL - patient comfortable and in NAD,
LUNGS - no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - Bowel sounds present, NO guarding/rebound, slightly
tender in LLQ (wrapping around flank)
EXTREMITIES - palpable peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, warm + well perfused
Pertinent Results:
ADMISSION LABS:
___ 02:56PM BLOOD WBC-7.6 RBC-4.95 Hgb-15.1 Hct-45.4 MCV-92
MCH-30.5 MCHC-33.3 RDW-16.8* Plt ___
___ 02:56PM BLOOD Neuts-58.9 ___ Monos-7.1 Eos-0.4
Baso-1.2
___ 03:25PM BLOOD ___ PTT-36.9* ___
___ 07:45AM BLOOD Glucose-106* UreaN-4* Creat-0.9 Na-136
K-4.1 Cl-101 HCO3-20* AnGap-19
___ 02:56PM BLOOD ALT-17 AST-41* AlkPhos-58 TotBili-0.4
___ 02:56PM BLOOD Lipase-18
___ 07:45AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.5*
___ 02:58PM BLOOD Glucose-168* Lactate-1.8 Na-141 K-4.9
Cl-101 calHCO3-23
DISCHARGE LABS:
___ 08:10AM BLOOD WBC-5.8 RBC-4.38* Hgb-13.4* Hct-41.0
MCV-94 MCH-30.7 MCHC-32.8 RDW-15.8* Plt ___
___ 08:10AM BLOOD Glucose-137* UreaN-2* Creat-0.8 Na-134
K-4.2 Cl-98 HCO3-23 AnGap-17
___ 07:45AM BLOOD ALT-23 AST-26 AlkPhos-72 TotBili-0.6
___ 08:10AM BLOOD Calcium-9.5 Phos-4.1 Mg-1.4*
OTHER CHEMISTRY:
___ 08:45AM BLOOD IGG SUBCLASSES 1,2,3,4-PND
URINE:
___ 02:18AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:18AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 02:18AM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
MICROBIOLOGY:
___ BLOOD CULTURE Blood Culture, Routine-FINAL
- No growth
___ BLOOD CULTURE Blood Culture, Routine-FINAL
- No growth
STUDIES:
___BD & PELVIS WITH CO
1. No acute intra-abdominal process to explain patient's
symptoms.
2. Stable findings of chronic pancreatitis with no evidence of
peripancreatic fluid collection or acute inflammatory changes.
3. Stable post-operative changes from cholecystectomy, ventral
hernia repair and Puestow procedure.
4. Hepatic steatosis.
___ Radiology CHEST (PA & LAT)
No acute cardiopulmonary process
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
A ___ Year old male with PMH significant for GERD, chronic
pancreatitis s/p puestow proceedure and recent celiac plexis
ablation who presents with abdominal pain and inability to
tolerate oral intake, consistent with flare of chronic
pancreatitis.
# Chronic pancreatitis: Abdominal symptoms were consistent with
prior flares of his chronic pancreatitis. Abdominal and pelvis
CT show no new pathology. He was made NPO and started on
dilaudid PCA and liberal IVF's. He had high narcotic
requirement, ultimately receiving up to 0.7mg of dilaudid/hour
basal rate plus 0.24mg PCA bolus with 15 minute lockout. Nausea
was controlled with IV zofran. His diet was slowly advanced and
by day prior to discharge, his pain and abdominal exam was
signficantly improved. He was transitioned to oral dilaudid and
was tolerating a full diet by day of discharge. GI and chronic
pain service were consulted for further guidance in long term
management of his chronic pancreatitis. Given he has already
undergone pleustow and celiac plexus block procedures,
additional interventions were deemed unlikely. Also, given his
signficant risk for abuse of long term narcotic use, he was
discharged on a week supply of oral dilaudid without long term
narcotics. Chronic pain service recommended consideration of
___ clinic at ___ at his primary care
physcician's discretion.
# Diarrhea: patient reports non-bloody non-bileous vomit in
association with abdominal pain and diarrhea. Diarrhea resolved
during hospital stay and he had no antibiotic exposure or
undercooked foods. He was continued on pancraetic enzyme
replacement.
# GERD: EGD ___ showed grade c esophagitis consistent with
refulx esophagitis. Continued Omeprazole 40mg BID. Discontinued
ranitidine on discharge.
# Diabetes Type II Placed on insulin sliding scale while in
hospital.
# Hypertension: Continued lisinopril 10mg daily.
# Hyperlipidemia: Continued simvastatin 20mg daily.
# Bipolar disorder: Continued amitriptyline 25 mg. Decreased pm
trazodone dose to 100mg as needed for insomnia.
MEDICATION CHANGES:
1. Start dilaudid as needed to manage pain for the next 7 days.
You should discuss chronic pain management with your PCP at your
appointment on ___.
2. Take miralax and senna as needed to maintain normal bowel
habits while on dilaudid, which can lead to constipation.
3. Stop ranitidine (Zantac)
4. Decrease trazodone to 100mg at night as needed for sleep
TRANSITIONAL ISSUES:
- ___ IgG Subclass to eval for AI pancreatitis
- Consider suboxone pain management at ___ per chronic pain
service recommendations
Medications on Admission:
-- Pancreaze 16,800-40,000-70,000 unit Cap 3 Caps TID w/ meals
-- Aspirin 81 mg Daily
-- lorazepam 1 mg TID
-- Lisinopril 10 mg Daily
-- Simvastatin 20 mg Tab
-- omeprazole 40 mg BID
-- Amitriptyline 25 mg QHS
-- Docusate Sodium 100 mg BID PRN
-- Trazodone 300 mg Daily (per patient, unable to confirm)
-- ranitidine 150 mg Daily
Discharge Medications:
1. Pancreaze 16,800-40,000 -70,000 unit Capsule, Delayed
Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO
three times a day: take with meals.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO three times a
day: do not drive, drink alcohol, or operate heavy machinery
with this medication.
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: ___ Tablets PO BID (2 times a day)
as needed for constipation.
Disp:*45 Tablet(s)* Refills:*0*
10. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
Disp:*7 day supply* Refills:*0*
12. hydromorphone 2 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for Pain: never drive, drink alcohol, or operate
heavy machienry with this medication.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Acute pancreatitis
2. Esophagitis
SECONDARY DIAGNOSIS:
- Chronic pancreatitis
- GERD
- Diabetes Type II
- Hypertension
- Hyperlipidemia
- PTSD
- Bipolar disorder with dissociative episodes
- Seizure disorder
- LUE DVT
- Pulmonary Embolism(currently off coumadin for one year)
- Chronic low back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital on ___ with pancreatitis.
You were given bowel rest, intravenous fluids, and pain
medications and you improved to the point that you were able to
tolerate a diet and take oral pain medications.
The following changes have been made to your medications:
1. Start dilaudid as needed to manage pain for the next 7 days.
You should discuss chronic pain management with your PCP at your
appointment on ___.
2. Take miralax and senna as needed to maintain normal bowel
habits while on dilaudid, which can lead to constipation.
3. Stop ranitidine (Zantac)
4. Decrease trazodone to 100mg at night as needed for sleep
Followup Instructions:
___
|
19764408-DS-47
| 19,764,408 | 21,958,137 |
DS
| 47 |
2131-08-03 00:00:00
|
2131-08-03 20:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Depakote / Keppra / Paxil / Sulfacetamide / Zoloft / Bactrim /
Fentanyl / Morphine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a significant PMH of
chronic pancreatitis (s/p pleustow procedure and celiac plexus
block), bipolar disorder and substance abuse with excessive
recent inpatient admissions for pain control related to his
chronic pancreatis who presents with worsening abdominal pain.
Patient was recently discharged with similar episodes on ___
and ___. He was provided 24 2mg dilaudid tabs on discharge. He
says he was feeling better, with manageable pain for several
days. He saw his PCP ___ ___ who provided an additional 3 days
of dilaudid, and efforts to enroll in a ___ clinic were
unsuccessful. He notes his pain again became unbearable about 4
days ago, when he passed out while urinating, saying 'the pain
caused me to pass out'. He reports LOC x5 minutes with
+headstrike to his occiput. He has had no neurologic deficits
since, but notes dizziness upon standing and persistent
headache. During this time he has also developed nausea,
vomiting (up to 6 times per day, nonbloody), productive cough,
?fevers, and sore throat. He describes his abdominal pain as if
someone is 'tearing [him] open' from his epigastrum radiating
around LUQ and LUQ and into his left flank. He reports normal
bowel movement this morning. Due to worsening pain and inability
to tolerate po, he presented to the ED today.
In the ED, initial VS at 16:28 were pain 10, T 97.9, HR 138, BP
150/106, RR 16, O2 98%RA. He triggered for HR >130 and EKG
showed sinus tachycardia. HR responded to 2L NS and he was given
1mg IV dilaudidx2 and 4mg IV zofranx2. Initial labs were notable
for HCO3 of 20 and AG of 18. Lactate was 2.3. His pain
persisted and he was admitted to medicine for pain control.
Prior to transfer he was given 10mg IV reglan and vitals were
T98.2 HR106 RR18 BP125/81 O2100%RA.
Currently, patient is very uncomfortable squirming in bed. He is
tearful about his persistent pain. He is also very upset he
cannot find his clothes. After speaking to his wife on the phone
following exam, she notes that she is concerned that Mr. ___
is addicted to dilaudid and is not taking some of his
medications in order to become sick and be admitted for pain
control. She says she did not take his temperature and does not
know of any fevers. She says he 'does a lot of talking'. She is
requesting psychiatric evaluation for the patient given his
recurrent admissions for pain control. Mr. ___ notably has
22 abdominal CT's and 10 head CT's since ___. He has had 3
EGD's since ___.
ROS: Endoreses: fever (patient reports his wife measured at
home), headache, sore throat, epistaxis, cough, SOB, abdominal
pain, nausea, and vomiting. Otherwise 10 point review of systems
is negative.
Past Medical History:
- Chronic pancreatitis
- GERD
- Diabetes
- Hypertension
- Hyperlipidemia
- PTSD
- Bipolar disorder with dissociative episodes
- History of alcohol abuse
- History of substance abuse
- LUE DVT
- Pulmonary Embolism
- Chronic low back pain
- Hx of electrocution
- Multiple stabbings
- h/o apnea on depakote requiring intubation
- s/p ERCP for pancreatitis ___ and ___
- s/p Puestow procedure with Roux-en-Y formation ___
- s/p cholecystectomy
- s/p appendectomy
- s/p open hernia repair with mesh ___
Social History:
___
Family History:
Mother with seizure disorder, HTN and DM. Father, Brother with
DM.
Physical Exam:
ON ADMISSION
VS - Temp 98.30 F, 148/99 BP , HR 96, R 18, O2-sat 100% RA
GENERAL - SOmewhat dishelved man, appears very uncomofortable,
squirming in bed, tearful
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no LAD
LUNGS - Nonlabored, CTAB with good air movement
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, nondistended, prominent scarring c/w prior
peustow procedure, intermittently voluntary guarding with
tenderness to palpation throughout, however most pronounced over
epigastrum and LUQ. Left ribs also TTP over midaxillary line.
Unable to appreciate HSM. No involuntary guarding or rebound
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, cerebellar
exam intact, gait deferred
On discharge:
VS - 98 128/90 HR ___ 100%RA
GENERAL - NAD, speaking full sentences
HEENT - MMM
LUNGS - Nonlabored, CTAB with good air movement
HEART - RRR, no MRG
ABDOMEN - No peritoneal signs, guarding or rebound tenderness.
Mild pain with palpation diffusely. Non-distended
SKIN - no rashes or lesions
NEURO - awake, A&Ox3
Pertinent Results:
ADMISSION LABS:
___ 04:40PM BLOOD WBC-7.8 RBC-4.85 Hgb-14.4 Hct-43.2
MCV-89# MCH-29.7 MCHC-33.4 RDW-16.4* Plt ___
___ 04:40PM BLOOD ___ PTT-37.0* ___
___ 04:40PM BLOOD Glucose-176* UreaN-4* Creat-1.2 Na-133
K-4.4 Cl-95* HCO3-20* AnGap-22*
___ 04:40PM BLOOD ALT-17 AST-27 AlkPhos-68 TotBili-0.2
___ 04:40PM BLOOD Albumin-4.9 Calcium-9.8 Phos-3.7 Mg-1.7
___ 06:00AM BLOOD Osmolal-316*
___ 06:00AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
URINE:
___ 02:44PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
CXR: Heart size is within normal limits. Lungs are clear
without focal
consolidation, pleural effusions, or signs of pulmonary edema.
Bony
structures are intact.
Discharge:
___ 06:00AM BLOOD WBC-7.4 RBC-4.10* Hgb-12.2* Hct-37.6*
MCV-92 MCH-29.8 MCHC-32.5 RDW-16.1* Plt ___
___ 09:22AM BLOOD Glucose-103* UreaN-2* Creat-0.9 Na-133
K-4.1 Cl-94* HCO3-19* AnGap-24*
___ 09:22AM BLOOD Calcium-9.6 Phos-4.1 Mg-1.5*
___ 06:57AM BLOOD Lactate-1.2
Brief Hospital Course:
SUMMARY: Mr. ___ is a ___ year old man with chronic
pancreatitis (s/p pleustow procedure and celiac plexus block),
and narcotic abuse with excessive recent inpatient admissions
for pain control related to his chronic pancreatitis admitted
for abdominal pain.
# Abdominal pain: His pain was consistent with prior episodes
of his chronic pancreatitis, but also may be related to narcotic
withdrawal and significant somatization versus drug-seeking
behavior. Given his exorbitant number of CT scans in the past,
clinical consistency, and relatively benign blood tests, further
diagnostic testing was not pursued. He was managed with IVF and
bowel rest, and improved after ___ days. Psychiatry was
consulted and felt narcotic seeking behavior and somatization
were likely contributing, and they recommended minimizing opiate
use as much as possible. He was given a short prescription for
dilaudid to help prevent withdrawal and rebound pain as a bridge
to PCP ___, and with the intent to have the patient seen
at suboxone and ___ clinic for management (the patient has
previously been evaluated at a different ___ clinic which
did not provide services on an outpatient basis). Management of
this patient's pain is limited, as he has been treated with
narcotics in addition to nerve blocks. The best option is to
wean off narcotics such as dilaudid, however this is very
difficult to accomplish on an inpatient basis given the
chronicity of use.
*****PLEASE NOTE: THIS PATIENT HAS BEEN ADMITTED MANY TIMES
THIS YEAR (___) FOR THE SAME COMPLAINT. A DISCUSSION WAS HAD
WITH MULTIPLE PROVIDERS, AND EVERYONE FEELS HE WOULD MOST
BENEFIT FROM MANAGEMENT WITH A CHRONIC PAIN SERVICE, THOUGH THIS
IS VERY LIMITED BY HIS INABILITY TO BE SEEN AT ___ PAIN
SERVICE. ***IF THIS PATIENT IS SEEN IN THE EMERGENCY ROOM FOR
THE SAME COMPLAINT, WOULD STRONGLY SUGGEST CRITICAL EVALUATION
OF HIS SYMPTOMS AND WHETHER THEY WARRANT AN ADDITIONAL
ADMISSION.
***ED Social worker ___ (who suggested ED physicians
___ and ___ be involved), ___, MD,
Outpatient interventional gastroenterology, ___
2 social worker, and ___, MD were all contacted about
the potential for a multidisciplinary meeting to discuss future
emergency room visits for this patient, and to begin the
discussion on a potential "ED pathway" to help prevent multiple
readmissions. Would strongly suggest contacting the above team
on future admissions/ED visits to arrange a meeting, and invite
the patient and his wife to partake in the discussion. The
patient's wife has been noted in previous notes to feel as
though the patient often exaggerates his symptoms
*** The patient has been referred to ___ Suboxone and
___ clinic (___). He is to be contacted by the
clinic shortly after discharge. The patient has been seen by
chronic pain at ___, however has reportedly been kicked out of
the program after threatening staff members. Please note, the
patient's primary care doctor is at ___ ___.
#Gap acidosis: Noted last admission. Lacate mildly elevated but
resolved with IVF's. Tox screen was negative except for known
opiate use. HCO3 was monitored and noted to be stable.
# Cough/fever: Patient complained of cough and possible fever
prior to admission. CXR did not show evidence of infection and
he was afebrile without cough during his stay.
# Diabetes: Diet controlled. HISS while in house.
# GERD: Continued omeprazole 40mg bid. Maalox/lidocaine prn.
# HTN: Stable with pain control and continued lisinopril 20mg
daily
# Bipolar disorder/PTSD: Continued amitryptiline and prn
benzodiazepines. Evaluated by psychiatry who did not feel
strongly about the patient's diagnosis, and did not suggest
changing further medications. See above discussion regarding
somatization.
TRANSITIONAL ISSUES:
-PLEASE SEE THE ABOVE DISCUSSION REGARDING CHRONIC ABDOMINAL
PAIN, POTENTIAL NARCOTIC SEEKING BEHAVIOR, AND FREQUENT
RE-ADMISSIONS
-If patient does not ___ with the Dimmock
___ clinic as planned, would strongly suggest
referral to a different chronic pain clinic if possible.
Medications on Admission:
1. Pancreaze 16,800-40,000 -70,000 unit Capsule, Delayed
Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO
three times a day: take with meals.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for Anxiety: Do not drink or drive while taking
this medication, it may make you drowsy. Has run out.
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime). Has run out
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Not taking
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation. Not taking
10. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for Insomnia. Not taking
11. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
Constipation. Not taking
12. Zofran 4 mg Tablet Sig: ___ Tablets PO every eight (8) hours
as needed for nausea.
Disp:*15 Tablet(s)* Refills:*0*
13. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO every four
(4) hours as needed for pain for 3 days: Do not drink or drive
while taking this medication.
Disp:*24 Tablet(s)* Refills:*0*. Patient has run out.
Discharge Medications:
1. Pancreaze 16,800-40,000 -70,000 unit Capsule, Delayed
Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO
three times a day: take with meals.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for anxiety: Do not drink or operate heavy
machinery while using this medication.
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
12. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
Disp:*15 Tablet(s)* Refills:*0*
13. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic pancreatitis
Substance abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for abdominal pain. We treated
you with bowel rest, IV fluids and pain medications and you
began to feel better. It is important that you limit the amount
of narcotics that you take (like dilaudid), as this medicine is
not the best option for your pain. We have contacted a suboxone
and ___ clinic, and they will contact you next week for a
___ appointment. Please take your medications as
prescribed.
It has been a pleasure taking care of you.
Followup Instructions:
___
|
19764618-DS-13
| 19,764,618 | 28,280,924 |
DS
| 13 |
2150-01-01 00:00:00
|
2150-01-01 11:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Low Back Pain and Lower Extremity Radiculopathy
Major Surgical or Invasive Procedure:
L4-5 Left microdiscectomy on ___
History of Present Illness:
___ presents with acute on chronic lumbar back pain with left
lower extremity radiculopathy. He reports several years of
similar pain for which he has done physical therapy with
temporary relief (most recently ___, and received a steroid
injection ___ by Dr. ___ provided no relief. In fact,
symptoms progressively worsened since that time, and over the
last three days, he has been unable to ambulate, perform ADLs,
etc due to excrutiating lumbar back and left leg pain. He
reports the pain begins in the midline at his lower back,
radiates to left buttocks, down hamstrings, to the knee, and to
the dorsum of his left foot. The pattern/distribution of pain
has not changed, though there is a significant increase in
severity. He was been taking Gabapentin 400mg QHS and Oxycodone
5mg q4h prn and NSAIDS without any relief. There is no
antecedent trauma/event to explain the acute worsening in his
symptoms. He also reports some urinary hesitancy and
constipation, but no urinary or bowel incontinence. He denies
any weakness, though reports inability to ambulate is strictly
from pain. Denies saddle anesthesia but does report
hyperesthesia in left leg. No fevers, chills, sweats, or recent
unintentional weight loss.
Past Medical History:
Right ankle ORIF
Atypical chest pain
Social History:
___. Married. Two children. Lives in ___.
Ambulatory status: Community ambulator
Tobacco: denies
ETOH: occasional
Illicits: denies
Physical Exam:
Admission Physical Exam:Vitals: AFVSS
General: AAOx3, NAD
Heart: RRR peripherally
Lungs: Breathing comfortably on RA
Spine exam: TTP over midline lumbar spine as well as paraspinal
muscles.
-Motor Exam: (0=total paralysis, 1=palpable contraction 2=AROM,
not against gravity,
3=AROM against gravity, 4=AROM against gravity +some resistance,
5=AROM against full resistance)
Motor Upper Extremities:
C5 (shoulder abduction, elbow flex palm up): R ___ L ___
C6 (elbow flexion w/thumbs up, wrist ext): R ___ L ___
C7 (elbow extension, wrist flexion): R ___ L ___
C8 (finger flexion): R ___ L ___
T1 (finger abduction): R ___ L ___
Motor Lower Extremities
L2/L3 (hip flexion, hip adduction - IO): R ___ L ___
L3/L4 (knee extension - Quads): R ___ L ___
L4/L5 (ankle dorsiflexion - TA): R ___ L ___
L5 (great toe extension - ___: R ___ L ___
S1 (ankle plantarflexion - GSC): R ___ L ___
S2 (toe flexion - FHL, FDL): R ___ L ___
-Sensory: (0=absent, 1=impaired, 2= intact)
Sensory Upper Extremities
C5 (Ax): R 2 L 2
C6 (MC): R 2 L 2
C7 (Mid finger): R 2 L 2
C8 (MACN): R 2 L 2
T1 (MBCN): R 2 L 2
T2-L2 Trunk: R 2 L 2
Sensory Lower Extremities
L2 (Groin): R 2 L 2
L3 (Leg) R 2 L 2
L4 (Knee) R 2 L 2
L5 (Grt Toe): R 2 L 2
S1 (Sm toe): R 2 L 2
S2 (Post Thigh): R 2 L 2
Sensation diffusely intact, though left lower extremity
diffusely TTP (hyperesthesia)
-Deep Tendon Reflexes: (0=absent, 1=trace, 2=normal,
3=brisk, 4=non-sustained clonus, 5=sustained clonus)
C5 (Biceps) R 2 L 2
C6 (Brachioradialis) R 2 L 2
C7 (Triceps) R 2 L 2
L1 (Cremaster) - male only, deferred
L4 (patellar) R 2 L 1
S1 (achilles) R 2 L 2
Straight leg raise: significant pain with LLE straight leg
raise, worse with dorsiflexion
___: neg
Babinski: downgoing
Clonus: none
Perianal sensation: intact
Rectal tone: intact
Physical Exam-
General:Well appearing, NAD, comfortable, sitting in bed
CV:RRR
Resp:CTAB
Abd:soft,ntnd,+bs's
Extremities:wwp,2+rad/2+dp pulses
___ BLE's throughout
+SILT BLE
Pertinent Results:
___ 10:10AM BLOOD WBC-9.4# RBC-4.15* Hgb-12.7* Hct-37.2*
MCV-90 MCH-30.6 MCHC-34.1 RDW-12.1 RDWSD-39.8 Plt ___
___ 12:00PM BLOOD Glucose-92 UreaN-16 Creat-0.9 Na-139
K-4.1 Cl-103 HCO3-27 AnGap-13
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. Intravenous antibiotics were
continued for 24hrs postop per standard protocol.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. Foley was removed on POD#1. The patient was
ambulating independently with nursing. 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.
Medications on Admission:
Gabapentin
MVI
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
may be taken over the counter
2. Docusate Sodium 100 mg PO BID
please take while on pain medication
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Gabapentin 400 mg PO QHS
4. Gabapentin 200 mg PO QAM
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
please do not operate heavy machinery,drink alcohol or drive
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
multilevel disc disease
L4-L5 prominent compression of L5 nerve root
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Microdiscectomy
You have undergone the following operation: Minimally Invasive
Microdiscectomy
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:
___ 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.
Brace: You do not need a brace.
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 narcotic
prescriptions (oxycontin, oxycodone, percocet) to the 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:
___
|
19764805-DS-7
| 19,764,805 | 22,346,719 |
DS
| 7 |
2159-08-04 00:00:00
|
2159-08-04 13:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Benadryl Decongestant
Attending: ___.
Chief Complaint:
Syncope, ___
Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube exchange
PICC placement
History of Present Illness:
This is an ___, CKD (sIV) secondary to hypertension and
diabetes, TAH-BSO (___) for endometrial cancer complicated by
vesiculocutaneous fistulas s/p bilateral nephrostomy tubes
(___), Afib, NIDDM, who presents with syncopal event, weakness
and ___.
This morning, pt was transitioning from sitting to the commode
with assistance when she syncopized. Per daughter this occurs
approximately once per month, always with standing, never
without positional change. The pt denies antecedent
palpitations, dyspnea, chest pain, visual change. Family caught
patient, no head strike. Daughter notes weakness and decreased
PO Drank less fluids yesterday and none today.
She was seen by infectious disease as an outpatient on ___
for persistent pyuria. Review of the outpatient ID note reveals
that she has been having dark, smelly urine since the ___
which has been treated intermittently with a quinolone. In
___, she was seen in the ED for hematuria. In ___ she
had cloudy urine and was treated with levaquin for appx 7 days
and then switched to augmentin for 3 days when the urine came
back growing enterobacter that was resistant to levaquin.
On ___, her ID doctor started her on ___ in conjunction
with her nephrologist and urologist. A plan was made to check
labs today and have her nephrostomy tubes changed on ___
___. Has had some loose stools since this time.
At baseline, knits, jigsaw puzzles, plays with great
grandchildren. Partially dresses herself, doesn't bathe herself.
B/l AOx3.
Labs significant for Cr 4.5, significantly increased from
previously. EKG unchanged.
In the ED, initial vitals: 97.4 64 141/63 16 98% ra
Labs were significant for Cr 4.5 (baseline 2.5-2.8), UA from L
nephrostomy WBCs > 182, many bacteria, UA from R nephrostomy
WBCs 10, moderate bacteria. Platelets 119.
She was started on NS at 125cc/hr. Cefepime was given. Vitals
prior to transfer:98.6 66 127/80 20 94% RA
Currently, the pt is without acute complaint. Earlier today she
was nauseous, no vomiting. No taste changes or itchiness.
Past Medical History:
1. Diabetes mellitus type 2 with diabetic nephropathy
2. Anemia
3. Depression
4. Hypertension
5. Urinary incontinence
6. Low back pain
7. Osteoarthritis
8. Endometrial Cancer- s/p Total abdominal hysterectomy with
bilateral salpingo-oophorectomy in ___, c/b urinary
incontinence, previously self cathing, then developed
vesiculocutaneous fistulas and given bilateral nephrostomy
tubes.
9. CKD, stage 4 from DM/HTN. Had fistula placed ___, but has
not matured. Surgical eval ___ recommended graft when reaches
ESRD.
Social History:
___
Family History:
Cancer in brother ("abdomen"), daughter (thyroid). DM in
sister.
Physical Exam:
ADMISSION:
Vitals- 97.9 129/65 70 18 97% RA
General- Alert, oriented to place and month but not year, no
acute distress
HEENT- Sclerae anicteric, dry MM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, ventral hernia
reproducible
GU- Nephrostomy tubes draining amber colored urine
Ext- warm, well perfused, 1+ nonpitting edema bilaterally R>L
per pt baseline. Flapping tremor, per daughter seems to be
baseline. L fistula with palpable pulse, no thrill, +bruit
DISCHARGE:
VS: 97.7 153/58 60 18 100RA
GENERAL: Well appearing, no acute distress.
HEENT: Sclerae anicteric, dry MM, 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, ventral hernia
reproducible
GU: Nephrostomy tubes draining pink colored urine on right,
amber urine on L
EXT: Warm, well perfused. PICC in Rt arm with surrounding
ecchymosis. Trace edema bilaterally R>L per pt baseline.
Pertinent Results:
ADMISSION:
___ 12:20PM URINE RBC->182* WBC->182* BACTERIA-MANY
YEAST-NONE EPI-0
___ 12:20PM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 12:20PM URINE COLOR-BROWN APPEAR-Cloudy SP ___
___ 12:20PM ___ PTT-45.0* ___
___ 12:20PM PLT COUNT-119*
___ 12:20PM NEUTS-87.3* LYMPHS-6.5* MONOS-4.6 EOS-1.6
BASOS-0
___ 12:20PM WBC-5.5 RBC-3.33* HGB-10.3* HCT-29.7* MCV-89
MCH-30.9 MCHC-34.5 RDW-16.1*
___ 12:20PM URINE UHOLD-HOLD
___ 12:20PM URINE HOURS-RANDOM
___ 12:20PM estGFR-Using this
___ 12:20PM GLUCOSE-120* UREA N-79* CREAT-4.5*#
SODIUM-133 POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-28 ANION GAP-14
___ 12:29PM LACTATE-1.4
___ 12:51PM URINE MUCOUS-RARE
___ 12:51PM URINE 3PHOSPHAT-RARE AMORPH-OCC
___ 12:51PM URINE RBC-100* WBC-10* BACTERIA-MOD YEAST-NONE
EPI-2
___ 12:51PM URINE BLOOD-LG NITRITE-POS PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-LG
___ 12:51PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 12:51PM URINE UHOLD-HOLD
___ 12:51PM URINE OSMOLAL-410
___ 12:51PM URINE HOURS-RANDOM UREA N-475 CREAT-68
SODIUM-39 POTASSIUM-28 CHLORIDE-34
DISCHARGE:
___ 05:22AM BLOOD WBC-6.4 RBC-3.34* Hgb-9.7* Hct-29.4*
MCV-88 MCH-29.1 MCHC-33.1 RDW-15.8* Plt ___
___ 05:22AM BLOOD ___ PTT-38.5* ___
___ 05:22AM BLOOD Glucose-131* UreaN-77* Creat-2.3* Na-138
K-3.3 Cl-99 HCO3-29 AnGap-13
___ 05:22AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.8
MICRO:
___ 7:12 pm URINE Source: Kidney.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 7:13 pm URINE Source: Kidney.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 2:08 am STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
CANCELLED.
This test was cancelled because a FORMED stool specimen
was
received, and is NOT acceptable for the C. difficile
DNA
amplification testing. See discussion in ___
laboratory manual.
__________________________________________________________
___ 1:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 12:51 pm
URINE RIGHT NEPHROSTOMY.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 12:20 pm URINE L : NEPHROSTOMY.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
__________________________________________________________
URINE CULTURE (Final ___:
FOSFOMYCIN SUSCEPTIBILITY PER ___. ___ (CELL
___
___.
ENTEROBACTER CLOACAE COMPLEX. >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.
CEFEPIME sensitivity testing confirmed by ___.
Piperacillin/tazobactam sensitivity testing available
on request.
FOSFOMYCIN ( 6 MM ZONE SIZE) sensitivity testing
performed by
___.
ENTEROBACTER CLOACAE COMPLEX. ___
ORGANISMS/ML..
___ MORPHOLOGY.
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.
FOSFOMYCIN (6 MM ZONE SIZE) sensitivity testing
performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
| ENTEROBACTER CLOACAE
COMPLEX
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- =>64 R <=1 S
CEFTRIAXONE----------- 32 R <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM------------- 0.5 S <=0.25 S
NITROFURANTOIN-------- 256 R 128 R
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
IMAGING:
TTE ___:
The left atrium is elongated. No atrial septal defect is seen
by 2D or color Doppler. The estimated right atrial pressure is
___ mmHg. There is mild symmetric left ventricular hypertrophy
with normal cavity size. Overall left ventricular systolic
function is low normal (LVEF 50-55%) with suggestion of relative
basal to mid inferolateral/ lateral hypokinesis. The right
ventricular cavity is mildly dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is severe
mitral annular calcification. There is mild functional mitral
stenosis (mean gradient 5 mmHg) due to mitral annular
calcification. Moderate (2+) mitral regurgitation is seen. [Due
to acoustic shadowing, the severity of mitral regurgitation may
be significantly UNDERestimated.] Moderate to severe [3+]
tricuspid regurgitation is seen. The tricuspid regurgitation jet
is eccentric and may be underestimated. There is severe
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
left ventricular function is less vigorous. The right ventricle
is mildly dilated with normal systolic function. The estimated
pulmonary pressures are greater (severe pulmonary hypertension).
Other findings are similar.
Renal US ___:
IMPRESSION:
Atrophic kidneys which demonstrate cortical thinning
bilaterally. No
perinephric fluid collection identified. Small bilateral renal
cysts are
incidentally noted. The left ureter is noted to be dilated
perhaps representing ectatic proximal ureter or extrarenal
pelvis; however, no frank hydronephrosis is visualized
bilaterally.
Brief Hospital Course:
___, CKD (sIV) secondary to hypertension and diabetes, TAH-BSO
(___) for endometrial cancer complicated by vesiculocutaneous
fistulas s/p bilateral nephrostomy tubes (___), Afib, NIDDM,
who presents with syncopal event, confusion, and ___.
# SYNCOPE: Likely orthostatic in the setting of hypovolemia as
occurred on rising to standing, and prior events have always
been positional. Less likely vasovagal as occurred prior to
attempting defecation. Also less likely primarily cardiogenic as
she had a prodrome, positional circumstance. No events on
telemetry. TTE showed mild aortic stenosis, unchanged from
prior. Buspirone and gabapentin may predispose to
ligtheadedness, therefore they were discontinued. The patient
wore TEDS and was encouraged to stay hydrated.
# ___: Cr 4.5 from baseline 2.5-2.8 on admission. Baseline CKD
thought due to DM/HTN. ___ be secondary to starting Bactrim DS
QD for UTI. She also had poor PO intake and orthostasis.
Therefore, she was treated for pre-renal etiology and given
gentle IVF. Cr trended back to baseline. The patient also had
tremor/myoclobus, which may have been due to gabapentin in the
setting of ___. Lisinopril and lasix were restarted once ___
improved. Lasix was started at 80mg BID to prevent further
orthostasis as the patient appeared euvolemic.
# UTI: Urine culture from ___ grew Enterobacter. Repeat urine
cultures were contaminated. In the setting of altered mental
status and worsening hematuria and purulent urine, therefore the
patient was treated with an active infection. She did not have
any evidence of pyelonephritis or perinephric abscess. She is
s/p percutaneous nephrostomy tube exchanged. She was started on
a 14 day course of cefepime via PICC line. She will require
outpatient urology follow up for other options besides
percutaneous nephrostomy.
# ENCEPHALOPATHY: Likely toxic/metabolic delirium in the setting
of UTI, hypovolemia, possible uremia, reduced clearance of
buspirone and gabapentin. Her mental status improved with
cessation of these medications.
# PULMONARY HYPERTENSION: TTE reported severe pulmonary
hypertension with 2+ mitral regurgitation.
# PANCYTOPENIA: Likely multifactorial: medication effect
(allopurinol and bactrim), urinary tract infection, and
age-related poor marrow reserve. Improved with treatment of
infection and cessation of Bactrim.
# ATRIAL FIBRILLATION: The patient was rate controlled with
metoprolol. CHADS2 = 3. INR was supratherapeutic on admission.
Warfarin was restarted at home dose when therapeutic. INR on day
of discharge was 3.0.
# GOUT: Allopurinol was restarted at every other day, given high
risk for gout given CKD.
# TREMOR: Improved after stopping gabapentin and buspirone.
# ANEMIA: Continued iron.
# DM: HbA1c was 6.7%. Given goal of <8%, Januvia was held. We
recommend close outpatient monitoring.
# DEPRESSION: She was continued on home citalopram.
# HYPERTENSION: Continued home metoprolol and lisinopril.
TRANSITIONAL ISSUES:
- The patient will complete a 2 week course of cefepime (day 1 =
___.
- Warfarin held on ___ for INR 3.0. Please recheck on ___.
- Please have the patient wear TEDS for orthostatic syncope.
- Gabapentin and buspirone were discontinued due to concern for
side effects.
- Outpatient urology followup regarding potential alternatives
to percutaneous nephrostomy tubes.
- HbA1c was 6.7%, therefore Januvia was held (Goal HbA1c < 8%).
- Lasix restarted at 80mg BID once ___ improved.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. BusPIRone 11.25 mg PO BID
3. Citalopram 20 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Furosemide 160 mg PO BID
6. Gabapentin 300 mg PO TID
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO BID
9. sitaGLIPtin 25 mg oral Daily
10. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
11. Warfarin 1.25 mg PO 3X/WEEK (MO,WE,SA)
12. Ferrous Sulfate 325 mg PO DAILY
13. Multivital Platinum
(
multivit-min-FA-lycopen-lutein;<br>multivitamin-minerals-lutein)
___ mcg oral Daily
14. Warfarin 2.5 mg PO 4X/WEEK (___)
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Furosemide 80 mg PO BID
5. Lisinopril 5 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO BID
7. Multivital Platinum
(
multivit-min-FA-lycopen-lutein;<br>multivitamin-minerals-lutein)
___ mcg oral Daily
8. Allopurinol ___ mg PO DAILY
9. CefePIME 250 mg IV Q24H
End date ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
___
UTI
Toxic/metabolic encephalopathy
Orthostatic syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
with renal injury, confusion, and a urinary tract infection.
These improved with IV fluids, antibiotics, and stopping
Bactrim. Your percutaneous nephrostomy tubes were also changed.
You will require a total of 2 weeks of antibiotics at home via a
PICC line.
Two medications that may have been making you more confused and
contributing to your passing out have been stopped (gabapentin
and buspirone).
We also suggest you wear thigh-high TEDS stockings to prevent
passing out in the future.
Best wishes,
Your ___ Team
Followup Instructions:
___
|
19764805-DS-9
| 19,764,805 | 20,549,280 |
DS
| 9 |
2159-11-12 00:00:00
|
2159-11-13 16:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Benadryl Decongestant
Attending: ___.
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
exchange of bilateral 10 ___ nephrostomy tubes ___
History of Present Illness:
Ms. ___ is a ___ w/ afib on coumadin, HTN, HLD, uterine CA,
CKD w/ bilateral nephrostomy tubes p/w bloody nephrostomy tube
output. She also has had fatigue for the past 2 days. There was
first a small amount of blood in the bilateral nephrostomy bags
yesterday, but last night the output was very dark, so she was
brought her to the emergency department. She reports generalized
weakness and fatigue for the past 2 days, but denies focal
symptoms such as headache, sore throat, chest pain, shortness of
breath, cough, abdominal pain, nausea, vomiting, back pain. She
does have history of urinary tract infections. Her INR has been
elevated recently, but family reports has been downtrending and
was about 3 the last time it was checked.
Of note, she was hospitalized at ___ in ___ and
treated for recurrent pyelonephritis associated with her
nephrostomy tubes, ___, C. difficile infection, and
supratherapeutic INR of 10. Her urine culture grew pan-sensitive
Pseudomonas on ___, and she was transitioned to
Ciprofloxacin PO with a planned 14-day course.
In the ED, initial VS were 0 97.8 76 124/41 18 99%ra
Exam significant for palor and bilateral nephrostomy tubes with
dark blood.
Labs significant for WBC 12, Cr 3.9, and INR 5.7. UA with 182
WBC, RBCs, large leuk, nitrite pos. Lactate 1.4.
Imaging significant for CXR with hilar congestion and tiny
pleural effusions. Renal ultrasound with no hydronephrosis on
preliminary read.
Received 2g IV cefepime and 10mg IV vitamin K
Transfer VS were 97.8 61 135/65 16 98% RA.
On arrival to the floor, patient has no complaints. She notes
chronic RLE pain and on questioning, notes that her RLE is
chronically more swollen than the LLE. She denies fevers/chills.
Does not know her home warfarin dose, but has assistance from
her daughter and ___ clinic.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia,
All other 10-system review negative in detail.
Past Medical History:
1. Diabetes mellitus type 2 with diabetic nephropathy
2. Anemia
3. Depression
4. Hypertension
5. Urinary incontinence
6. Low back pain
7. Osteoarthritis
8. Endometrial Cancer- s/p Total abdominal hysterectomy with
bilateral salpingo-oophorectomy in ___, c/b urinary
incontinence, previously self cathing, then developed
vesiculocutaneous fistulas and given bilateral nephrostomy
tubes.
9. CKD, stage 4 from DM/HTN. Had fistula placed ___, but has
not matured. Surgical eval ___ recommended graft when reaches
ESRD.
10. Hypercholesterolemia
11. Gait disturbance
12. Atrial fibrillation
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1 67 131/75 20 100%ra wt of 84.3 kg
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: umbilical hernia noted, soft. nondistended, +BS,
nontender in all quadrants, no rebound/guarding, no
hepatosplenomegaly.
BACK: bilateral nephrostomy tubes with dressings in place. R
side with sanguinous drainage. Both tubes with ~50 cc dark red
output. No surrounding erythema or tenderness to palpation.
EXTREMITIES: moving all extremities well. RLE> LLE edema. Both
lower extremities equally warm, nontender. Venous stasis changes
noted.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, fluent speech, aox3
SKIN: warm and well perfused
DISCHARGE PHYSICAL EXAM:
Afebrile, VSS
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: umbilical hernia noted, soft. nondistended, +BS,
nontender in all quadrants, no rebound/guarding, no
hepatosplenomegaly.
BACK: bilateral nephrostomy tubes with dressings in place
draining yellow urine.
No surrounding erythema or tenderness to palpation.
EXTREMITIES: moving all extremities well. RLE> LLE edema. Both
lower extremities equally warm, nontender. Venous stasis changes
noted.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, fluent speech, aox3
SKIN: warm and well perfused
Pertinent Results:
LABS ON ADMISSION
___ 10:50AM BLOOD WBC-12.0*# RBC-2.88* Hgb-8.7* Hct-26.2*
MCV-91 MCH-30.3 MCHC-33.3 RDW-16.4* Plt ___
___ 10:50AM BLOOD Neuts-85.5* Lymphs-8.3* Monos-5.0 Eos-1.2
Baso-0
___ 10:50AM BLOOD ___ PTT-53.9* ___
___ 10:50AM BLOOD Plt ___
___ 10:50AM BLOOD Glucose-152* UreaN-91* Creat-3.9*# Na-135
K-6.8* Cl-101 HCO3-25 AnGap-16
___ 07:00AM BLOOD Calcium-8.6 Phos-5.1* Mg-1.8
___ 11:01AM BLOOD Lactate-1.4 K-4.2
___ 01:08PM BLOOD K-4.1
___ 11:00AM URINE Color-Red Appear-Cloudy Sp ___ TO
REPORT, GROSSLY BLOODY SPECIMEN
___ 11:00AM URINE Blood-LG Nitrite-POS Protein->300
Glucose-250 Ketone-40 Bilirub-LG Urobiln->8 pH-9.0* Leuks-LG
___ 11:00AM URINE RBC->182* WBC->182* Bacteri-MANY
Yeast-NONE Epi-0
___ 11:00AM URINE WBC Clm-MOD
LABS ON DISCHARGE
___ 06:40AM BLOOD WBC-14.6* RBC-2.86* Hgb-8.4* Hct-26.4*
MCV-93 MCH-29.3 MCHC-31.7 RDW-17.0* Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD ___ PTT-32.9 ___
___ 06:40AM BLOOD Glucose-139* UreaN-100* Creat-3.9* Na-141
K-4.4 Cl-102 HCO3-23 AnGap-20
___ 06:40AM BLOOD Calcium-9.3 Phos-6.2* Mg-2.3
MICRO
___ 11:00 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
___ 10:50 am BLOOD CULTURE
Blood Culture, Routine (Pending):
STUDIES
CXR ___:
1. Cardiomegaly and hilar congestion.
2. Tiny bilateral pleural effusions.
3. Calcified mitral annulus.
Renal ultrasound ___: The right kidney measures 9.8 cm. A simple
cyst is demonstrated in the right midpole. No hydronephrosis.
There is increased echogenicity of the renal cortex suggesting
chronic medical renal disease. The partially imaged nephrostomy
catheter is demonstrated in the central collecting system. Trace
perinephric fluid is demonstrated.
The left kidney measures 9.3 cm. No hydronephrosis. There is
increased
echogenicity of the renal cortex, suggesting chronic medical
renal disease. The nephrostomy catheter is not seen.
The bladder is decompressed.
IMPRESSION:
As above.
URIN CATH REPLC Study Date of ___
FINDINGS:
1. Existing bilateral 10 ___ nephrostomy tubes. The right
nephrostomy tube was noted to be displaced and nearly dislodged
from the right kidney. The left nephrostomy tube was in
appropriate position in the renal pelvis.
2. Successful placement of new, bilateral 10 ___ nephrostomy
tubes.
IMPRESSION:
Successful exchange of bilateral 10 ___ nephrostomy tubes.
Brief Hospital Course:
Hospital course: Ms. ___ is a ___ w/ afib on coumadin, HTN,
HLD, uterine CA, CKD w/ bilateral nephrostomy tubes p/w bloody
nephrostomy tube output, found to have UTI, ___,
supratherapeutic INR, and LGIB. UTI was treated with initially
with cefepime, then with zosyn, transitioned to ciprofloxacin on
discharge. ___ presented with a Cr of 3.9 from prior value of
2.8. LGIB characterized by one loose brown BM accompanied by
~30cc BRBPR; thought to be due to previously noted colonic
angioectasias in the setting of supratherapeutic INR; this did
not recur or require pRBC transfusion.
Active issues:
#UTI/hematuria: UA with >182 WBC, RBCs, large leuk, nitrite pos,
suggestive of UTI. Hematuria may be ___ UTI, supratherapeutic
INR, or less likely urologic malignancy.
UTI was treated with initially with cefepime, then with zosyn,
transitioned to ciprofloxacin on discharge. Urine culture with
mixed flora. Supratherapeutic INR treated as below. Recommend
outpatient follow up to assess for resolution of hematuria once
infection is resolved.
#LGIB: On ___, pt had loose brown BM accompanied by ~30cc BRBPR;
thought to be ___ previously noted colonic angioectasias in the
setting of supratherapeutic INR. This did not recur; she was
hemodynamically stable; and Hgb was stable on recheck.
Supratherapeutic INR treated as below.
#Leukocytosis: Pt with known UTI as above. Also with a hx of
C.diff colitis on a prior admission. She had one loose bowel
movement in the hospital, which did not recur and she attributed
this to lactose intolerance. As it did not recur, a sample could
not be sent for evaluation, but consider C.diff toxin assay if
diarrhea recurs
#Anemia: Recent baseline Hb appears to be ___. Hbg is 8.7 on
admission. This may be secondary to worsening renal function,
bleeding from her nephrostomy, and LGIB as above.
#Supratherpeutic INR: Patient presenting with INR 5.7 and
hematuria as above. She was treated with IV vitamin K in the ED.
Warfarin was initially held, and a smaller dose of 1 mg was
resumed prior to discharge, with plans for ___
clinic follow up
___: Cr was 2.8 in ___ however, ranged up to 4.6 during
her ___ admission. On admission, Cr of 3.9 above recent
baseline. Likely prerenal ___ infection and concurrent volume
depletion. Renal ultrasound reassuring against hydronephrosis;
however, ___ evaluated her PCNs in the ED, and noted that the
right PCN was not draining and noted bloody drainage around skin
site. The drain was flushed, and 3 way adapters added to both
drains. She then underwent ___ guided PCN exchange. By the time
of discharge, Cr was 3.9. Furosemide was held with plans to
follow up in clinic.
#Atrial fibrillation: Rate controlled and anticoagulated.
Continued home metoprolol; managed warfarin as above
Chronic issues:
#Depression: Continued home Citalopram 10mg, BusPIRone 15 mg PO
BID
#Hx of gout: Continued home allopurinol
#HTN: Well controlled
Transitional issues:
- She was discharged on ciprofloxacin to complete a 14-day
course for UTI
- Warfarin dose reduced to 1mg daily at discharge (on cipro).
INR to be checked on ___
- Lasix held at discharge given ___ restart pending outpatient
reassessment of electrolytes and volume status
- She was discharged on her home metoprolol succinate with BID
dosing. Would consider once daily dosing for this medication
unless otherwise contraindicated
- The patient had diarrhea prior to discharge that self-resolved
before sample could be sent for c. diff. Should diarrhea recur,
would send off stool studies
- Leukocytosis at discharge (WBC 14.6). Please recheck at ___
office visit on ___ to confirm downtrending
- Discharge Cr: 3.9
- CODE STATUS: Patient reported preference for DNR/Ok to
intubate. Would benefit from further goals of care discussions
with her outpatient providers
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Januvia (sitaGLIPtin) 25 mg oral daily
3. Metoprolol Succinate XL 25 mg PO BID
4. Gabapentin 100 mg PO BID
5. Warfarin 2.5 mg PO 3X/WEEK (___)
6. Allopurinol ___ mg PO EVERY 3 DAYS
7. BusPIRone 15 mg PO BID
8. Acetaminophen 500 mg PO Q4H:PRN pain
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Warfarin 1.25 mg PO 4X/WEEK (___)
11. Furosemide 160 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q4H:PRN pain
2. Allopurinol ___ mg PO EVERY 3 DAYS
3. BusPIRone 15 mg PO BID
4. Citalopram 20 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Multivitamins 1 TAB PO DAILY
7. Januvia (sitaGLIPtin) 25 mg oral daily
8. Loratadine 10 mg PO EVERY OTHER DAY
9. Metoprolol Succinate XL 25 mg PO BID
10. Ciprofloxacin HCl 250 mg PO Q24H Duration: 10 Days
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth daily Disp
#*10 Tablet Refills:*0
11. Warfarin 1 mg PO DAILY16
This is a lower dose than usual since you were bleeding. Your
primary care doctor can reassess.
RX *warfarin 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Gabapentin 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Urinary tract infection
Supratherapeutic INR
Acute kidney injury
Lower GI bleeding
Secondary diagnoses:
Atrial fibrillation
Chronic kidney disease
Diabetes mellitus, type 2
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 bloody output from your nephrostomy tubes, and found to
have a urinary tract infection, an elevated INR (meaning that
your warfarin level was too high), and a bloody bowel movement.
Because your warfarin contributed to episodes of bleeding in the
tubes and in the stool, the dose was reduced on discharge. You
were also started on ciprofloxacin, an antibiotic for urinary
tract infection.
Please take all your medications as listed and follow up with
your doctors and the ___ clinic. You should have
your INR checked on ___.
We wish you all the best!
Your ___ Medicine Team
Followup Instructions:
___
|
19765157-DS-20
| 19,765,157 | 21,427,281 |
DS
| 20 |
2168-05-11 00:00:00
|
2168-05-13 20:29:00
|
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:
ruptures ectopic
Major Surgical or Invasive Procedure:
RIGHT LAPAROSCOPIC salpingo-oophorectomy
History of Present Illness:
Ms. ___ is a ___ G1 with no significant
history, OB/GYN was consulted for evaluation of a 6 wks ruptured
ectopic.
She presented to the ED with sudden onset cramping , bloating,
and pain during sexual intercourse. This happened night prior to
admission ___ 1130 ___ while having intercourse with her husband.
She reports diaphoresis. Denies CP, sob, n/v. Has no significant
GYN history.
In the ED, evaluation notable for:
VS:
Today 04:55 97.7 109 106/70 18 100% RA
Today 06:05 93 118/71 18 97% RA
Today 06:42 81 123/77 18 100% RA
Labs HCT 34.3
Imaging PUS showing right ruptured ectopic
Interventions: Morphine 4mg x 2, fentanyl x 1, LR 1000
Past Medical History:
Denies
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: stable and within normal limits
Gen: no acute distress; alert and oriented to person, place, and
date
CV: regular rate and rhythm; no murmurs, rubs, or gallops
Resp: no acute respiratory distress, clear to auscultation
bilaterally
Abd: soft, appropriately tender, no rebound/guarding; incisions
clean, dry, intact
Ext: no tenderness to palpation
Pertinent Results:
Labs on Admission:
___ 06:06AM BLOOD HCG-3975
___ 06:06AM BLOOD Albumin-4.4
___ 06:06AM BLOOD Lipase-21
___ 06:06AM BLOOD ALT-6 AST-16 AlkPhos-37 TotBili-0.4
___ 06:06AM BLOOD Glucose-125* UreaN-13 Creat-0.8 Na-136
K-4.5 Cl-105 HCO3-20* AnGap-11
___ 06:06AM BLOOD Plt ___
___ 01:01PM BLOOD Plt ___
___ 03:53PM BLOOD Plt ___
___ 06:06AM BLOOD Neuts-83.9* Lymphs-10.5* Monos-4.6*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-11.68* AbsLymp-1.47
AbsMono-0.64 AbsEos-0.02* AbsBaso-0.04
___ 01:01PM BLOOD WBC-9.9 RBC-2.90* Hgb-9.2* Hct-26.5*
MCV-91 MCH-31.7 MCHC-34.7 RDW-12.6 RDWSD-41.7 Plt ___
___ 03:53PM BLOOD WBC-12.6* RBC-3.33* Hgb-10.3* Hct-30.2*
MCV-91 MCH-30.9 MCHC-34.1 RDW-12.5 RDWSD-40.8 Plt ___
Labs at discharge:
___ 05:45AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.9
___ 05:45AM BLOOD Glucose-96 UreaN-7 Creat-0.8 Na-141 K-4.0
Cl-107 HCO3-25 AnGap-9*
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD WBC-8.5 RBC-3.09* Hgb-9.5* Hct-28.3*
MCV-92 MCH-30.7 MCHC-33.6 RDW-12.8 RDWSD-42.5 Plt ___
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
after undergoing laparoscopic right salpingo-oophorectomy due to
ruptured ectopic pregnancy. Please see the operative report for
full details.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with PO Tylenol and ibuprofen.
On post-operative day 1, her foley was removed with successful
backfill trial of void. Her diet was advanced without
difficulty, and she was tolerating a regular diet. She was
ambulating. She was then discharged home in stable condition
with outpatient follow-up scheduled.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
Do not take more than 4000 mg in 24 hours
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*50 Tablet Refills:*1
2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
Take with food. Alternate every 3 hours with tylenol
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*50 Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
ruptured ectopic pregnancy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. ___ office
with any questions or concerns. Please follow the instructions
below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking opioids (e.g. oxycodone,
hydromorphone)
* Take a stool softener such as colace while taking opioids to
prevent constipation.
* Do not combine opioid and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina for two weeks
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* Leave the steri-strips in place. They will fall off on their
own. If they have not fallen off by 7 days post-op, you may
remove them.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
Constipation:
* Drink ___ liters of water every day.
* Incorporate 20 to 35 grams of fiber into your daily diet to
maintain normal bowel function. Examples of high fiber foods
include:
Whole grain breads, Bran cereal, Prune juice, Fresh fruits and
vegetables, Dried fruits such as dried apricots and prunes,
Legumes, Nuts/seeds.
* Take Colace stool softener ___ times daily.
* Use Dulcolax suppository daily as needed.
* Take Miralax laxative powder daily as needed.
* Stop constipation medications if you are having loose stools
or diarrhea.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19765159-DS-12
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| 12 |
2183-02-23 00:00:00
|
2183-02-23 14:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with COPD, chronic Renal Insufficiency and HLD presents with
1 week of SOB and DOE. Patient describes that over the past week
she has become increasingly dyspnic with minimal exertion. No
dyspnea at rest, but even minimal exertion such as walking
around the house results in dyspnea which the patients describes
as "breathlessness". Pt achieved symptomatic improvement with
use of inhaler. Also complained of increase in chronic cough
frequency now minimally productive of clear sputum. Patient
denies chest pain, jaw pain, arm pain, fever or chills,
worsening ___ edema, calf pain.
In the ED, initial VS were 98.1 46 161/62 20 100%. Patient had
labs drawn. A CXR, UA were obtained. A DDimer was checked which
was elevated and patient had a VQ scan which on preliminary read
was read as low probability for PE. She was given prednisone 60
and combinebs.
.
Upon transfer to the floor,Temp: 97.8, Pulse: 43, RR: 18, BP:
139/88, O2Sat: 100%RA. Patient is comfortable and has no
complaints while resting.
Past Medical History:
Hypertension
High cholesterol
COPD
HTN
HLD
L TKR ___
OA
GERD
lysis of adhesions
appendectomy
Social History:
___
Family History:
Mother died of COPD. Father died of MI.
Physical Exam:
On admission:
VS - Temp 96.7F, BP 130/50 , HR88 , R20 , O2-sat 96% RA
GENERAL - well-appearing elderly female, comfortable,
appropriate speaking in full senteces
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
LUNGS - diminished breath sounds. no r/rh/wh, resp unlabored, no
accessory muscle use
HEART - RRR, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+edema at ankles bilaterally. 2+ peripheral
pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
.
On discharge:
VS - Temp 97.7F, BP 110/50 , HR56 , R20 , O2-sat 94% RA
GENERAL - well-appearing elderly female, comfortable,
appropriate speaking in full senteces
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear
NECK - supple, no JVD
LUNGS - diminished breath sounds. no wheezes or crackles. resp
unlabored.
HEART - RRR, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, 1+edema at ankles bilaterally. 2+ peripheral
pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
LABS
On admission:
___ 12:10PM BLOOD WBC-7.9 RBC-3.84* Hgb-10.1* Hct-32.0*
MCV-83 MCH-26.2* MCHC-31.4 RDW-14.9 Plt ___
___ 12:10PM BLOOD Neuts-70.7* Lymphs-17.5* Monos-8.6
Eos-2.5 Baso-0.7
___ 12:10PM BLOOD Glucose-109* UreaN-24* Creat-1.4* Na-142
K-4.6 Cl-105 HCO3-25 AnGap-17
___ 12:10PM BLOOD Calcium-9.7 Phos-3.3 Mg-2.1
___ 12:17PM BLOOD D-Dimer-1800*
___ 05:50AM BLOOD calTIBC-391 ___ Folate-11.7
___ Ferritn-14 TRF-301
___ 12:10PM BLOOD cTropnT-<0.01
___ 12:10PM BLOOD proBNP-5011*
___ 09:45PM BLOOD cTropnT-<0.01
.
On discharge:
___ 08:05AM BLOOD WBC-6.6 RBC-3.21* Hgb-8.5* Hct-26.7*
MCV-83 MCH-26.6* MCHC-32.0 RDW-14.6 Plt ___
___ 08:05AM BLOOD Glucose-97 UreaN-31* Creat-1.7* Na-139
K-4.3 Cl-105 HCO3-25 AnGap-13
___ 08:05AM BLOOD Calcium-8.7 Phos-4.3 Mg-2.2
.
DIAGNOSTICS:
CHEST (PA & LAT) ___ IMPRESSION: Slightly thickened
fissures and small pleural effusions, which
may suggest mild congestion or fluid overload; otherwise
unremarkable.
.
TTE ___ : left atrium mildly dilated. Color-flow imaging
of the interatrial septum raises the suspicion of an atrial
septal defect, but this could not be confirmed on the basis of
this study. The estimated right atrial pressure is ___ mmHg. LV
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). Doppler parameters are
indeterminate for LV diastolic function. The right ventricular
cavity is mildly dilated with normal free wall contractility.
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. Mild (1+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Preserved biventricular regional and global systolic
function. Mild right ventricular dilatation with moderate
pulmonary systolic hypertension.
.
LUNG SCAN ___ : Ventilation images obtained with Tc-99m
aerosol in 8 views demonstrate patchy non-segmental ventilation
defects that are matched with non-segmental perfusion defects.
Blunting is seen at bilateral costophrenic angles, which is
compatible with the pleural effusions present on the chest
radiograph. The lungs are hyperexpanded on the chest radiograph,
fitting with the patient's clinical history of COPD. IMPRESSION:
Low likelihood of pulmonary embolism.
.
Brief Hospital Course:
___ with COPD, HTN, HLD presents with 1 week of Dyspnea on
excertion.
.
#DYSPNEA:
In the ED, a CXR, UA were obtained which did not show evidence
of infection. Patient remained afebrile with no other signs of
infection throughout admission. A DDimer was checked which was
elevated and patient had a VQ scan which was read as low
probability for PE. She was given prednisone 60 and started on
combinebs. Patient's EKG had no significant change from prior
and troponins were negative x2. CXR showed slight pleural
effusions and lower extremity edema concerning for CHF. BNP was
elevated. Patient was diuresed with furosemide 20mg IV with
resolution of bibasilar crackles and improved in breathing. ECHO
___ mild to moderate TR and moderate pulmonary hypertension.
Patient may have some diastolic heart failure worsened acutely
by COPD exacerbation. Cardiology was consulted and it was
recommended to send patient on torsemide 10mg PO prn weight gain
of ___ pounds, Patient educated about this and has scale at
home, Patient also educated on low salt intake. Patient will
follow-up with primary care doctor and with cardiologist Dr.
___.
.
#COPD: On admission, it appeared her dyspnea might be related to
a COPD exacerbation. Combinebs, prednisone, and azythromycin
were started. Upon further evaluation, it seemed the dyspnea was
more secondary to fluid overload, and patient was transitioned
to home spiriva and albuterol PRN.
.
#Constipation: Patient did not have a BM during hospitalization.
Patient declined an enema, but was started on Senna and
dulcolax. Patient believed she will be ok, once patient returns
to her normal day routine. Patient did not have any abdominal
pain. Patient will follow up with primary care doctor at ___ for
further treatment.
.
#HLD: Patient was continued statin
.
#HTN: Patient was continued on amlodipine at half dose while
admitted.
.
#OA: Patient received tylenol for pain control.
.
#GERD: Patient was continued on omeprazole.
.
Medications on Admission:
90 mcg HFA Aerosol Inhaler 2 puffs QID PRN SOB
alendronate 70 mg weekly
amlodipine 5 mg daily
omeprazole 20 mg daily
pravastatin 60 mg daily
tiotropium bromide [Spiriva] 18 mcg Capsule INH Daily
acetaminophen 1000 mg PRN pain
pyridoxine 100 mg DAILY
.
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. pravastatin 40 mg Tablet Sig: 1.5 Tablets PO once a day.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO HS (at bedtime).
4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for fluid retention: monitor weight and use as needed for
weight gain of 2 or 3 pounds.
Disp:*5 Tablet(s)* Refills:*0*
7. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation four times a day as needed for
shortness of breath or wheezing.
9. Tylenol 8 Hour 650 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO every six (6) hours as needed for
pain.
10. pyridoxine 100 mg Tablet Sig: One (1) Tablet PO once a day.
11. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*40 Tablet(s)* Refills:*0*
12. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day as needed for
constipation.
Disp:*15 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Dyastolic Heart Failure
COPD
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ were evaluated for your shortness of breath. Based on our
evaluation, it seems this was most likely due to some fluid in
your lungs due to your heart not pumping as well as needed. ___
improved when ___ had some fluid removed with a diuretic. ___
had a ECHO (an ultrasound of your heart) that showed a leaky
valve (tricuspid regurgitation). Nothing concerning at this
time, but please follow-up with your cardiologist.
.
The following changes were made to your medications:
#ADD torsemide 10mg by mouth as needed when ___ notice your
weight increased by 2 or 3lbs above your "dry weight" of 126lbs
as explained by the cardiology team.
#START senna 2 tabs by mouth at night
#STOP fexofenadine
It was a pleasure taking care of ___.
Followup Instructions:
___
|
19765159-DS-13
| 19,765,159 | 26,830,726 |
DS
| 13 |
2183-05-20 00:00:00
|
2183-05-20 13:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ COPD, chronic Renal Insufficiency and diastolic CHF
presents with bilateral lower extremity leg swelling and
shortness of breath with exertion over the past several days.
She also reports that she has gained two pounds. Has been taking
medications appropriately and does not report any dietary
restriction. Had some cough earlier but it is improving, non
productive. No specific sick contacts. No chest pain or fever.
Also increased ___ pitting edema to knees 2+ pitting edema to
knees, fine insp crackles throughout
In ED initial vitals 97.3 80 121/47 18 95%. A CXR was performed
that was unchanged, BNP obtained similar to ___. Creatinine
at baseline. Given nebulizer therapy and admitted. Vitals upon
transfer 97.6, 115/42, RR 18, 74 NSR with ventric. bigeminy at
times, 96% RA.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, sore throat, cough, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria. Mild congestion.
.
Past Medical History:
Hypertension
High cholesterol
COPD
HTN
HLD
L TKR ___
OA
GERD
lysis of adhesions
appendectomy
Social History:
___
Family History:
Mother died of COPD. Father died of MI.
Physical Exam:
PHYSICAL EXAM:
VS - Temp 97.8F, BP 135/53 , 72 HR , 18R , 95 O2-sat % RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 2+ pitting edema to knees, R slightly more
than left.
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Vital Signs: 98.2, 113/42, 84 (note frequent PVCs falsely alter
hr), 94% RA
Gen: Woman appearing younger than stated age, reading book, NAD,
AA0x3.
HEENT - sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, JVD at 8cm,
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - Bilateral breath sounds with slight expiratory wheeze,
minimal bibasilar inspiratory crackles. No rhonchi. No accessory
muscles.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, 1 pitting edema to knees,
NEURO - awake, A&Ox3, CNs II-XII grossly intact
.
Pertinent Results:
Lab results:
___ 06:00AM BLOOD WBC-8.8 RBC-3.79* Hgb-8.8* Hct-29.7*
MCV-78* MCH-23.3* MCHC-29.7* RDW-15.8* Plt ___
___ 06:00AM BLOOD Glucose-87 UreaN-36* Creat-2.1* Na-138
K-3.4 Cl-93* HCO3-33* AnGap-15
___ 06:00AM BLOOD Calcium-9.2 Phos-4.2 Mg-1.9
___ 07:24AM BLOOD WBC-8.8 RBC-3.64* Hgb-8.4* Hct-29.2*
MCV-80* MCH-23.0* MCHC-28.6* RDW-15.8* Plt ___
___ 09:40AM BLOOD WBC-10.3 RBC-4.02* Hgb-9.5* Hct-33.1*
MCV-82 MCH-23.5* MCHC-28.6* RDW-16.1* Plt ___
___ 07:57AM BLOOD WBC-7.7 RBC-3.64* Hgb-8.4* Hct-29.8*
MCV-82 MCH-
23.0* MCHC-28.1* RDW-15.9* Plt ___
___ 06:30PM BLOOD WBC-9.4 RBC-3.91* Hgb-9.1* Hct-31.9*
MCV-82 MCH-23.2*# MCHC-28.4*# RDW-16.0* Plt ___
___ 09:40AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Burr-OCCASIONAL Bite-
OCCASIONAL
___ 07:24AM BLOOD Glucose-88 UreaN-31* Creat-1.7* Na-145
K-3.6 Cl-99 HCO3-35* AnGap-15
___ 04:45PM BLOOD Glucose-104* UreaN-29* Creat-1.8* Na-143
K-4.3 Cl-101 HCO3-27 AnGap-19
___ 11:55PM BLOOD Glucose-121* UreaN-31* Creat-1.7* Na-143
K-3.4 Cl-103 HCO3-28 AnGap-15
___ 06:30PM BLOOD Glucose-108* UreaN-43* Creat-1.8* Na-137
K-4.6 Cl-100 HCO3-23 AnGap-19
___ 06:30PM BLOOD cTropnT-<0.01 proBNP-5628*
___ 07:24AM BLOOD Calcium-9.0 Phos-3.9 Mg-1.8
___ 04:45PM BLOOD Calcium-9.4 Phos-2.9 Mg-2.1
___ 06:30PM URINE Color-Straw Appear-Clear Sp ___
___ 06:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
___ 06:30PM URINE RBC-<1 WBC-7* Bacteri-NONE Yeast-NONE
Epi-1 TransE-<1
___ 06:30PM URINE CastHy-7*
Chest Xray ___: Small bilateral pleural effusions and
pulmonary vascular congestion and top normal heart size overall
unchanged since ___. Moderate-to-large hiatus hernia is
chronic. There are no focal findings in the lungs to
suggestpneumonia.
Brief Hospital Course:
___ with COPD and diastolic heart failure here with dypsnea on
exertion improved with diuresis and optimization of medical
therapy.
.
# Diastolic CHF: Patient's dyspnea is mild and primarily on
exertion. She does not have diffuse wheeze or other suggestion
of COPD flare. She has no evidence of cardiac ischemia on EKG
and no chest pain. Her clearest symptom is her weight gain and
lower extremity swelling--although her BNP is at "baseline" it
is being compared to her initial BNP last time she presented
with fluid overload. Today appears to be nearing euvolemic
status. Patient will be discharged home on torsemide 10mg 5
days/wk (holiday on tues and sat) as well as new metolazone, to
be taken as needed for 3 pound weight gain or increased lower
extremity swelling. Patient also with close follow up
appointment with PCP who can monitor patient's fluid status. Dry
weight is 110 pounds, about 8 pounds lower than previously
recorded dry weight. Patient's Cr with slight bump from 1.7-1.8
baseline to 2.1 today, should improve with equilibration and
also with reduction in diuretic dose moving forward. Patient's
electrolytes were repleted as needed and inhalers were
continued.
.
# Chronic renal failure: close to baseline, will monitor as
diurese.
.
# CAD: pravastatin, ASA
.
# Hypertension: Amlodipine
.
# Continue Cymbalta
.
# GERD: Omeprazole
.
# Osteoporosis: Calcium
.
Transitional Issues:
-PCP outpatient follow up on weight, fluid status, and chemistry
panel.
Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
___.
3. amlodipine 7.5mg daily
4. Pravachol 40 mg Tablet Sig: 1.5 Tablets PO once a day.
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
7. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
10. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO three times a day.
13. torsemide 10 mg 5 times a week
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
___.
3. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Pravachol 40 mg Tablet Sig: 1.5 Tablets PO once a day.
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath or wheezing.
7. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: 0.5 Tablet
PO DAILY (Daily).
10. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
12. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO three times a day.
13. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
please take 30 minutes prior to torsemide .
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Compensated acute on chronic congestive heart failure with
preserved ejection fraction.
2. Chronic Obstructive Pulmonary Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted for an episode of fluid overload secondary to
congestive heart failure. You were admitted with shortness of
breath and excess fluid in your legs. We had to titrate the
amount of diuretics (water pill) to decrease the amount of fluid
in your legs and in your lungs. You are doing an excellent job
in complying with your medications and eating a low sodium diet.
You should continue to do so. It is important that you weigh
yourself every day. If your weight goes up by more than 3 pounds
please call your doctor, as you might need to take more of your
torsemide (water pill). We have made the following changes to
your medications going forward. We have added a medication
called metolazone which is synergistic with torsemide in
removing water from your body.
1. Please START 2.5mg of metolazone by mouth 30 minutes before
you take torsemide.
2. Please INCREASE Torsemide 20mg by mouth once a day.
If you experience any of the danger signs listed below please
call your doctor and go to the nearest emergency department.
Followup Instructions:
___
|
19765159-DS-14
| 19,765,159 | 22,647,428 |
DS
| 14 |
2188-01-20 00:00:00
|
2188-01-20 16:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / colchicine
Attending: ___.
Chief Complaint:
Food impaction
Major Surgical or Invasive Procedure:
Intubation (___)
Extubation (___)
Upper Endoscopy (___)
History of Present Illness:
___ with PMH of COPD, ___, CKD stage IV, GERD who presented to
___ with mild chest discomfort. She reported developing
nausea and having to spit out her saliva after eating dinner
last night. She reports that the dinner was uneventful and she
ate fish/mussels without the sensation of any food becoming
stuck in her throat. In the ___ she was unable to swallow
even water or a GI cocktail. Therefore she underwent a CT of
the chest which revealed significant esophageal food impaction.
GI at ___ recommended transfer to a tertiary care center
based on her age and comorbidities so she was transferred to
___.
Upon arrival in the ___, she was reportedly saturating in the
___ on room air. She was placed on several liters nasal cannula
with improvement of her oxygenation. Given plan for EGD, she
was intubated without remarkable events. There was reported
concern based on imaging the she could have tracheal collapse
related to a mass or her esophageal impaction so she underwent
bronchoscopy through the ETT to the level of the carina which
was unremarkable other than some reported scattered secretions.
GI was consulted with plans for urgent endoscopy tonight.
Upon arrival to the MICU, she is intubated, sedated, and
normotensive.
Past Medical History:
Hypertension
High cholesterol
COPD
HTN
HLD
L TKR ___
OA
GERD
lysis of adhesions
appendectomy
Social History:
___
Family History:
Mother died of COPD. Father died of MI.
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
Vitals: T: 98.4 BP: 172/79 P: 108 O2: 98%
Vent: VCV ___
GENERAL: Intubated, sedated
HEENT: Food and secretions leaking from mouth
NECK: supple, JVP normal
LUNGS: Clear to auscultation anteriorly
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
GU: Foley in place
EXT: Mildly cool distally, warm proximally, 2+ pulses, no
clubbing, cyanosis or edema
SKIN: No lesions.
ACCESS: PIVs
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: 98.2, 90-124/42-58, 82-86, ___ on 1.5L, 96 on
2.5L
Weight: 57kg
GENERAL: NAD, pleasant in conversation
HEENT: PERRL, EOMI, sclerae anicteric, conjunctiva not pale. OP
clear with MMM.
NECK: No elevated JVP.
LUNGS: Better air movement to bases bilaterally, R>L, CTABL.
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: WWP, 2+ pulses, no clubbing, cyanosis or edema.
SKIN: No lesions.
ACCESS: PIVs
Pertinent Results:
ADMISSION LABS
=======================
___ 11:39PM BLOOD WBC-16.3*# RBC-3.47* Hgb-8.7* Hct-28.7*
MCV-83 MCH-25.1* MCHC-30.3* RDW-17.4* RDWSD-52.2* Plt ___
___ 11:39PM BLOOD ___ PTT-27.5 ___
___ 11:39PM BLOOD Glucose-102* UreaN-37* Creat-1.8* Na-140
K-4.5 Cl-103 HCO3-20* AnGap-22*
___ 11:39PM BLOOD Calcium-9.0 Mg-2.0
___ 12:43AM BLOOD Type-ART pO2-117* pCO2-44 pH-7.25*
calTCO2-20* Base XS--7
___ 03:19AM BLOOD Lactate-1.9
OTHER PERTINENT LABS:
=======================
___ 07:10AM BLOOD ___
___ 04:09AM BLOOD ALT-6 AST-18 LD(LDH)-160 AlkPhos-78
TotBili-<0.2
___ 04:09AM BLOOD calTIBC-295 ___ Ferritn-41 TRF-227
___ 07:36PM BLOOD Lactate-1.8
DISCHARGE LABS:
==================
___ 07:25AM BLOOD WBC-15.0* RBC-2.98* Hgb-7.6* Hct-24.4*
MCV-82 MCH-25.5* MCHC-31.1* RDW-19.2* RDWSD-56.3* Plt ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-84 UreaN-47* Creat-2.1* Na-140
K-4.8 Cl-100 HCO3-22 AnGap-23*
___ 07:25AM BLOOD Calcium-8.6 Phos-5.0* Mg-2.0
URINE STUDIES:
===============
___ 12:29AM URINE Color-Straw Appear-Clear Sp ___
___ 12:29AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 12:29AM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
MICROBIOLOGY:
==============
___ 9:33 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 7:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:03 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:26 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 2:17 pm URINE Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 2:18 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 12:29 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH
IMAGING/STUDIES:
=================
Chest Xray (___):
1. ET tube tip is approximately 1.9 cm above the carina and
slight retraction may provide more optimal placement.
2. Patchy right basilar opacities may be due to aspiration.
3. Dense retrocardiac atelectasis.
4. Linear density projecting over the right lateral ribs is
presumably exterior to the patient. Correlate with physical
exam.
Chest Xray (___):
ET tube tip 3.5 cm above the carinal. Heart size and
mediastinum are
unchanged. There is interval development of pulmonary edema.
Left basal
consolidation is most likely consistent with massive aspiration.
Large bilateral pleural effusions are extensive. There is no
pneumothorax.
Upper Endoscopy (___):
The entire esophagus was coated with food (what appeared to be
consistent with fish and mussels). There was no obstruction or
mass noticed but a large hiatal hernia was found. The esophagus
was entering the hiatal hernia at a very sharp angle which could
be responsible for food not passing into the stomach. (foreign
body removal)
Otherwise normal EGD to duodenum
Chest Xray (___):
1. New consolidation in the right mid lung is consistent with
right upper lobe pneumonia.
2. Mildly improved mild pulmonary edema.
3. Improved moderate left pleural effusion. Unchanged moderate
right pleural effusion.
4. Persistent bibasilar retrocardiac opacities, likely
reflecting atelectasis.
Lower Extremity Doppler Ultrasound (___):
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. Large right ___ cyst and suprapatellar effusion on the
right.
CT Chest w/o Contrast (___):
There are infiltrates in superior segment of left upper lobe,
right upper
lobe, consistent with pneumonia. There is complete collapse of
the right lower lobe with extensive mucous plugging. Moderate
volume loss, moderate mucous plugging in the left lower lobe
with atelectasis. Mild bilateral pleural effusions, partially
loculated. Moderate centrilobular emphysema.
1 cm left inferolateral margin aortic arch pseudoaneurysm versus
penetrating atheromatous ulcer.
Chest Xray (___):
Heart size and mediastinum are stable. Large bilateral pleural
effusions are unchanged. Right upper lung consolidation has
improved. Patient continues to be in moderate pulmonary edema.
There is most likely present large hiatal hernia and giving the
lucency projecting over the mediastinum
Brief Hospital Course:
Ms. ___ is a lovely ___ with PMH of COPD, GERD, CKD, ___ who
presented initially on ___ after a food impaction.
Hospitalization subsequently complicated by aspiration
pneumonia, acute on CKD, and acute on chronic diastolic heart
failure.
# Food Impaction: On presentation, Ms. ___ was intubated
given concern for ongoing aspiration with desaturation and for
endoscopy. A CT scan at OSH was concerning for food impaction.
She underwent upper endoscopy which demonstrated food impaction
likely due to large hiatal hernia at sharp angle and likely
esophageal dysmotility. Recommended a liquid diet, although okay
for po medications. Her diet was liberalized to soft foods,
although recommended that she keep the HOB up at all times, and
only eating while sitting up to prevent further aspiration.
# Aspiration pneumonia: Patient was initially intubated for
airway protection given concern for aspiration. CXR after
extubation was notable for possible aspiration pneumonia so she
was started on levofloxacin on ___. She subsequently declined
with worsening hypoxia requiring facemask and had intermittent
desaturations to the low ___ with mucous plugging so was
broadened on ___ to cefepime/flagyl/vancomycin. She remained
tenuous, so CT scan of the chest was performed which
demonstrated ongoing multifocal pneumonia and small effusions.
Interventional pulmonology was consulted, although effusions not
large enough to tap. She had a second aspiration event on ___.
Initially on vanc/cefepime/flagyl and transitioned to
cefpodoxime/flagyl on ___ to continue through ___ for a
7-day course from last aspiration event.
# Hypoxic Respiratory Failure: Patient intubated on ___ to
protect her airways due to concern for aspiration as well as for
upper endoscopy. She was successfully extubated on ___
following the procedure.
# Acute on chronic diastolic heart failure: After patient was
extubated, noted to have pulmonary edema concerning for acute on
chronic diastolic heart failure. She was diuresed with Lasix
60mg IV boluses, and her home torsemide was increased to 20mg po
daily. She was then transitioned back to her home torsemide 10mg
po daily.
# Acute on chronic kidney injury: Baseline Cre of about 1.8 on
presentation to ___. Subsequently peaked to 2.5 in the setting
of pneumonia. She was initially given IVF with some improvement.
___ have subsequently developed cardiorenal, so she was diuresed
as above. Creatinine on discharge of 2.1.
# Anemia: Baseline Hgb is around 8s, thought to be due to CKD,
per family. After EGD, patient required 1U PRBC transfusion. She
had no evidence of bleeding. Iron studies obtained consistent
with iron deficiency anemia. She was given IV iron during her
hospitalization. She was not transitioned to oral iron given her
age and difficulty swallowing.
CHRONIC ISSUES:
# COPD: mild based on most recent PFTs from ___. She received
standing duonebs with PRN albuterol during hospitalization.
# RLE pain: Ultrasound obtained without evidence of DVT, however
notable for a Bakers Cyst. She was started on low dose
gabapentin 100mg po daily to help with leg pain.
***TRANSITIONAL ISSUES***
-Summary of IV antibiotic course
- IV cefepime/flagyl (___)
- IV vanco (___)
- Patient should continue cefpodoxime and flagyl through ___
to complete a 7-day course from last witnessed aspiration event
- Patient with sats 93-96% on 2.5L NC on day of discharge (no
baseline O2 requirement)
- Should remain on soft diet, with as many meds crushed as
possible. Continue to address diet in regards to goals of care
- Patient would benefit from psychiatric appointment to help
with coping given recent hospitalization; she expressed interest
in this at ___
- Patient received 1U of PRBCs during admission for anemia;
follow-up as outpatient
- Noted to have increased thrombocytosis during hospitalization,
please recheck platelets in 1 week
- Given IV iron during hospitalization for iron deficiency
anemia
- Patient with hyperphosphatemia, likely in setting of CKD,
should continue monitoring as outpatient
- Considering trial of discontinuing gabapentin as uncertain if
this is necessary for ___ cyst.
- CODE: DNR/DNI
- Contact: Daughter ___ (HCP) ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
2. Allopurinol ___ mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. Pravastatin 60 mg PO QPM
6. Tiotropium Bromide 1 CAP IH DAILY
7. DULoxetine 30 mg PO BID
8. Torsemide 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q4H:PRN Pain - Mild
2. Cefpodoxime Proxetil 400 mg PO Q24H Duration: 2 Days
Last dose on ___. Docusate Sodium 100 mg PO BID:PRN constipation
4. Gabapentin 100 mg PO DAILY
5. GuaiFENesin 10 mL PO Q6H:PRN cough
6. MetroNIDAZOLE 500 mg PO Q8H Duration: 2 Days
Last day ___
7. Pantoprazole (Granules for ___ ___ 40 mg PO DAILY
8. Allopurinol ___ mg PO EVERY OTHER DAY
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheeze
10. amLODIPine 5 mg PO DAILY
11. DULoxetine 30 mg PO BID
12. Pravastatin 60 mg PO QPM
13. Tiotropium Bromide 1 CAP IH DAILY
14. Torsemide 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Food impaction
Aspiration pneumonia
Secondary Diagnosis:
Acute hypoxic respiratory failure
Acute on chronic diastolic heart failure
Acute on chronic kidney injury
Leukocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after
you were eating and food was stuck in your esophagus. This was
removed by an upper endoscopy when you were in the Intensive
Care Unit. On the upper endoscopy the doctors noted that ___ had
a large hernia and your esophagus was at a sharp angle, which is
likely why food was getting stuck. We recommend that you remain
on a soft diet to prevent any other food from becoming stuck.
You also developed a pneumonia during your hospitalization that
was treated with a course of IV antibiotics. You improved during
your hospital stay, however you would benefit from physical
therapy to help you get stronger.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
19765303-DS-20
| 19,765,303 | 20,617,928 |
DS
| 20 |
2146-04-27 00:00:00
|
2146-05-25 18:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / cantalope /
epinephrine / chocolate flavor / pitted fruits
Attending: ___.
Chief Complaint:
Increased abdominal distention, lower extremity edema, dyspnea
on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ w/ history of Afib on coumadin, GERD, and
osteoporosis who presented to GI clinic today with early satiety
and abdominal distension for the last month; was also found to
have new ___ edema and crackles, so was sent to ED for further
evaluation of new CHF. She also endorsed dyspnea on exertion and
___ edema progressively worsening over the past month. She
usually sleeps propped up on ___ pillows due to back pain; this
has not changed recently. For the past week, she has been unable
to do chores around the house. Her PCP ordered ___ CT torso
yesterday that showed cardiomegaly, LVH, and new 4.2 cm aortic
root aneurysm and and enlargement of pulmonary artery suggestive
of pulm HTN. In GI clinic today, she was also found to have HR
in the 110-130 (in afib), with BP 160/113. She was short of
breath but reportedly satting adequately (not documented). In GI
clinic she reported a 5 lb weight gain in the past week;
however, her admission weight of 188 lbs is lower than any other
recorded weight in OMR (most recently 195 in ___. She
denies recent surgeries, prolonged travel, hemoptysis, history
of DVT or PE.
In the ED intial vitals were: 98.0 78 127/104 18 98% RA. Labs
remarkable for Hgb 11.6 (baseline 12), INR 2.8, BNP 3,200,
BUN/Cr ___, lytes WNL, Trop <0.01, D-dimer 306. CXR showed
cardiomegaly with mild pulmonary edema and likely small
bilateral pleural effusions. Patient received Pantoprazole 80 mg
IV x1, furosemide 20 mg IV x1, tramadol and was admitted. Vitals
on transfer were: 98 95 139/83 18 99% RA.
On the floor, the patient complained of abdominal distension /
indegestion which was improved with Tums.
ROS: On review of systems, denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies recent fevers, chills or rigors.
Denies exertional buttock or calf pain. All of the other review
of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG: never
- PERCUTANEOUS CORONARY INTERVENTIONS: never
- PACING/ICD: never
3. OTHER PAST MEDICAL HISTORY:
Atrial fibrillation, on warfarin
?History of stroke
Osteoarthritis
Osteoporosis c/b vertebral Fx s/p kyphoplasty
GERD
Venous insufficiency
Obesity
Hip replacement
s/p laminectomy
Social History:
___
Family History:
Mother and father w/ CHF, son and daughter w/ cronh's disease,
nephew w/ celiac dz. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
Admissions Physical:
VS: 97.8 159/95 107 20 95%
GENERAL: NAD. Oriented x3 Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP noted mid-neck seated upright.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Kyphosis. Resp were unlabored, no accessory muscle use.
Decreased breath sounds at bilateral bases with dullenss to
percussion. Crackles at L base.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: 1+ pitting edema to mid-shins bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge Physical:
VS: 98 100s-130/60s-70s ___ 95%RA
GENERAL: in NAD. Oriented x2.
HEENT: Sclera anicteric.
NECK: Supple with JVP of 9 cm.
CARDIAC: Irregular rhythm, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Bilateral bibasilar crackles. Kyphotic spine. No use of
accessory muscles. No wheezes or rhonchi.
ABDOMEN: Soft, NT, softly. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: 2+ pitting edema of lower extremities.
SKIN: Bilateral erythema of lower extremities up to mid shin.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
Pertinent Results:
Admissions Labs:
___ 07:03PM D-DIMER-306
___ 06:10PM GLUCOSE-137* UREA N-16 CREAT-0.8 SODIUM-137
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14
___ 06:10PM estGFR-Using this
___ 06:10PM cTropnT-<0.01
___ 06:10PM proBNP-3254*
___ 06:10PM ALBUMIN-3.8
___ 06:10PM WBC-4.4 RBC-3.84* HGB-11.6* HCT-34.8* MCV-91
MCH-30.1 MCHC-33.2 RDW-16.6*
___ 06:10PM NEUTS-72.5* LYMPHS-17.5* MONOS-9.0 EOS-0.9
BASOS-0.1
___ 06:10PM ___ PTT-42.2* ___
___ 06:10PM PLT COUNT-164
Discharge Labs:
___ 06:05AM BLOOD WBC-3.8* RBC-3.72* Hgb-11.3* Hct-33.8*
MCV-91 MCH-30.3 MCHC-33.4 RDW-17.0* Plt ___
___ 06:05AM BLOOD Plt ___
___ 06:05AM BLOOD Glucose-94 UreaN-22* Creat-0.9 Na-137
K-4.1 Cl-99 HCO3-28 AnGap-14
___ 06:05AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.9
Imaging: Echo
IMPRESSION: Biatrial enlargement. Mild symmetric left
ventricular hypertrophy with normal systolic function. Likley
moderate to severe mitral regurgitation accounting for shadowing
from calcification (can be better quantified by TEE if
clinically indicated). Right ventricular systolic dysfunction.
Moderate sized posteriorly located pericardial efusion without
2D echocadiographic evidence of tamponade
Brief Hospital Course:
Ms. ___ is an ___ w/ history of Afib on coumadin, GERD, and
osteoporosis admitted with likely new CHF with possible
pulmonary hypertension based on dilated PA on CT.
# New ___: Patient admitted with SOB and feeling like her
abdomen was become more distended and had associated pressure at
the flanks as well as early satiety. She did not have known CAD
although she had risk factors. Echo completed while admitted
shows preserved ejection fraction (60%) with moderate to severe
mitral regurgitation (3+) which was thought to be the most
likely cause of her new CHF. She was ruled out for MI with
negative troponins. The decision was made to optimize MR
medically with afterload reduction and diuresis. She was
diuresed while admitted once daily with IV lasix 40-60 mg. She
was also started on spironolactone 12.5 mg daily. She was
discharged on a PO regimen of lasix (40 mg daily),
Spironolactone 12.5 mg daily, and lisinopril 5 mg daily.
# Afib: Longstanding diagnosis with HR in the 110s-120s on
admission. Her home carvedilol was increased from 12.5 mg BID to
25 mg BID with overall improvement in HRs to ___ on
discharge. At discharge, the patient was switched back to her
home dose of 12.5 mg BID. She was continued on her home dose of
warfarin, 2.5 mg.
# Abdominal distension: Patient complaining of progressively
worsening abdominal distention and early satiety for the last
month and was being evaluated by GI for this issue with unclear
etiology at the time of admission. Given concomitant symptoms of
lower extremity edema and severe mitral regurgitation, it was
thought that this was also due to fluid overload. The feeling of
"pulling" and dissension that the patient described improved
through the course of her hospitalization along with diuresis.
# Osteoporosis: Stable while admitted. The patient did describe
pain related to her recent kyphoplasty, but this was relieved by
her previously prescribed tramadol. Home calcitonin, vitamin D,
and tramadol were continued.
# GERD: Stable, continued home omeprazole
# HLD: Continued home lovastatin
# Insomnia: Continued on home zolpidem.
Transitional Issues:
-Patient will need to weigh herself daily. Discharge weight 180
lbs.
-The patient will need to establish cardiology care with Dr.
___ or other cardiologist at ___
-The patient will need to follow up with her outpatient PCP ___.
___
-___ patient will need an Chem 7 INR check on ___ or
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain, fever, ha
2. Calcitonin Salmon 200 UNIT NAS DAILY
3. Carvedilol 12.5 mg PO BID
4. Vitamin D 1000 UNIT PO DAILY
5. Lovastatin 20 mg oral QHS
6. Omeprazole 40 mg PO DAILY
7. Senna 8.6 mg PO BID
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
9. Warfarin 2.5 mg PO DAILY16
10. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
11. Multivitamins 1 TAB PO DAILY
12. Cyanocobalamin 50 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain, fever, ha
2. Calcitonin Salmon 200 UNIT NAS DAILY
3. Carvedilol 12.5 mg PO BID
4. Cyanocobalamin 50 mcg PO DAILY
5. Lovastatin 20 mg oral QHS
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Senna 8.6 mg PO BID
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 2.5 mg PO DAILY16
12. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
13. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
14. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
15. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*0
16. Outpatient Lab Work
Please draw a Chem 7 and INR on ___
ICD-9 Code: ___
Please fax this to Dr. ___ at ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: new onset diastolic heart failure
Secondary Diagnoses: Hypertension, atrial fibrillation, GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of your increased
abdominal distension and leg swelling. It was found that you
have increased fluid in your body that required diuretics. You
breathing and swelling improved and we also were able to find a
regimen to control your blood pressure.
Please weigh yourself every day and call your doctor if your
weight goes up by more than 3 lbs.
You are now ready to be discharged. Please follow up with Dr.
___ cardiologist at ___ and your primary
care doctor, ___.
Followup Instructions:
___
|
19765544-DS-12
| 19,765,544 | 28,026,444 |
DS
| 12 |
2188-05-31 00:00:00
|
2188-08-26 12:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Motor vehicle crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o EtOH cirrhosis w ascites, squamous cell cancer of the
mouth transferred from ___ s/p ___ MVC's (___). In the
first event, he was rear-ended at low speed without damage to
the car and did not seek treatment. About an hour later he
swerved to avoid a car that had stopped suddenly and hit a
telephone pole. +airbag deployment, significant damage to car
and pole. He self-extricated and was a&o x3 on scene, no LOC,
complaining of back pain and upper chest pain. Initial
evaluation at ___ revealed L 1st rib fracture and R
anterior 5th rib fracture with possible fracture of C5 left
anterior/inferior endplate. Currently c/o upper chest pain and
lower back pain. GCS 15. AAOx3 and answers appropriately.
Past Medical History:
Squamous cell cancer of the mouth s/p radiation and
ongoing chemo. Alcoholic cirrhosis with ascites. Had a previous
esophageal dilation.
Social History:
___
Family History:
noncontributory
Physical Exam:
Gen: NAD, AAOx3
HEENT: PERRLA, EOMI, mucosa pink, no LAD, c-collar intact
CV: RRR no mrg
Pulm: Crackles ___. TTP over rib fractures.
Abd: s/nt/nd; bsx4; inc: c/d/i
MS/Ext: no c/c/e; +2 pulses. very mild TTP L-spine. No stepoffs
/ deformities.
Pertinent Results:
___ 08:11AM ___ PTT-30.3 ___
___ 08:00AM URINE HOURS-RANDOM
___ 08:00AM URINE UHOLD-HOLD
___ 08:00AM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-NEG
___ 08:00AM URINE RBC-6* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-1
___ 08:00AM URINE GRANULAR-2*
___ 08:00AM URINE MUCOUS-RARE
___ 06:24AM GLUCOSE-78 UREA N-11 CREAT-0.4* SODIUM-135
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-23 ANION GAP-15
___ 06:24AM estGFR-Using this
___ 06:24AM WBC-8.6 RBC-3.73* HGB-11.1* HCT-33.1* MCV-89
MCH-29.8 MCHC-33.5 RDW-18.6* RDWSD-57.6*
___ 06:24AM NEUTS-83.6* LYMPHS-6.4* MONOS-8.7 EOS-0.5*
BASOS-0.2 IM ___ AbsNeut-7.17* AbsLymp-0.55* AbsMono-0.75
AbsEos-0.04 AbsBaso-0.02
___ 06:24AM PLT COUNT-107*
Brief Hospital Course:
___ h/o EtOH Cirrhosis, HNN squamous cell carcinoma s/p MVC on
___. He was transferred from OSH for mgt ___ to findings L
1st rib fx and R anterior 5th rib fx with possible fracture of
C5 left anterior/inferior endplate. Pertinent negative on
imaging at OSH includes no traumatic head injuries. Consulting
team deemed the cervical fracture was non-operative and
recommend mgt via c-collar with outpatient follow up. pt was
placed under the care of ___ team.
N:pt was AAOx3 throughout hospitalization. pain managed fairly
conservatively with morphine, per pt.
CV: Cardiovascular functions were monitored routinely
noninvasively and pt was hemodynamically stable.
Pulm: Pulmonary toilet was encouraged. However, pt's O2
saturation persists in the low 90's, of which he said was his
baseline. Upon discharge on HD#2, pt had an episode of desating
into the high 80's despite being on high O2 NC. He was
asymptomatic. At this point had decided to leave AMA and left
the hospital despite discussion regarding his respiratory
status.
GIGUFEN: pt has a known baseline dysphagia ___ his h/o CA. pt
was kept NPO with discussion with this primary oncologist / PCP
(at ___ regarding nutrition. Both she and the patient
felt it was appropriate for him to continue eating soft solids
as he has been doing. He had no aspiration events. pt's fluid
balance was recorded and electrolytes were repleted
appropriately.
ID: pt was afebrile throughout hospitalization.
DVT ppx was given as HSQ.
Upon d/c, pt was doing well, afebrile, and without pain. He did
desat to the high 80's just prior to his leaving and it was
recommended to him to stay until stabilization. Pt was adamant
about being transferred back to the care at ___, reasons
of which relates to his continuing therapy for cancer. ___
d/w his oncologist relating to his best interest to remain at
___ until medically cleared, pt opted to leave AMA. Risks and
benefits of his decision was explained to the patient throughout
his hospital course. pt verbalizes understanding but left the
___ on his own in a private vehicle.
Discharge Medications:
1. Lactulose 20 mL PO BID
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Mirtazapine 15 mg PO QHS
4. Ondansetron 4 mg IV Q8H:PRN nausea
5. Scopolamine Patch 1 PTCH TD Q72H oral secretions Duration: 72
Hours
6. Sucralfate 1 gm PO QID
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
C5 endplate fracture
Rib fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ACS service at ___ following two
motor vehicle accidents. Initial evaluation at ___
revealed several rib fractures, and cervical spine fractures.
Orthopedic surgery was consulted due to injury to your cervical
spine, with the following assessment: You have a non-displaced
C5 inferior endplate fracture, which is a non-operative injury
that can be treated in a c-collar. This collar should be left on
at all times with manual stabilization for changes. You are
recommended to follow up in ___ weeks as an outpatient in the
spine clinic for further evaluation.
Due to injuries to your ribs, which can cause severe pain, you
are at an increased risk for pneumonia. 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. 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. 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. Non-steroidal
anti-inflammatory 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).
Due to your severe baseline dysphagia, an assessment by speech
and swallow team was obtained. You have a history of difficulty
managing secretions and risk for respiratory compromise /
aspiration. It was recommended that you adhere to strict NPO
with all nutrition and hydration. However, you have expressed
your desire to have close follow up with speech and swallow
therapy and nutrition at ___. Your oncologist has been
made aware of the situation and was agreeable to help coordinate
your on-going nutrition requirement with your radiation therapy
at ___.
We wish you all the best with your recovery
Followup Instructions:
___
|
19765629-DS-3
| 19,765,629 | 23,364,124 |
DS
| 3 |
2189-09-26 00:00:00
|
2189-09-26 19:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cimetidine / codeine / diclofenac / ibuprofen / Naprosyn /
Penicillins
Attending: ___
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
CC: ___ of breath
HPI: Ms. ___ is a ___ woman with history of HTN, HLD,
DMII, PVD, depression, uterine cancer, iron deficiency anemia
presenting with shortness of breath.
The patient tells me that her shortness of breath began about 1
month ago. This was initially associated with a cough. No fevers
or chills. She had a negative CXR on ___. She saw her PCP ___
___, who diagnosed her with bronchitis and prescribed her a
10-day course of doxycycline. Over the course of the month, the
patient notes that her shortness of breath, which is primarily
dyspnea on exertion, has progressively worsened. She also notes
some dizziness with position change. She denies any hemoptysis,
hematemesis, hematuria, melena, hematochezia. She reports that
she has iron deficiency anemia and is prescribed an iron
supplement but she has not taken it in about a month due to
feeling generally unwell. Patient does not take NSAIDS. Rare
alcohol use and none recently.
She presented to her PCP ___ ___ primarily to discuss her leg
pain. She has neuropathy that has been present for years. It
began about ___ years ago after she completed her chemotherapy for
her uterine cancer. However, recently, the pain in her feet has
been worse. She describes it as a deep ache. No claudication.
She
reports mild swelling in her legs, left>right. The gabapentin
helps, and has been recently increased. She has been taking
tramadol, but says this does not help.
In the ED, initial vitals were 96.6 89 155/76 19 100% RA. On
exam, patient is in no acute distress, with clear lungs, trace
lower extremity edema. Guaiac testing was negative. Labs showed
hemoglobin 5.8, Na 128, bicarbonate 20, magnesium 1.4, LDH 252.
She received 4 grams magnesium sulfate, 50 mg tramadol, and 1000
mg acetaminophen. DVT ultrasound was negative. Chest x-ray was
unremarkable. The patient was not transfused.
On arrival to the floor, the patient reports that she has severe
leg pain. Otherwise, she denies dizziness, lightheadedness,
shortness of breath, chest pain, palpitations, or any other
complaints at present.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- DMII c/b neuropathy
- HTN
- HLD
- PVD
- Iron deficiency anemia
- Uterine cancer s/p TAH/BSO, chemo
- S/p bilateral knee arthroplasties
- Remote DVT
Social History:
___
Family History:
- Mother: CAD, HTN
- Brother: HTN
Physical ___:
ADMISSION:
==========
VITALS: 97.9 160/90 79 18 99 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs, trace bilateral pedal
edema
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE:
==========
24 HR Data (last updated ___ @ 811)
Temp: 98.2 (Tm 98.3), BP: 114/73 (114-171/69-90), HR: 92
(80-95),
RR: 18, O2 sat: 100% (97-100), O2 delivery: RA/amb
Amb sat 100% on RA
GENERAL: NAD, lying comfortably in bed
EYES: PERRL, anicteric sclerae, no conjunctival pallor
ENT: OP clear
CV: RRR, nl S1, S2, no M/R/G, no JVD
RESP: CTAB, no crackles, wheezes, or rhonchi
GI: obese, + BS, soft, NT, ND, no rebound/guarding, reducible
ventral hernia, non-tender
GU: No suprapubic fullness or tenderness to palpation
SKIN: mild induration and tenderness at R AC at site of PIV
removal with possible scant purulent discharge; no erythema,
warmth, or fluctuance
NEURO: AOx3, CN II-XII intact, ___ strength in upper extremities
b/l, ___ in lower extremities, sensation grossly intact
throughout, gait testing deferred
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION:
===========
___ 11:35AM BLOOD WBC-8.2 RBC-2.97* Hgb-5.8* Hct-19.9*
MCV-67* MCH-19.5* MCHC-29.1* RDW-19.1* RDWSD-46.4* Plt ___
___ 11:35AM BLOOD ___ PTT-24.5* ___
___ 07:20AM BLOOD ___ 11:35AM BLOOD Ret Aut-2.5* Abs Ret-0.08
___ 11:35AM BLOOD Glucose-136* UreaN-6 Creat-0.7 Na-128*
K-4.7 Cl-95* HCO3-20* AnGap-13
___ 11:35AM BLOOD ALT-6 AST-12 LD(LDH)-252* AlkPhos-98
TotBili-0.3
___ 07:20AM BLOOD cTropnT-<0.01
___ 11:35AM BLOOD cTropnT-<0.01
___ 11:35AM BLOOD proBNP-291
___ 11:35AM BLOOD Lipase-28
___ 11:35AM BLOOD Albumin-4.2 Calcium-9.5 Phos-3.6 Mg-1.4*
Iron-20*
___ 11:35AM BLOOD calTIBC-517* Hapto-240* Ferritn-8.0*
TRF-398*
___ 07:20AM BLOOD VitB12-356 Folate-6
DISCHARGE:
===========
WBC 8.9, Hgb 8.2 (from 8.0), Plt 452
BMP WNL (Glu 161)
Ca 9.2, Mg 1.8, Phos 5.1
UA: neg blood, neg nit, neg ___, tr prot, 3 RBCs, 1 WBCs, few
bact
UCx (___): 10K-100K GNRs
IMAGING:
========
Left lower extremity ultrasound (___):
No evidence of deep venous thrombosis in the left lower
extremity
veins.
CXR (___):
No acute cardiopulmonary abnormality.
EKG (___):
NSR at 96 bpm, nl axis, PR 130, QRS 73, QTC 458, early R wave
progression, non-specific ST-T wave abnormalities
Prior:
------
Colonoscopy ___, NOT THIS HOSPITALIZATION):
12 mm sessile polyp in ileocecal valve. Polypectomy performed
with hot snare. Polyp retrieved.
3 - 3 to 5 mm sessile polyps in hepatic flexure. Polypectomy
performed with cold biopsy forceps and cold snare (1). Polyp
retrieved.
6 mm semi-pedunculated polyp in mid transverse colon.
Polypectomy
performed with hot snare. Polyp retrieved.
8 mm semi-pedunculated polyp in mid transverse colon with broad
stalk. Polypectomy performed with hot snare. Polyp retrieved.
3 mm sessile polyp in mid transverse colon. Polypectomy
performed
with cold biopsy forceps. Polyp retrieved.
5 mm sessile polyp in splenic flexure. Polypectomy performed
with
cold snare. Polyp retrieved.
3 mm sessile polyp in mid descending colon. Polypectomy
performed
with cold biopsy forceps. Polyp retrieved.
3 and 6 mm sessile polyp 30 cm. Polypectomy performed with cold
biopsy forceps and cold snare. Polyp retrieved.
4 mm sessile polyp 20 cm. Polypectomy performed with cold snare.
Polyp retrieved.
7 - 2 to 5 mm sessile polyp in rectum. Polypectomy performed
with
cold biopsy forceps and cold snare (1). Polyp retrieved.
Sigmoid diverticulosis with totuosity and spasm.
Internal hemorrhoids.
Brief Hospital Course:
___ woman with history of HTN, HLD, DMII, depression,
uterine cancer s/p hysterectomy, iron deficiency anemia
presenting with progressive dyspnea on exertion, found to have
symptomatic, hemodynamically stable iron-deficiency anemia.
# Dyspnea on exertion:
# Acute on chronic iron-deficiency anemia:
Patient presented with progressive dyspnea on exertion
unresponsive to outpatient treatment for bronchitis (with
doxycycline and inhaled steroids). Hgb 5.8 on admission with
ferritin of 8, consistent with severe iron deficiency anemia. HD
stable. CXR negative. No clear bleeding, and guaiac negative in
the ED. Of note, was previously diagnosed with iron deficiency
anemia in ___ (Hgb 7.1), at which time guaiac was positive
and
patient was started on iron supplementation (which she had
self-discontinued). Underwent colonoscopy ___ with multiple
polyps resected, diverticulosis, internal hemorrhoids. Possible
etiologies for her iron-deficiency anemia include occult GI
bleeding, less likely iron malabsorption in absence of
significant diarrhea or prior bowel resection. Given degree of
microcytosis, would also consider superimposed thalassemia.
B12/folate WNL; no evidence of hemolysis. Hgb bumped
appropriately to 8.0 with 2u pRBCs on ___ and was stable at
8.2 at the time of discharge. She received ferric gluconate
125mg
IV on ___. She had no bowel movements while hospitalized, and
there was no evidence of hematuria or hemoptysis. Her dyspnea on
exertion had largely resolved after transfusion, and ambulatory
saturation was 100% on RA at discharge. She will ___ with her
PCP's office on ___, at which time a CBC should be checked. She
has a referral for a colonoscopy through ___ and will call to
schedule an appointment after discharge (if negative, would
consider referral for EGD). In addition, she was referred to
___
hematology for consideration of thalassemia w/u and further IV
iron infusions. She was encouraged to resume ferrous sulfate on
discharge, dosing changed to 325mg every other day given recent
data on equivalent outcomes to daily dosing. Home doxycycline
was
discontinued in absence of clear pneumonia or bacterial
bronchitis. Home flovent continued on discharge.
# Moderate hyponatremia:
Na 128 on admission. Asymptomatic, unknown chronicity as nor
recent BMP in Atrius records. Suspect hypoosmolar hyponatremia
secondary to anemia. Resolved with transfusion.
# Bilateral chronic leg pain:
# Neuropathy:
Chronic b/l leg pain over years, previously attributed to
diabetic neuropathy compounded by chemotherapy-induced
neuropathy. Has hx of PVD but no symptoms to suggest
claudication. Has followed at ___ pain clinic and palliative
care
previously and was weaned off narcotics ___. Recently trialed
tramadol through her PCP with minimal improvement. She was
continued on her home gabapentin 600mg BID and 1200mg QHS with
intermittent oxycodone PRN. She was discharged on home
gabapentin
and Tylenol and was given additional tramadol 50mg q8h (15
tablets) to bridge her to her PCP office appointment on ___.
Further ___ could be considered with ___ pain clinic (previously
seen by Dr. ___ and with ___ palliative care (NP ___, last
seen ___.
# Nicotine dependence:
Patient is trying to quit. Prescribed nicotine patch on
discharge.
# DMII:
Patient on home metformin and recently prescribed Jardiance,
which she has not yet initiated. Treated with ISS while
hospitalized, continued on metformin and Jardiance on discharge.
# Depression:
Continued home sertraline.
# Endometrial cancer:
Stage IV, s/p chemo completed ___. Followed by Dr. ___ at
___. Reportedly no e/o active disease. Outpatient ___ per Dr.
___.
# Asymptomatic bacteriuria:
UCx growing 10K-100K GNRs. UA was negative on admission, and
patient without symptoms; suspect asymptomatic bacteriuria. Was
not treated with antibx.
# Right AC induration at PIV site:
On PIV removal from R AC at discharge was noted to have scant
purulence and tenderness. No erythema, warmth, or fluctuance to
suggest clear cellulitis or abscess. Likely superficial
thrombophlebitis. Patient was encouraged to keep extremity
clean, elevate, and apply warm compresses. Return precautions
given. Would reassess site at PCP ___ on ___.
# Code Status/Advance Care Planning: FULL (confirmed)
** TRANSITIONAL **
[ ] please assess right AC at PCP ___ (site of prior PIV) to
ensure no abscess or cellulitis
[ ] would check CBC at PCP ___ Hgb on d/c 8.5
[ ] ___ with hematology for further w/u, consideration of
additional IV iron
[ ] will require outpatient colonoscopy and EGD ___ negative
[ ] ___ smoking cessation; prescribed nicotine patch on d/c
[ ] further w/u and management of chronic pain
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO BID
2. Gabapentin 1200 mg PO QHS
3. Sertraline 37.5 mg PO QHS
4. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
5. Jardiance (empagliflozin) 10 mg oral DAILY
6. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
7. Ferrous Sulfate 325 mg PO DAILY
8. fluticasone 220 mcg/actuation inhalation BID
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. calcium carbonate-vitamin D3 600 mg (1,500 mg)-800 unit oral
daily
12. Cyanocobalamin 1000 mcg PO DAILY
13. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
14. Ranitidine 150 mg PO BID
15. Doxycycline Hyclate 100 mg PO Q12H
Discharge Medications:
1. Benzonatate 100 mg PO BID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth twice a day as
needed Disp #*30 Capsule Refills:*0
2. Nicotine Patch 14 mg/day TD DAILY
RX *nicotine 14 mg/24 hour Apply one patch daily Disp #*14 Patch
Refills:*0
3. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
RX *ferrous sulfate [iron] 325 mg (65 mg iron) 1 tablet(s) by
mouth every other day Disp #*30 Tablet Refills:*0
4. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
6. calcium carbonate-vitamin D3 600 mg (1,500 mg)-800 unit oral
daily
7. Cyanocobalamin 1000 mcg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. fluticasone 220 mcg/actuation inhalation BID
10. Gabapentin 600 mg PO BID
11. Gabapentin 1200 mg PO QHS
12. Jardiance (empagliflozin) 10 mg oral DAILY
13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
14. Ranitidine 150 mg PO BID
15. Sertraline 37.5 mg PO QHS
16. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every 8 hours as needed
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Iron deficiency anemia
Diabetes mellitus
Chronic neuropathic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with shortness of breath and
found to have low blood counts. There was no evidence of
bleeding. You were treated with blood transfusion and
intravenous iron with improvement in your blood counts and
symptoms.
You will need to follow up with your primary care doctor and
with a blood doctor for further workup. It will be very
important to have a colonoscopy done to look for sources of
bleeding in the GI tract, so please schedule your colonoscopy as
soon as possible.
Please follow up with your outpatient doctors as ___ and
take your medications as prescribed.
With best wishes,
___ Medicine
Followup Instructions:
___
|
19766179-DS-18
| 19,766,179 | 27,629,697 |
DS
| 18 |
2130-08-16 00:00:00
|
2130-08-16 18:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Right Heart Catheterization: ___
History of Present Illness:
Mr. ___ is a ___ with CAD s/p PCI, hypertension, COPD with
emphysema (___), active smoker who presents with 8
weeks of progressive shortness of breath, dyspnea of exertion,
weightloss.
Patient shares he has intermittent shortness of breath. Baseline
function: can walk up a flight of stairs, ___ blocks, functions
well with daily activities, previous exercise stress tests with
no problem. Not a very active person, does not exercise. 2
months
ago, SOB/DOE worsened, and currently he cannot do his usual
flight of stairs, and he cant go more than 15 steps without
significant dyspnea. He shares after minimal exertion, he is
"gasping for air". Today, he went to his friends house whose
wife
is a ___, his O2 saturation was 72% and went up to 82% with
rest and deep breathing. He then came to ___ ED.
ROS: No chest pain, chest pressure, chest tightness, arm pain,
presyncope, PND, weight gain, constipation, diarrhea, abdominal
swelling, leg swelling. Mild dry cough few weeks ago that has
resolved. Endorses ___ pound weight loss as of 6 months ago.
In the ED, initial VS: AF, BP 132/70, HR 65, RR 26, SaO2 85%
RA.
On exam he was noted to be in mild respiratory distress.
Tachypnea and O2 saturation improved on 3L NC.
Labs/studies notable for a negative troponin x1, elevated BNP >
1000, normocytic anemia H/H ___ and a glucose of 132.
CXR: mild to moderate pulmonary edema and small right pleural
effusion.
Patient was given: IV Lasix 20mg x1
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
- Impaired fasting glucose
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: MI (___) s/p
DES(unknown, no report available)
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- Mild CVA in ___, no deficits, +several TIAs
- Asthma, COPD
- Iron deficiency anemia
- MGUS (___)
- Possible colitis (IBD vs ischemic)
- Gastritis, negative for H. pylori
- Pericardial effusion ___ with tamponade physiology, unclear
etiology
- Gout
- s/p Cholecystectomy
Social History:
___
Family History:
- Father with HTN and heart disease died at ___
- Mother ___ died of lymphoma
- Sister MI, HTN, DM ___
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM
=========================
VS: 128 / 85 60 20 99 3L NC
87.3kg
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with
CARDIAC: distant S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: CTAB with bibasilar crackles, R>L ___ of the way up
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
=========================
DISCHARGE PHYSICAL EXAM
=========================
VS: Afebrile, 100-140s/50-90s, 50-60s, ___, 91-100% RA-3L
(recently 2l)
I/Os: ___
Wt: 87.3kg -> 86 -> 86.6 -> 86.2 -> 85.5 -> 85.9 -> 86.2 ->
86.4
-> 85.9
GENERAL: NAD. Oriented x3. Sitting in bed.
HEENT: JVP low-neck slightly above clavicle.
CARDIAC: Distant S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: Bibasilar crackles R>L
ABDOMEN: Soft, NTND. No HSM or tenderness. No CVAT.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
===================
ADMISSION LABS
===================
___ 04:45PM BLOOD WBC-6.3 RBC-4.46* Hgb-11.0* Hct-37.2*
MCV-83 MCH-24.7* MCHC-29.6* RDW-18.6* RDWSD-55.7* Plt ___
___ 04:45PM BLOOD Neuts-86.8* Lymphs-9.9* Monos-2.7*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-5.47 AbsLymp-0.62*
AbsMono-0.17* AbsEos-0.01* AbsBaso-0.01
___ 04:45PM BLOOD ___ PTT-27.5 ___
___ 04:45PM BLOOD Plt ___
___ 07:25AM BLOOD Ret Aut-3.3* Abs Ret-0.12*
___ 04:45PM BLOOD Glucose-132* UreaN-12 Creat-0.9 Na-142
K-4.6 Cl-106 HCO3-22 AnGap-14
___ 07:25AM BLOOD ALT-5 AST-10 LD(LDH)-196 AlkPhos-47
TotBili-0.5
___ 01:30AM BLOOD CK(CPK)-57
___ 04:45PM BLOOD proBNP-1095*
___ 04:45PM BLOOD cTropnT-<0.01
___ 01:30AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:30AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.8
___ 07:25AM BLOOD calTIBC-239* Hapto-228* Ferritn-52
TRF-184*
___ 04:45PM BLOOD TSH-1.4
___ 04:45PM BLOOD Free T4-1.3
___ 07:20AM BLOOD HIV Ab-NEG
===================
DISCHARGE LABS
===================
___ 07:50AM BLOOD WBC-4.6 RBC-4.02* Hgb-9.9* Hct-32.9*
MCV-82 MCH-24.6* MCHC-30.1* RDW-17.2* RDWSD-51.6* Plt ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-93 UreaN-19 Creat-1.1 Na-141
K-4.7 Cl-104 HCO3-27 AnGap-10
___ 07:50AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8
===================
IMAGING/STUDIES
===================
V/Q scan ___: Very low likelihood of pulmonary embolism.
CT chest non-contrast ___: Mild pulmonary edema, slight bl
pleural effusions new since ___, upper-lobe predominant
centrilobular and paraseptal emphysema, diffuse airway
thickening
suggesting chronic bronchitis, large # of borderline mediastinal
lymph nodes enlarged compared to ___
RHC ___: RA 7, PA ___ (mPAP 40), PCWP 13, Fick CO 5.61,
PVR
4.81 ___.
100% O2: mPAP 33, PCWP 13, CO 6.77, PVR 2.95.
iNO: mPAP 30, PCWP 12, CO 7.56, PVR 2.38
TTE ___: EF>60%, mild symmetric LVH with normal cavity size
and global systolic function, mildly dilated RV cavity, mild
global RV free wall hypokinesis, abnormal systolic septal motion
c/w RV pressure overload, PASP 54+RAP, no AS, trivial MR.
___ to ___ new RV dilation and free wall hypokinesis,
prior
PASP indeterminate. Bubble study without PFO.
Inpatient PFTs ___: FEV1/FVC 63%, FEV1 1.81(59%), FVC
2.86(70%), large BD response in FEV1 and FVC, TLC 6.91(105),
DLCO[Hb] 11.15(44%). Moderate obstruction with large BD
response,
moderate gas exchange deficit.
PFTs ___: FEV1/FVC 48%, FEV1 2.00(64%), FVC 4.17(102%),
DLCO[Hb] 12.90(50%). Moderate obstructive ventilatory deficit
with a moderate gas exchange deficit.
Brief Hospital Course:
==========================
PATIENT SUMMARY
==========================
Mr. ___ is a ___ with CAD s/p PCI, hypertension, COPD with
emphysema, and an active smoker who presented with 8 weeks of
progressive shortness of breath, dyspnea of exertion, and weight
loss - found to have moderate PAH that was responsive to
Sildenafil, with course complicated by development of
microscopic hematuria and UTI.
==========================
ACTIVE ISSUES
==========================
#Pulmonary Artery Hypertension: Mr. ___ presented with
subacute shortness of breath and dyspnea on exertion, and was
found to be hypoxemic on admission (SO2 to the 70-80s on RA). He
was subsequently placed on supplemental oxygen (3L initially).
CT scan demonstrated mild pulmonary edema, emphysema, and
chronic bronchitis. TTE was suggestive of PAH. RHC on ___
showed PAH that was O2 and NO responsive. As such, he was
started on Furosemide 20mg daily (likely a component of HFpEF
involved) and Pulmonary was consulted who recommended V/Q scan
and PFTs (to provide baseline prior to starting Sildenafil). V/Q
showed low likelihood of PE, with non-segmental irregularities
noted. Repeat PFTs were largely unchanged from ___. Given
findings that suggested a Type III PAH ___ COPD, he was started
on Sildenafil 10mg TID with close monitoring for worsened VQ
mismatch/hypoxemia, which he did not exhibit. He was increased
to 20mg TID with good response. At discharge, he was continued
on Sildenafil 20mg TID (insurance prior authorization approved)
and Furosemide 20mg daily.
# UTI
# Painless microscopic hematuria: Mr. ___ noted that he had
gross hematuria on ___, with a subsequent UA that demonstrated
>120 RBCs. No dysuria, increased urinary frequency, or increased
urinary urgency at this time - and as such this was initially
concerning for bladder cancer in the setting of ongoing smoking
history vs traumatic injury (however no Foleys placed during
this hospitalization). His repeat UA demonstrated RBC 1, WBC 24,
and +Leukocyte Esterase - most consistent with UTI. As such, he
was started on PO Bactrim for a 7 day course given complicated
UTI in a male (D1 ___. He is to follow up with his PCP to
obtain ___ repeat UA to evaluate for microscopic hematuria (after
completion of antibiotics), and if positive to discuss potential
outpatient cystoscopy and Urology evaluation for bladder cancer.
==========================
CHRONIC ISSUES
==========================
#COPD: Was continued on home Spiriva and provided Duonebs PRN.
Per Pulmonary, discontinued Spiriva and started Stiolto inhaler.
Was discharged with home oxygen.
#CAD: Continued his home Pravastatin, Aspirin, Clopidogrel, and
Carvedilol
#HTN: Continued home Amlodipine and Valsartan. Reduced home dose
of Lisinopril from 30mg daily to 10mg daily given hypotension.
Discontinued Hydralazine 100mg BID at admission given
hypotension. Has not been hypertensive on his new regimen during
this hospitalization.
#Anemia: Discontinued home ferrous sulfate given constipation.
Repleted iron stores with IV Iron Dextran. Recommend following
up with PCP ___ 3 months to monitor CBC/iron studies.
#Tobacco Use: Declined nicotine patch, however requested Chantix
at discharge. Has taken in the past without side effects -
recommend follow up with new PCP to discuss.
==========================
TRANSITIONAL ISSUES
==========================
[ ] DISCHARGE WEIGHT: 85.9 kg (189.37 lb)
[ ] DISCHARGE DIURETIC: Furosemide 20mg PO daily
[ ] DISCHARGE ANTICOAGULATION: None
[ ] FOLLOW UP LABORATORY TESTING: Repeat UA in 1 week to
evaluate resolution of UTI and microscopic hematuria (to be
followed up by PCP). Repeat CBC/iron studies in 3 months to
evaluate anemia (to be followed up by PCP).
[ ] MEDICATION CHANGES:
[ ] NEW: Furosemide 20mg PO daily, Sildenafil 20mg PO three
times daily, Stiolto inhaler daily
[ ] STOPPED: Hydralazine 100mg PO twice daily, Ferrous Sulfate
325mg daily, Spiriva (transitioned to Stiolto)
[ ] CHANGED: Lisinopril 30mg PO daily to Lisinopril 10mg PO
daily.
[ ] Follow up with PCP ___ ~1 weeks to evaluate resolution of UTI
and microscopic hematuria. Follow up urine culture results. If
still has microscopic hematuria, consider outpatient cystoscopy
and Urology evaluation.
[ ] Follow up with PCP ___ ~3 weeks to follow up repeat CBC/Iron
studies for iron deficiency anemia now s/p IV Iron Dextran
[ ] Repeat PFTs on ___
[ ] Follow up with Pulmonology on ___ for re-evaluation of
pulmonary hypertension/Sildenafil with Dr. ___.
[ ] Will need 3 month interval follow-up chest CT for
mediastinal lymph nodes
[ ] Will need Outpatient sleep study to exclude OSA
[ ] Will need outpatient pulmonary rehabilitation - script given
to patient
[ ] Patient would like medication to help with smoking
cessation. Please discuss at outpatient PCP ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 15 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Clopidogrel 75 mg PO QHS
4. HydrALAZINE 100 mg PO BID
5. Pravastatin 80 mg PO QPM
6. Tiotropium Bromide 1 CAP IH DAILY
7. Aspirin 81 mg PO BID
8. Vitamin D 400 UNIT PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Lisinopril 30 mg PO DAILY
Discharge Medications:
1. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Nicotine Patch 14 mg TD DAILY Duration: 1 Month
RX *nicotine 14 mg/24 hour apply to skin daily Disp #*30 Patch
Refills:*0
3. Sildenafil 20 mg PO TID
RX *sildenafil 20 mg 1 tablet(s) by mouth three times a day Disp
#*9 Tablet Refills:*0
4. Stiolto Respimat (tiotropium-olodaterol) 2.5-2.5
mcg/actuation inhalation DAILY
RX *tiotropium-olodaterol [Stiolto Respimat] 2.5 mcg-2.5
mcg/actuation 2 puffs INH daily Disp #*30 Vial Refills:*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID Complicated UTI
Duration: 7 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*12 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. amLODIPine 15 mg PO DAILY
9. Carvedilol 25 mg PO BID
10. Clopidogrel 75 mg PO QHS
11. Pravastatin 80 mg PO QPM
12. Vitamin D 400 UNIT PO DAILY
13.Outpatient Physical Therapy
Outpatient pulmonary rehabilitation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Pulmonary Arterial Hypertension
Urinary Tract Infection
Microscopic Hematuria
Secondary:
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Hypertension
Anemia
Tobacco Use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had been feeling
short of breath and you were found to have high blood pressure
in your lungs, called pulmonary hypertension. This was felt to
be due to your lung disease. We started you on a medication
called Sildenafil, which lowered the amount of oxygen you
needed. You were also found to have a urinary tract infection,
for which we prescribed antibiotics. You improved considerably
and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Seek medical attention if you have new or concerning symptoms
or you develop acutely worsened shortness of breath, dizziness,
blood in your urine, or an erection lasting for than 4 hours.
It was a pleasure participating in your care. We wish you the
best!
-Your ___ Care Team
Followup Instructions:
___
|
19766412-DS-12
| 19,766,412 | 22,080,981 |
DS
| 12 |
2176-06-26 00:00:00
|
2176-06-26 16:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:This is a ___ y/o female with a history of low back pain who
has been undergoing a pulmonary workup for possible sarcoid and
was placed on three weeks of steroids. One week ago after
lifting
something out of her car she started experiencing a different
and
more intense back pain, she tried managing her pain at home but
became increasingly immobile secondary to pain. She contacted
her PCP and requested imaging. An MRI was performed that showed
a T12 compression fracture.
Patient presents to the ED today for evaluation. She denies
loss
of bowel or bladder function, sensory or motor loss in her ___
and denies any shooting pain.
Past Medical History:
High cholestrol
hypothyroidism
Anxiety
Currently undergoing a workup for pulmonary sarcoid
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
O: T:98.9 BP:134 /78 HR:100 R 18 O2Sats91
Gen: WD/WN, comfortable, NAD.
HEENT:
Neck: WNL
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round
mm 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.
Point tenderness noted along low thoracic, and entire lumbar
spine
Sensation: Intact to light touch
NO Clonus
Toes downgoing bilaterally
Exam on Discharge:
A&OX3
MAE, bilateral lower extremities ___ strength
No numbness or tingling.
No clonus
Pertinent Results:
CT T spine: ___
IMPRESSION:
1. Severe compression fracture at T12 with 3 mm of retropulsion
causing
slight encroachment on the thecal sac. There is also mild
compression
deformity of the superior endplate of L1 with 3 mm retropulsion.
These
findings are similar to those seen on MRI from ___
and were
demonstrated to be acute or subacute in nature. The T7
compression fracture is unchanged and previously demonstrated to
be chronic on MRI.
2. Ground-glass opacities septal thickening throughout bilateral
lung fields, more prominent in the lower lobes, possibly due to
interstitial lung disease. The distribution of disease appears
similar to those described on chest CT report from At___ from
___, though direct imaging comparison is not
available.
Brief Hospital Course:
Ms. ___ was admitted to the hospital for pain control and
further workup on ___. She underwent a CT of the Spine which
showed the T12 acute fracture and a T7 fracture to be chronic in
nature. She was placed on bedrest and was measured for a TLSO
brace.
On ___, her TLSO brace arrived, the patient was out of bed with
no difficulty. She was evaluated by physical therapy, which
found the patient to be safe for discharge home. The patient did
not complain of pain while in patient but did take tylenol for
discomfort, refused Oxycodone. The patient was discharged in
stable conditions with TLSO brace on at all times when out of
bed.
Medications on Admission:
Fluoxetine 20mg po
Levothyroxine 75mcg
Dicyclomine 10mg qhs prn
Simvastatin 20mg po
Symbicort 4.5mcg inhaler bid
Proair 90mcg 2 puffs Q4-6hrs
Fluticosone 50mcg daily
Iron/B12/D3 daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H
3. DiCYCLOmine 10 mg PO TID:PRN IBS
4. Docusate Sodium 100 mg PO BID
5. Estrogens Conjugated 0.625 mg PO 2X/WEEK (___)
6. Fluoxetine 20 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU BID
8. Levothyroxine Sodium 75 mcg PO QAM
9. Loratadine 10 mg PO ONCE Duration: 1 Dose
10. Multivitamins 1 TAB PO DAILY
11. Simvastatin 20 mg PO QPM
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic T12 fracture
Back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
Limit your use of stairs to ___ times per day.
>> Wear your TLSO brace whenever you are out of bed. You may
shower withought your brace in a sitting position.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc for Three months.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 10.5° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
___
|
19767133-DS-27
| 19,767,133 | 25,637,810 |
DS
| 27 |
2138-12-17 00:00:00
|
2138-12-28 11:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"I think I took twice my daily dose of medications"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with DMII c/b neuropathy, nephropathy, retinopathy,
diastolic CHF, and obsessive compulsive disorder presenting with
LLE cellulitis. He initially presented to the ED with concern
that he accidentally took twice as much of his home medications
as prescribed and did not have any concerns about his leg. Of
note, the pt was recently hospitalized with R Hallux toe
osteomyelitis treated with 4 weeks of Vanc/Cipro and right
hallux partial distal phalangectomy. He denies F/C/N/V,
lightheadedness, palpitations, chest pain or shortness of
breath. He has noted increased swelling and erythema of the LLE
for the past ___ days and states that he has been only
intermittently compliant with his diuretics at home because he
does not like getting up to urinate at night. He has not noted
any increased pain of the LLE.
.
In the ED, initial VS were:
T 98.5 HR 76 BP 143/58 RR 12 O2 Sat 99% RA
Blood cultures were drawn and he was given 1g Vanc IV and
admitted to medicine.
.
On the floor, initial VS were:
T 97 BP 117/70 HR 61 RR 18 O2 Sat 96% RA
Past Medical History:
Diabetes ___ type II- followed at ___ for neuropathy,
nephropathy, retinopathy
Chronic kidney disease- baseline Cr 1.3-1.6
Hypertension
Diastolic cardiomyopathy- last echo ___, EF >60%
Obsessive compulsive disorder
Anxiety
Social History:
___
Family History:
Father- died of pulmonary fibrosis, h/o HTn
Mother- glucose intolerance
Grandfather- diabetes ___
Physical Exam:
Admission Exam:
VS - T 97 BP 117/70 HR 61 RR 18 O2 Sat 96% RA
GENERAL - Obese, anxious man in NAD
HEENT - NCAT, EOMI, MMM
LUNGS - CTAB, no increased WOB, no wheezes, rales or rhonchi
HEART - RRR, no MRG, nl S1-S2, no S3-S4
ABDOMEN - Obese, non tender, NABS, no rebound/guarding
EXTREMITIES - BLE non-pitting edema to the knee L>R,
hyperpigmentation of the BLEs L>R consistent with chronic venous
infufficiency. No warmth or open wounds, no discharge. The LLE
is erythematous to the patella, marked in pen.
NEURO - A/Ox3, CN II-XII intact, non focal
.
Discharge Exam:
VS - T 97 BP 120/60 HR 70 RR 18 O2 Sat 96% RA
GENERAL - Obese, anxious man in NAD
HEENT - NCAT, EOMI, MMM
LUNGS - CTAB, no increased WOB, no wheezes, rales or rhonchi
HEART - RRR, no MRG, nl S1-S2, no S3-S4
ABDOMEN - Obese, non tender, NABS, no rebound/guarding
EXTREMITIES - BLE non-pitting edema to the knee L>R,
hyperpigmentation of the BLEs L>R consistent with chronic venous
infufficiency. No warmth or open wounds, no discharge. The LLE
is erythematous to the patella, marked in pen.
NEURO - A/Ox3, CN II-XII intact, non focal
Pertinent Results:
Admission Labs:
___ 05:02PM BLOOD WBC-9.8 RBC-4.35* Hgb-12.4* Hct-35.2*
MCV-81* MCH-28.4 MCHC-35.1* RDW-14.4 Plt ___
___ 05:02PM BLOOD Neuts-73.1* Lymphs-16.7* Monos-4.3
Eos-4.8* Baso-1.1
___ 05:02PM BLOOD Glucose-167* UreaN-28* Creat-1.1 Na-140
K-5.3* Cl-104 HCO3-26 AnGap-15
___ 06:40AM BLOOD Calcium-9.2 Phos-4.9*# Mg-1.8
___ 05:06PM BLOOD Lactate-1.5
Discharge Labs:
___ 06:40AM BLOOD WBC-10.4 RBC-4.47* Hgb-12.3* Hct-36.3*
MCV-81* MCH-27.6 MCHC-34.0 RDW-14.6 Plt ___
___ 06:40AM BLOOD Glucose-97 UreaN-32* Creat-1.1 Na-141
K-4.3 Cl-101 HCO3-28 AnGap-16
___ (___):
Real-time grayscale and color Doppler with spectral analysis
sonographic evaluation of the left common femoral, superficial
femoral,
popliteal veins was performed. There is normal compressibility,
wall-to-wall color flow, and augmentation throughout. The calf
veins were not visualized.
IMPRESSION: No evidence of left lower extremity deep venous
thrombosis. Calf veins not visualized.
Brief Hospital Course:
Primary Reason for Admission: ___ y/o man with DM c/b
retinopathy, nephropathy and neuropathy and recent R Hallux toe
osteomyelitis presenting with LLE cellulitis.
.
Active Problems:
.
# Cellulitis: Mr ___ presentation was concerning for LLE
cellulitis given increased edema and erythema of the left leg.
___ was negative for DVT. There were no open wounds or
increased TTP. He was started on Vanc/Unasyn without significant
change in his clinical exam. He was discharged with 6 days of
Bactrim/Augmentin and will f/u with his PCP. It is unclear
whether Mr ___ actually had a cellulitis, or if his
increased edema and erythema was due to diuretic non-compliance,
which the patient admitted to. However, given his erythema and
edema were asymmetric, we eleceted to treat him with a short
course of antibiotics. The importance of taking his home
diuretics was stressed to the patient. We also recommended he
keep his legs wrapped and elevated to the extent possible.
.
# DM: Pt has significant insulin requirement. He takes 100U
Lantus qam, 70U with lunch and 100U qpm. He overeats as an
outpatient, we decreased his insulin dose while hospitalized to
prevent hypoglyceia. In house, he received Lantus 80U qam, 60u
with lunch, 80U qpm. He was also given ISS coverage. His BG was
well controlled throughout his course.
.
Chronic Problems:
.
# dCHF: LVEF is >60% on TTE from ___. He is currently not
grossly volume overloaded, no e/o active CHF exacerbation.
- cont Atenolol 50mg po qday
- cont Lisinopril 5mg po qday
- cont Lasix 60mg po bid
- cont Spironolactone 25mg po qday
- cont ASA 81mg
.
# HLD:
- cont Atorvastatin 10mg po qday
.
# Obsessive Compulsive Disorder:
- cont Citalopram 20mg po qday
- cont Lorazepam 1mg po q4h
.
# GERD:
- cont Omeprzaole 20mg po qday
.
Transitional Issues: He was d/c with a total of 1 week of
antibioitcs. He will f/u with his PCP, ___ and Cardiology.
Medications on Admission:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic BID (2
times a day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
8. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. insulin lispro protam & lispro 100 unit/mL (75-25)
Suspension Sig: as directed Subcutaneous three times a day:
100U at breakfast, 70U at lunch, and 100U at dinner.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
piggyback Intravenous Q 8H (Every 8 Hours) for 27 days: day 1 =
___
final day = ___.
Disp:*81 piggybacks* Refills:*0*
15. ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1)
piggyback Intravenous Q12H (every 12 hours) for 27 days: day 1=
___
last day = ___.
Disp:*54 piggyback* Refills:*0*
16. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous with meals and at bedtime: as per sliding scale.
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
8. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. insulin lispro protam & lispro 100 unit/mL (75-25)
Suspension Sig: One (1) as directed Subcutaneous three times a
day: 100U with breakfast, 70U with lunch, 100U with dinner.
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. insulin lispro 100 unit/mL Solution Sig: One (1) as directed
Subcutaneous three times a day: per sliding scale as directed.
15. Augmentin 875-125 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
16. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a
day for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary Diagnosis:
Cellulitis
Secondary Diagnosis:
DM
Obesity
HTN
dCHF
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 the ___
___. You were admitted for cellulitis. We performed
an ultrasound that showed you do not have a blood clot in your
leg. We gave you IV antibiotics overnight and feel that you are
safe to return home on oral antibiotics. It will be important
for you to keep your legs wrapped.
Please note the following changes to your medications:
STARTED Bactrim DS by mouth twice a day for 6 days
STARTED Augmentin 875mg by mouth twice a day for 6 days
Thank you for allowing us to particiapte in your care.
Followup Instructions:
___
|
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DS
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|
2141-03-19 15:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R ___ interspace ulcer infection
Major Surgical or Invasive Procedure:
___: R ___ toe amp and closure
History of Present Illness:
___ y/o DM M patient of Dr. ___ with a h/o diabetes,
neuropathy, ulcers between the fourth and fifth toes bilateral,
Charcot deformity presents c/o right foot toe ulcer b/w ___ and
___ toe. He states he has had an ulcer there for approx 2 months
but notes there has been increasing drainage and odor since
___ when he called the on-call pager. He presents today
complaining of increased redness and drainage, and complaining
of chills, although he denies f/c/n/v/sob. Of note he finished a
course of cipro/clinda on ___.
Past Medical History:
Diabetes ___ type II- followed at ___ for neuropathy,
nephropathy, retinopathy
Chronic kidney disease- baseline Cr 1.3-1.6
Hypertension
Diastolic cardiomyopathy- last echo ___, EF >60%
Obsessive compulsive disorder
Anxiety
Social History:
___
Family History:
Father- died of pulmonary fibrosis, h/o HTn
Mother- glucose intolerance
Grandfather- diabetes ___
Physical Exam:
Vitals- 98.1 132/68 73 18 98%RA
I/O 24 hr 129___/___
General- Alert, oriented, no acute distress, anxious but
appropriate
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP difficult to assess
Lungs- CTAB, no wheezes or rales
CV- RRR, Nl S1, S2, No MRG
Abdomen- +obese, soft, NT/ND bowel sounds present, no rebound
tenderness or guarding, +hepatomegaly
GU- no foley
Ext- warm, well perfused, ___ pitting edema to the lower
thighs, chronic venous stasis changes b/l, R foot bandage is
c/d/i
Pertinent Results:
ADMISSION LABS
___ 04:30PM BLOOD WBC-12.8* RBC-3.58* Hgb-10.2* Hct-29.6*
MCV-83 MCH-28.6 MCHC-34.6 RDW-14.5 Plt ___
___ 04:30PM BLOOD Neuts-80.7* Lymphs-11.6* Monos-5.3
Eos-1.9 Baso-0.5
___ 04:30PM BLOOD Glucose-171* UreaN-42* Creat-1.5* Na-135
K-4.0 Cl-100 HCO3-22 AnGap-17
___ 06:05AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0
___ 06:05AM BLOOD %HbA1c-7.4* eAG-166*
___ 04:34PM BLOOD Lactate-1.3
DISCHARGE LABS
___ 04:43AM BLOOD WBC-10.0 RBC-3.85* Hgb-10.4* Hct-32.7*
MCV-85 MCH-26.9* MCHC-31.6 RDW-15.0 Plt ___
___ 04:43AM BLOOD Glucose-134* UreaN-57* Creat-1.6* Na-143
K-5.1 Cl-100 HCO3-28 AnGap-20
___ 08:35AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.0
OTHER LABS
___ 06:25AM BLOOD Glucose-199* UreaN-67* Creat-3.1* Na-129*
K-5.1 Cl-93* HCO3-21* AnGap-20
MICRO
___ 3:59 pm SWAB Source: right ___ interspace.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT ___
this culture..
STAPH AUREUS COAG +. MODERATE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
___ 5:10 pm TISSUE Site: TOE R ___ TOE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
TISSUE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT ___
this culture..
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
STAPH AUREUS COAG +. SPARSE GROWTH. ___ MORPHOLOGY.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STAPH AUREUS COAG +
| |
CLINDAMYCIN----------- =>8 R =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- 2 S 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
VANCOMYCIN------------ 1 S 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
JOINT FLUID Source: Knee.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH
Cdiff, blood and urine cxs negative
PATH
Bone fragments, pending
IMAGING
Toe XR ___. Findings concerning for osteomyelitis ___ the terminal
phalanx of the small toe.
2. Severe midfoot arthropathy.
Foot XR ___
Expected appearance following amputation of the fifth toe.
R Knee XR ___
Moderate degenerative change ___ the medial and patellofemoral
compartments grossly stable when compared to the prior
radiographs.
Renal US ___
Limited, but normal renal ultrasound
Brief Hospital Course:
___ with DM2 w/microvascular complications, HTN, dCHF, CKD who
was electively admitted for ___ toe amputation for osteomyelitis
initially to the podiatry service whose course was complicated
by acute on chronic diastolic heart failure and acute kidney
injury, both resolved.
# Osteomyelitis of the toe: Patient underwent right ___ toe
amputation and closure by Podiatry on ___. Pathology pending.
Wound culture grew MRSA. Patient was initially on vancomycin,
ciprofloxacin, and flagyl but was narrowed to single agent
vancomycin therapy after consultation with infectious disease.
He remained afebrile and without leukocytosis on this regimen.
He has a PICC ___ place and will be on antibiotics for at least
two weeks. He will follow-up with ID on ___ and they will
determine the duration of his antibiotic course at that time. He
will follow-up with podiatry for wound check and suture removal.
His pain was well-controlled with tylenol and oxycodone.
# Acute on chronic kidney disease: Patient's creatinine peaked
to 3.1 after surgery, felt to be a combination of postrenal and
cardiorenal etiologies. Bladderscan demonstrated 1L of urine ___
the bladder so Foley catheter was placed. Retention was felt to
be related to opiate use and likely neuropathy from diabetes.
Renal US was negative. Patient was also quite volume overloaded
so patient was diuresed aggressively and his creatinine returned
to baseline by discharge. He was put back on his home torsemide
and had consistently good urine output on this regimen. His ACE
was held and can be restarted after discharge if his creatinine
continues to be stable. Will follow with his nephrologist Dr.
___.
# Acute exacerbation of dCHF: TTE ___ showed mild LVH,
dilated RV and EF 60%, mild pulmonary HTN. Patient had 3+
pitting edema to his sacrum and admitted to poor compliance with
diet and medications at home. He was initially diuresed with IV
lasix then transitioned to his home torsemide regimen. He was
continued on his beta-blocker but his ACE and spironolactone
were held ___ the setting of ___. He needs to be continued on a
low-sodium diet and daily weights should be obtained if
possible. Will be seen by his cardiologist after discharge.
# Hyperkalemia: Peaked at 5.8. No ECG changes. Patient admitted
to dietary indiscretions that likely contributed. K normalized
at discharge. ACE and spironolactone were held but can likely be
restarted after discharge. Patient should be encouraged to keep
a low potassium diet.
# Right Knee Pain: Patient noted onset of knee pain on ___ that
was tapped by Ortho with minimal fluid aspirated. XR
unremarkable. Benign appearing on exam and fluid culture with no
growth to date. Pain control with oxycodone and APAP as above.
CHRONIC ISSUES
# Anxiety/OCD: Continued citalopram 20mg and clonazepam 1mg bid.
He will follow-up with psychiatry as an outpatient.
# Diabetes-Last A1c 7.4 on current regimen. Continued home
regimen with fairly good control. Followed by ___.
# HL - Continued statin
# HTN - Continued diltiazem, metoprolol, and ___ dose
nifedipine. Holding ACE and spironolactone for now.
# CONTACT: ___ ___
TRANSITIONAL ISSUES
-Osteomyelitis: Culture growing MRSA. On IV vancomycin for at
least two weeks but this might be extended depending on final
path results. ID will follow as an outpatient and determine
course. Podiatry will follow next week for suture removal.
-___: Patient should be weighed daily and adhere to 2g low
sodium diet. Diuresing well on home torsemide.
-HTN: His ACE and spironolactone were held ___ the setting ___
and hyperkalemia and his nifedipine was resumed at half-dose
with good BP control. These three medications can be resumed at
his prior dose as needed if his creatinine and potassium remain
stable
Medications on Admission:
albuterol sulfate HFA 90 mcg/actuation ___ puffs INH ___ prn
wheezing or shortness of breath
ATORVASTATIN 10 mg qd
Citalopram 20 mg qd
Clonazepam 0.5 mg tablet. TID prn anxiety
Cartia XT 240 mg qd
INSULIN LISPRO PROTAM-LISPRO [HUMALOG MIX ___ KWIKPEN] -
Humalog Mix ___ KwikPen 100 unit/mL subcutaneous insulin pen.
100 units am, 70 units 12 noon and 100 units at 5 pm as directed
INSULIN LISPRO [HUMALOG] - Dosage uncertain - (Prescribed by
Other Provider: ___ as per ___ sliding scale)
Lisinopril 10 mg qd
Metoprolol succinate ER 50 mg qd
Omeprazole 20 mg qd
Spironolactone 25 mg tablet qd
Demadex ___ mg tablet. 2 tablets(s) BID
Medications - OTC
aspirin 81 mg qd
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH QID:PRN SOB
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
5. ClonazePAM 1 mg PO BID
6. Humalog ___ 100 Units Breakfast
Humalog ___ 100 Units Lunch
Humalog ___ 80 Units DinnerMax Dose Override Reason: home dose
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY
11. Senna 8.6 mg PO BID constipation
12. Diltiazem Extended-Release 240 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Citalopram 20 mg PO DAILY
15. Torsemide 40 mg PO BID
16. Acetaminophen 1000 mg PO TID
17. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN mod-severe
pain
RX *oxycodone 5 mg ___ capsule(s) by mouth every six (6) hours
Disp #*40 Capsule Refills:*0
18. Vancomycin 750 mg IV Q 12H
19. NIFEdipine CR 30 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
Osteomyelitis of the right ___ toe
Acute on chronic kidney disease
Acute exacerbation of diastolic heart failure
Secondary
Anxiety
DM2
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:
You were admitted to remove an infected portion of the fifth toe
on your right foot. You have to be treated for this infection
with an IV antibiotic called vancomycin for at least two weeks.
You will follow-up with the ID doctors to decide if you need to
be on this medication for longer.
You developed a mild injury to your kidneys likely because you
had trouble urinating and because your heart was not pumping as
well as it usually does. This improved after placed a catheter
and removed extra fluid from your body. It is important that you
take your torsemide regularly and not miss ___ dose. You should
also be very careful with your diet and avoid salty foods or
foods high ___ potassium. All of these things will help remove
fluid from your legs.
Followup Instructions:
___
|
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DS
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2142-11-18 21:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypokalemia, hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with history of CHF (LVEF 60%), poorly
controlled DM2, OCD and anxiety, and history of osteomyelitis
s/p multiple amputations who presents with hypokalemia and
hematuria. He was seen in clinic one day prior to admission with
hematuria. This was first noticed by his PCA while cleaning the
patient after a bowel movement. The patient reports continued
hematuria throughout the day, which is tomato juice colored. He
denies dysuria but reports increase urinary frequency, urgency,
and sensation of incomplete voiding. He denies any recent
instrumentation or history of radiation. At clinic, there was
dried blood noted around the penis meatus. Labs including CBC,
coags and renal function were obtained. Patient was empirically
started on Bactrim for 7 week course with plan for urology
referral. He has not started Bactrim yet as he planned on
picking it up from the pharmacy today. Patient was called later
that day with abnormal labs: WBC 15.1, Na 130, K 2.5, Cr 1.6
(baseline 1.3). EMS was called and the patient was brought to
the ED for further evaluation.
In the ED, initial VS were: 98.1 56 145/56 15 100% RA.
- Labs: WBC 13.5, H/H 14.3/40.8, plt 497, INR 1.1, Na 130, K
2.4, Cr 1.7 (baseline 1.2), lactate 2.7. UA showed large blood,
45 RBCs, moderate leukocytes, negative nitrites, 35 WBC, no
bacteria.
- EKG: QTc 516.
- CTU: No urolithiasis, no acute process within the abdomen or
pelvis to explain symptoms. Prominent bilateral external iliac
and inguinal lymph nodes of normal morphology.
- Patient was given ceftriaxone 1gm, 40mEQ KCl/1000mL NS, 40mEQ
KCL PO x 2.
On arrival to the floor, patient the did not have any specific
complaints. Overall he has been feeling weak with poor PO
intake. He has not been checking fingersticks. He reports 36 lb
weight loss over past ___ months with 3lb weight loss over the
past week.
REVIEW OF SYSTEMS:
(+) For chills. Otherwise denies fevers, headache, vision
changes, cough, shortness of breath, orthopnea, chest pain,
abdominal pain, nausea, vomiting, diarrhea, BRBPR, peripheral
edema.
Past Medical History:
- Diabetes mellitus complicated by foot ulcers and osteomyelitis
with multiple amputations
- Congestive heart failure (LVEF 60%)
- Hypertension
- Venous insufficiency
- OSA on BIPAP
- Obesity
- Glaucoma
- Obsessive-compulsive disorder
- Gait disorders
- Knee pain
- History of C difficile
PAST SURGICAL HISTORY:
- Rt ___ toe amputation ___ osteomyelitis
- Rt foot hallux amputation
- Left hallux debridement
- Patellar tendon rupture repair
Social History:
___
Family History:
Father died in ___. Had pulmonary fibrosis and colon cancer.
Mother is ___ years old without significant medical problems.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: 97.7 144/52 54 18 96% RA FSBG 461.
GENERAL: Anxious appearing, speaks slowly and asks provider to
repeat things. A+Ox3. No acute distress.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, moist mucous
membranes. Oropharynx clear.
NECK: Obese, unable to assess JVP.
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Clear to auscultation bilaterally. No wheezes, crackles,
or rhonchi.
ABDOMEN: +BS, soft, nondistended, nontender to palpation.
EXTREMITIES: Warm and well perfused. Lower extremities wrapped
in ACE-bandages. No peripheral edema.
NEURO: CN II-XII intact
DISCHARGE PHYSICAL EXAM
Vitals: T97.5 151/64 HR61 18 100%RA ___ no BM LBM12/18
GENERAL: appears well, sitting on chair, speaks slowly, A+Ox3.
No acute distress.
HEENT: ncat, oriented x 3
NECK: Obese, unable to assess JVP.
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Clear to auscultation bilaterally. No wheezes, crackles,
or rhonchi.
ABDOMEN: +BS, soft, nondistended, nontender to palpation.
EXTREMITIES: Warm and well perfused. Lower extremities wrapped
in ACE-bandages. R foot noted to have ___ hallux amputation.
No peripheral edema. Lipodermatosclerotic changes of b/l ___.
Erythema an scaling noted of b/l thighs
NEURO: CN II-XII grossly intact
GU: Penis with no lesions or blood noted
RECTAL: no boggy or tender prostate on DRE, noted to have brown
stool with trace flecks of brb (prior exam)
Pertinent Results:
ADMISSION LABS
___ 10:41PM BLOOD WBC-13.5* RBC-5.39 Hgb-14.3 Hct-40.8
MCV-76* MCH-26.5 MCHC-35.0 RDW-15.1 RDWSD-40.5 Plt ___
___ 10:41PM BLOOD Neuts-80.3* Lymphs-10.9* Monos-7.0
Eos-1.0 Baso-0.4 Im ___ AbsNeut-10.85* AbsLymp-1.47
AbsMono-0.94* AbsEos-0.14 AbsBaso-0.05
___ 12:10AM BLOOD ___ PTT-28.9 ___
___ 04:50PM BLOOD Glucose-424* UreaN-74* Creat-1.6* Na-130*
K-2.5* Cl-83* HCO3-25 AnGap-25*
___ 10:41PM BLOOD ALT-29 AST-23 AlkPhos-151* TotBili-0.4
___ 04:50PM BLOOD Albumin-4.3 Calcium-9.5 Phos-4.6* Mg-2.5
___ 08:03AM BLOOD Osmolal-300
___ 07:35AM BLOOD Osmolal-290
___ 01:32PM BLOOD ASA-NEG
___ 12:28AM BLOOD Lactate-2.7*
URINE
___ 05:55PM URINE Color-Straw Appear-Clear Sp ___
___ 05:55PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-300 Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
___ 05:55PM URINE RBC-70* WBC-11* Bacteri-NONE Yeast-NONE
Epi-1
___ 05:55PM URINE Hours-RANDOM Creat-49 Albumin-0.6
Alb/Cre-12.2
___ 01:44AM URINE ___ Urine cytology negative for malignant cells
MICROBIOLOGY
___ & ___ URINE CULTURE CONTAMINATED
___ BLOOD CULTURE X 2 NEGATIVE
___ URINE GONORRHEA/CHLAMYDIA NEGATIVE
___ STOOL C DIFF NEGATIVE
PERTINENT IMAGING
___ CTU ABD/PELVIS W/O CONTRAST
1. No urolithiasis. No acute process within the abdomen or
pelvis to explain the patient's symptoms within the limitations
of this noncontrast enhanced study.
2. Prominent bilateral external iliac and inguinal lymph nodes
with normal morphology.
DISCHARGE LABS
___ 07:18AM BLOOD WBC-8.5 RBC-4.72 Hgb-12.5* Hct-37.8*
MCV-80* MCH-26.5 MCHC-33.1 RDW-16.2* RDWSD-46.5* Plt ___
___ 07:18AM BLOOD Glucose-108* UreaN-31* Creat-1.4* Na-134
K-4.1 Cl-104 HCO3-16* AnGap-18
___ 07:18AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.4
___ 09:12PM BLOOD K-3.7
Brief Hospital Course:
Mr. ___ is a ___ year old male with history significant for
CHF (LVEF 60%), poorly controlled DM2, OCD and anxiety, and
history of osteomyelitis s/p multiple amputations who presents
with hypokalemia and hematuria.
ACTIVE ISSUES
# ACID-BASE DISORDER: Of unclear etiology though diarrhea,
severe hyperglycemia, and distal rta in the setting of
underlying diabetes could all be potential etiologies of low
bicarbonate and hypokalemia. Nephrology was consulted. Potassium
was repleted aggressively and patient was discharged on
potassium and sodium bicarbonate supplementation.
# HYPOKALEMIA: Likely related to home medications of torsemide
and acetazolamide, ongoing hyperglycemia, and diarrhea while
hospitalized. EKG was notable for prolonged QTc (500 to 516)
without U waves. This appears to be his baseline Qtc on review
of prior EKGs. Potassium was aggressively repleted while
hospitalized. Acetazolamide was initially held but restarted
prior to discharge given concern for increased blurriness in
vision.
# GROSS HEMATURIA, resolved: Concern for UTI vs malignancy.
Patient reported gross hematuria though no clots and had no
further episodes of hematuria while hospitalized. He did
describe one week of urinary frequency, urgency, and sensation
of incomplete voiding and had urinalysis with pyuria and
hematuria but no bacteria/nitrates. He was treated with bactrim
for 7 day course (___) for complicated UTI. Of note, CTU
was without stones, hydronephrosis, and renal lesions. There was
concern for malignancy especially in the setting of ongoing
weight loss and decreased appetite though urine cytology
negative for malignant cells. He had follow-up arranged with
urology for consideration of outpatient cystoscopy.
# DM2: Poorly controlled. Patient reports taking Humalog ___
100 units with meals and is on high Humalog sliding scale.
Patient was placed on HISS which was uptitrated with assistance
___ in the setting of ongoing hyperglycemia.
# HYPONATREMIA: Corrected Na for glucose is 137. Volume status
was difficult to assess given obesity but patient appeared to be
euvolemic. Torsemide was discontinued given hypokalemia and ___
and ___ was started on low dose spironolactone.
# ___: Admission Cr 1.7 from baseline of 1.2 with elevated
lactate. Likely pre-renal in setting of infection, diuresis, and
hyperglycemia. He was given IVF while hospitalized with
improvement in creatinine to 1.4 on discharge.
# QTC PROLONGATION: Likely secondary to hypokalemia. Patient on
QTc prolonging medications such as risperidone (though says has
not been taking) and fluoxetine. EKG QTc improved from 516 to
501 with potassium repletion. QTc 500 appears to be his
baseline. Home Risperdal and trazadone were held on discharge.
He was restarted on low dose fluoxetine.
# Chronic dCHF (EF>60% ___ TTE): Volume exam difficult to
assess though notably patient remained asymptomatic and without
dyspnea during hospitalization. Home torsemide was held in the
setting of hypokalemia and patient was started on
spironolactone.
# HTN: Continued home diltiazem 240mg, metoprolol XL 50mg.
# GLAUCOMA: Initially held acetazolamide as it can contribute to
hypokalemia. Acetazolamide was restarted prior to discharge
given patient c/o of mild blurriness in vision. Patient was
continued on equivalent version of travoprost 0.004 % ophthalmic
QHS / latanoprost while in house and was discharged on home eye
drops. He has follow-up arranged with outpatient
ophthalmologist.
# TRANSITIONAL ISSUES
- F/u qtc at next visit to ensure no further prolongation, qtc
501 during hospitalization (QTC 469 on day of discharge) - if
normalized, consider restarting home Risperdal and trazadone
which were held on discharge
- Patient was restarted on low dose fluoxetine on discharge
- Complete 7 days of Bactrim (day1: ___, last dose ___
- Please assess volume status and adjust spironolactone dose as
this is a new medication. Torsemide was held in the setting of
hypokalemia.
- Patient was started on potassium and bicarbonate
supplementation per nephrology recommendations
- Please have chem10 rechecked on ___
- Please adjust insulin sliding scale accordingly
- f/u plasma ___ levels
- Patient should f/u with urology in the outpatient setting for
evaluation of hematuria and need for cystoscopy
# CODE: Full (CONFIRMRED)
# CONTACT: ___ (Friend) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
2. Fluocinolone Acetonide 0.01% Cream 1 Appl TP DAILY
3. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
4. RISperidone 0.5 mg PO QHS
5. ClonazePAM 1 mg PO TID:PRN anxiety
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Diltiazem Extended-Release 240 mg PO DAILY
8. AcetaZOLamide 500 mg PO Q12H
9. Docusate Sodium 100 mg PO DAILY
10. Atorvastatin 10 mg PO QPM
11. Torsemide 40 mg PO BID
12. travoprost 0.004 % left eye only QHS
13. Omeprazole 20 mg PO DAILY
14. Aspirin 81 mg PO DAILY
15. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN wheeze
16. Fluoxetine 60 mg PO DAILY
17. TraZODone 50-100 mg PO QHS:PRN insomnia
18. Humalog ___ 100 Units Breakfast
Humalog ___ 100 Units Lunch
Humalog ___ 100 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: Patient's home dose
19. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Atorvastatin 10 mg PO QPM
RX *atorvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
RX *brimonidine 0.15 % 1 drop both eyes every 8 hours Disp #*15
Milliliter Milliliter Refills:*0
4. ClonazePAM 1 mg PO TID:PRN anxiety
RX *clonazepam 1 mg 1 tablet(s) by mouth every 8 hours Disp #*63
Tablet Refills:*0
5. Diltiazem Extended-Release 240 mg PO DAILY
RX *diltiazem HCl [Cardizem CD] 240 mg 1 capsule(s) by mouth
daily Disp #*30 Capsule Refills:*0
6. Docusate Sodium 100 mg PO DAILY
RX *docusate sodium 100 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
7. Fluocinolone Acetonide 0.01% Cream 1 Appl TP DAILY
RX *fluocinolone 0.01 % apply to bilateral lower extremities
daily Refills:*3
8. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
9. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
10. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
11. travoprost 0.004 % ophthalmic QHS apply to left eye only
RX *travoprost [Travatan Z] 0.004 % 1 drop left eye every night
Refills:*0
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
RX *triamcinolone acetonide 0.1 % apply to bilateral lower
extremities twice daily Refills:*0
13. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN wheeze
RX *albuterol sulfate [ProAir HFA] 90 mcg 1 puff inh every 4
hours Disp #*1 Inhaler Refills:*0
14. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice daily Disp #*3 Tablet Refills:*0
15. Potassium Chloride 40 mEq PO DAILY
Hold for K > 5
RX *potassium chloride [K-Tab] 20 mEq 2 tablet(s) by mouth daily
Disp #*60 Tablet Refills:*0
16. AcetaZOLamide 500 mg PO Q12H
RX *acetazolamide 500 mg 1 capsule(s) by mouth twice daily Disp
#*60 Capsule Refills:*0
17. Humalog ___ 80 Units Breakfast
Humalog ___ 80 Units Lunch
Humalog ___ 80 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: Patient's home dose
RX *insulin lispro protam-lispro [Humalog Mix 75-25] 100 unit/mL
(75-25) AS DIR 80 Units before BKFT; 80 Units before LNCH; 80
Units before DINR; Disp #*1 Vial Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL AS DIR Up to 30 Units
QID per sliding scale Disp #*1 Vial Refills:*0
RX *lancets [BD Ultra Fine Lancets] 33 gauge use to check blood
sugars three times daily Disp #*2 Packet Refills:*0
18. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE DAILY
RX *prednisolone acetate 1 % 1 drop right eye daily Refills:*0
19. Sodium Bicarbonate 1300 mg PO TID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth three times a
day Disp #*126 Tablet Refills:*0
20. Fluoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
21. Outpatient Lab Work
ICD10: E87.6 Hypokalemia
Please obtain chem10 on ___ and fax results to:
Name: ___.
Location: HEALTHCARE ASSOCIATES
___
Address: ___, ___, ___,
___
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary diagnosis: Hematuria, Hypokalemia
Secondary diagnosis: UTI
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 here at ___. You were
admitted for blood in your urine and low potassium levels.
Regarding the blood in your urine, you were started on an
antibiotic called Bactrim to treat a urinary tract infection
(last dose: ___. You should go to your appointment as
scheduled with the urologist to determine if any further testing
should be done for the blood that was seen in your urine. You
were also found to have low potassium levels thought to be due
to possibly taking extra torsemide. We gave you potassium and
bicarbonate tablets while you were in the hospital and stopped
your torsemide. We also found that you had very high blood
sugars for which you were given higher doses of insulin. You
will have a visiting nurse to help you with medications. Please
have your bloodwork rechecked on ___. We wish you all the
best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19767133-DS-30
| 19,767,133 | 29,190,754 |
DS
| 30 |
2143-06-21 00:00:00
|
2143-06-21 20:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain.
Major Surgical or Invasive Procedure:
TEE with cardioversion ___
History of Present Illness:
Mr. ___ is a ___ year old man with HFpEF, T2DM on insulin,
HTN, and obesity, who presents with chest pain and EKG changes.
The patient shares that the day before presentation he awoke and
felt left sided head pain, jaw pain, throat pain, left arm pain
and central chest pain/tightness. He also felt left hand
numbness, but said that this has been present for the past few
weeks-months. He is unsure if this pain woke him up, but said it
might have. The pain lasted all day. The pain was constant and
then resolved. He said the pain got someone better when he would
do a "windmill" exercise, which is an exercise in which he
extends his arms and then brings them into his chest and then
repeats. He has had chest pain/tightness in the past, but is
unable to give a time course. He said that it will typically be
at rest and he thinks it may be related to physical therapy
exercises he does. He does not have chest pain with exertion and
does not feel short of breath with these episodes.
At the time of the pain the day prior to presentation he called
his GI doctor, who urged him to come to the ED, which he did not
do. The day of presentation the patient came in for capsule
endoscopy to source for a source of iron deficiency anemia. He
had an EKG done, which revealed new atrial flutter with 4:1
block. The patient was not having chest pain at this time. He
was sent to the ED.
In the ED, initial vitals were: T97.8 HR86 BP144/105 RR20 O2100
RA
Exam was notable for nonreproducible chest pain, no abdominal
tenderness, venous stasis in BLE. Labs were notable for troponin
0.03, creatinine of 1.6 (baseline 1.2-1.4), WBC 14.9. EKG showed
Aflutter with 4:1 block. CXR with no overt pulmonary edema. He
was given aspirin 324 mg and 1L NS.
On the floor, patient gives the above history. He is not
currently having pain or discomfort.
ROS: as per HPI.
Past Medical History:
- Diabetes mellitus complicated by foot ulcers and osteomyelitis
with multiple amputations
- Congestive heart failure (LVEF 60%)
- Hypertension
- Venous insufficiency
- OSA on BIPAP
- Obesity
- Glaucoma
- Obsessive-compulsive disorder
- Gait disorders
- Knee pain
- History of C difficile
PAST SURGICAL HISTORY:
- Rt ___ toe amputation ___ osteomyelitis
- Rt foot hallux amputation
- Left hallux debridement
- Patellar tendon rupture repair
Social History:
___
Family History:
Father died in ___. Had pulmonary fibrosis and colon cancer.
Mother is ___ years old without significant medical problems.
Physical Exam:
Admission Exam:
VITALS: 97.9, 119 / 54, 70, 18, RA
General: morbidly obese, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops; no chest tenderness
Lungs: CTAB with good inspiratory effort
Abdomen: obese, soft, nontender, nondistended.
GU: No foley
Ext: Warm, well perfused, venous stasis changes in BLE up to
knee with ___ pitting edema; s/p multiple R toe amputations; no
erythema, discharge, open wounds; Left ___ toe bruised
Neuro: sensation intact bilaterally, ___ strength upper/lower
extremities.
Discharge Exam:
TEMP: 97.4, 121 / 57, 57, 18, 98 RA
I/Os:
24H: ___ 133.9 kg 295.19 lb I:1480 ___ (net: -470)
Blood sugars: 155-374
General: morbidly obese, alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops; no chest tenderness
Lungs: Faint bibasilar crackles, otherwise clear to
auscultation.
Abdomen: obese, soft, nontender, nondistended.
GU: No foley
Ext: Warm, well perfused, venous stasis changes in BLE up to
knee with 1+ pitting edema; s/p multiple R toe amputations; no
erythema, discharge, open wounds; Left ___ toe bruised
Neuro: sensation intact bilaterally, ___ strength upper/lower
extremities.
Pertinent Results:
Admission Labs:
___ 04:15PM BLOOD WBC-14.9* RBC-4.45* Hgb-11.8* Hct-36.3*
MCV-82 MCH-26.5 MCHC-32.5 RDW-15.9* RDWSD-47.5* Plt ___
___ 04:15PM BLOOD Neuts-79.2* Lymphs-9.3* Monos-8.5 Eos-1.5
Baso-0.5 Im ___ AbsNeut-11.80*# AbsLymp-1.39 AbsMono-1.26*
AbsEos-0.22 AbsBaso-0.07
___ 04:15PM BLOOD ___ PTT-31.9 ___
___ 04:15PM BLOOD Glucose-95 UreaN-34* Creat-1.6* Na-138
K-4.1 Cl-102 HCO3-22 AnGap-18
___ 03:37AM BLOOD ALT-21 AST-17 LD(LDH)-212 AlkPhos-134*
TotBili-0.3
___ 04:15PM BLOOD cTropnT-0.03*
___ 10:01PM BLOOD cTropnT-0.03*
___ 03:37AM BLOOD CK-MB-5 cTropnT-0.02*
___ 01:02AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0
___ 03:37AM BLOOD CRP-197.0*
___ 10:27AM BLOOD ___ pO2-157* pCO2-31* pH-7.35
calTCO2-18* Base XS--7 Comment-GREEN TOP
___ 10:27AM BLOOD Lactate-1.1
Discharge Labs:
___ 05:44AM BLOOD WBC-11.2* RBC-4.33* Hgb-11.3* Hct-34.5*
MCV-80* MCH-26.1 MCHC-32.8 RDW-15.8* RDWSD-45.6 Plt ___
___ 05:44AM BLOOD Glucose-298* UreaN-20 Creat-1.0 Na-135
K-3.8 Cl-98 HCO3-26 AnGap-15
___ 05:44AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8
EKG ___: Atrial flutter with 4:1 block
CXR:
IMPRESSION
Trace bilateral pleural effusions. Grossly stable enlargement
of the cardiac silhouette given differences in inspiration. No
overt pulmonary edema.
Echo:
No spontaneous echo contrast is seen in the left atrial
appendage. No thrombus is seen in the left atrial appendage.
Right atrial appendage ejection velocity is good (>20 cm/s). No
thrombus is seen in the right atrial appendage.There is possibly
a small patent foramen ovale. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to 35 cm
from the incisors. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is mild anterior leaflet mitral valve
prolapse. An eccentric, anteriorly 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). There is no pericardial
effusion.
Brief Hospital Course:
Mr. ___ is a ___ year old man with HFpEF, T2DM on insulin,
HTN, and obesity, who presents with resolved chest pain, flat
troponins and CK-MB and EKG changes suggestive of a-flutter with
4:1 block.
#A-flutter: Patient initially presented with atypical chest pain
that was initially concerning for ACS; however, he had negative
troponins and CKMB x2 and so chest pain was thought to be ___
new onset a-flutter vs less likely GERD. EKG was notable for 4:1
block atrial flutter. Etiology for new-onset was unclear, but
possibly due to obesity, OSA and pHTN. He was started on a
heparin drip and received a TEE with DCCV the following morning.
He converted to NSR after 1 shock. His anticoagulation was
transitioned to Apixaban 5 mg BID. He was also rate-controlled
on his home regimen of metoprolol and diltiazem. He will
follow-up in the outpatient setting to set up a potential
ablation with the EP team. If he remains in NSR after 1 month,
anticoagulation may be discontinued
#CAD primary prevention: He was continued on his home aspirin.
His atorvastatin was increased to 20 mg given ASCVD risk.
___ on CKD: his baseline is 1.2-1.4 and had a Cr of 1.6 on
admission. It improved with IVF to 1.1 and was felt to
originally be in the setting of poor PO and volume depletion.
His home diuretics were originally held, but restarted once Cr
improved.
#HFpEF: Patient initially appeared volume overloaded given
diuretics being held for ___ and ___ receiving IVF. He was
diuresed during hospital course with IV Lasix 40 then resumed on
home Torsemide and spironolactone prior to discharge.
#T2DM: his blood sugars were initially uncontrolled (400 on
admission and multiple blood sugars to 400 during first 2 days).
He was placed on home Humalog ___ 100U qAC with improvement in
his FSG.
#Venous stasis: continued home skin cream regimens of
fluocinolone and betamethasone. No acute complications of this
issue.
#OCD: continued fluoxetine.
#Glaucoma: continued home eye drop regimen.
Transitional Issues:
** Anticipate <30 days of rehab needs **
- Patient is on metoprolol and diltiazem per outpatient
cardiologist. If bradycardic, please consider discontinuing 1 or
both medications.
- Patient should remain on apixaban for 1 month (end ___ to
reduce risk of clot with post DCCV cardiac stunning - please
consider continuing anticoagulation at that time
- Please consider ablation for new a-flutter. We have requested
EP appointment, and patient should be contacted for follow up.
- Patient has labs concerning for combination of iron deficiency
and anemia of chronic disease. He was actually at a
capsule-study when the atrial flutter was diagnosed. Please make
sure he follows-up this work-up and has GI work-up for the
anemia as per outpatient providers.
- Given his multiple cardiac risk factors and chest pain
complaint, we strongly recommend a stress test in the outpatient
setting.
- We increased his atorvastatin from 10 to 20 mg due to ASCVD
risk
- Given his occasional left hand numbness, please consider
outpatient MRI to evaluate for cervical or brachial plexus
cause.
- Discharge weight: 132 kg
- Code: Full
- Contact: Per OMR HCP: ___ Phone number:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. ClonazePAM 1 mg PO TID:PRN anxiety
5. Durezol (difluprednate) 0.05 % ophthalmic BID
6. Diltiazem Extended-Release 240 mg PO DAILY
7. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
8. Fluocinolone Acetonide 0.01% Cream 1 Appl TP BID
9. FLUoxetine 40 mg PO DAILY
10. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using humalog mix ___ Insulin
11. Methazolamide 50 mg PO BID
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Potassium Chloride 20 mEq PO DAILY
15. Spironolactone 25 mg PO DAILY
16. Torsemide 20 mg PO DAILY
17. travoprost 0.004 % ophthalmic qhs
18. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Atorvastatin 20 mg PO QPM
3. Humalog ___ 100 Units Breakfast
Humalog ___ 100 Units Lunch
Humalog ___ 100 Units DinnerMax Dose Override Reason: home
dose
4. Aspirin 81 mg PO DAILY
5. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
7. ClonazePAM 1 mg PO TID:PRN anxiety
8. Diltiazem Extended-Release 240 mg PO DAILY
9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
10. Durezol (difluprednate) 0.05 % ophthalmic BID
11. Fluocinolone Acetonide 0.01% Cream 1 Appl TP BID
12. FLUoxetine 80 mg PO DAILY
13. Methazolamide 50 mg PO BID
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Omeprazole 20 mg PO BID
16. Potassium Chloride 20 mEq PO DAILY
Hold for K >
17. Spironolactone 25 mg PO DAILY
18. Torsemide 40 mg PO BID
19. travoprost 0.004 % ophthalmic qhs
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Atrial Flutter with 4:1 block s/p TEE and DCCV
Secondary:
___ on CKD
HTN
HFpEF
T2DM
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
We have cared for you in the hospital for your atrial flutter.
Fortunately, your heart is now beating regularly after
cardioversion. We are also giving you medications that prevent
clots (Apixaban 5 milligrams twice a day). Additionally, we
increased your cholesterol medication from 10 milligrams to 20
milligrams. Please make sure to attend all your follow-up
appointments and return for evaluation if you develop chest
pain/pressure, worsened shortness of breath, chest palpitations,
acute leg pain or acute severe discomfort of any kind.
We have greatly appreciated taking part in your care.
Best wishes,
___ 7 Care Team
Followup Instructions:
___
|
19767133-DS-31
| 19,767,133 | 20,975,150 |
DS
| 31 |
2144-05-19 00:00:00
|
2144-05-20 09:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fever, left foot pain
Major Surgical or Invasive Procedure:
--Partial left-third toe amputation
--PICC line placement (R-arm)
History of Present Illness:
___ with hx IDDM, CHF, HTN, OSA presenting with fever and left
foot swelling and bacteremia.
Patient has very poor sensation to his feet but he has had
multiple toe amputations and has known Charcot foot after having
diabetes for many years. He has a known left third toe
ulceration which is now draining purulent starting today. His
left foot also today is newly more swollen and erythematous. He
has chronic bilateral lower extremity venous stasis changes and
has warm hot areas. Patient is also had some shortness of breath
which is close to his baseline with some nonproductive cough. No
nausea, vomiting or chest pain.
-___ the ED, initial VS:
100.6 79 169/67 18 96% Nasal Cannula
-Exam notable for bibasilar crackles
-Labs showed Trop 0.4, Pro BNP 629, CRP 114.4, WBC 16.8
-Imaging showed:
CXR: IMPRESSION: Stable cardiomegaly, congestion with probable
mild interstitial pulmonary edema.
Foot xray: No convincing evidence for osteomyelitis. Soft tissue
swelling may reflect cellulitis.
- Received: Vancomycin 1500mg, ciprofloxacin 400mg, Furosemide
40mg, Ondansetron 4mg, Morphine sulfate 4mg.
Transfer VS were:
97.8 84 175/78 20 95% RA
Podiatry was consulted and concluded patient was very
overloaded, his left third distal toe probes to bone with no
surrounding erythema looking benign. Recommended admission to
medicine for IV abx (vanc, cipro, flagyl), treatment of CHF and
NPO after midnight for possible surgical intervention given xray
is c/f ___ distal tip osteomyelitis.
On arrival to the floor, patient reports that at 5am on ___ he
awoke with rigors, fever, nausea, constipation, HA, back/neck
pain. He denies chest pain. He is having trouble breathing, but
near baseline (has OSA). Headache has nearly resolved. He is
having a new cough and continues to have constipation.
REVIEW OF SYSTEMS:
(+)PER HPI
Past Medical History:
- Diabetes mellitus complicated by foot ulcers and osteomyelitis
with multiple amputations
- Congestive heart failure (LVEF 60%)
- Hypertension
- Venous insufficiency
- OSA on BIPAP
- Obesity
- Glaucoma
- Obsessive-compulsive disorder
- Gait disorders
- Knee pain
- History of C difficile
PAST SURGICAL HISTORY:
- Rt ___ toe amputation ___ osteomyelitis
- Rt foot hallux amputation
- Left hallux debridement
- Patellar tendon rupture repair
Social History:
___
Family History:
Father died ___ ___. Had pulmonary fibrosis and colon cancer.
Mother is ___ years old without significant medical problems.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.6PO 146 / 69L Lying 78 22 93 1L
___: NAD, normally conversant but falling asleep ___ lulls
HEENT: AT/NC, EOMI, PERRL, R pseudophakia, anicteric sclera,
pink conjunctiva, dry MMM, poor dentition
NECK: supple, no JVD noted
HEART: RRR, exam limited by body habitus
LUNGS: Trace wheeze
ABDOMEN: obese, nondistended, nontender ___ all quadrants, no
rebound/guarding
EXTREMITIES: 2+ edema distally. S/p amputations. Bandages
clean/dry.
NEURO: A&Ox3, moving all 4 extremities with purpose
DISHCARGE PHYSICAL EXAM:
VS: 97.5 PO BP 115 / 66 HR 62 RR 18 SpO2 97
___: NAD, awake and alert
HEENT: AT/NC, EOMI, poor dentition
NECK: supple, no JVD seen
HEART: RRR, exam limited by body habitus
LUNGS: CTAB
ABDOMEN: obese, nondistended, nontender ___ all quadrants, no
rebound/guarding
EXTREMITIES: 2+ edema distally. Chronic venous stasis skin
changes ___ lower legs bilaterally. S/p amputations. Left foot
wrapped with clean bandage and ACE after surgery.
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION RESULTS:
=================
___ 09:15PM BLOOD WBC-16.8* RBC-4.24* Hgb-11.2* Hct-33.8*
MCV-80* MCH-26.4 MCHC-33.1 RDW-16.1* RDWSD-46.1 Plt ___
___ 09:15PM BLOOD Neuts-91.2* Lymphs-2.6* Monos-5.2
Eos-0.0* Baso-0.2 Im ___ AbsNeut-15.28*# AbsLymp-0.43*
AbsMono-0.87* AbsEos-0.00* AbsBaso-0.04
___ 09:15PM BLOOD Glucose-271* UreaN-22* Creat-1.1 Na-134
K-4.2 Cl-98 HCO3-21* AnGap-19
___ 09:15PM BLOOD CK(CPK)-450*
___ 09:15PM BLOOD CK-MB-5 proBNP-629*
___ 09:15PM BLOOD Calcium-8.2* Phos-2.4* Mg-1.8
___ 09:15PM BLOOD CRP-114.4*
___ 09:21PM BLOOD Lactate-1.6
MICROBIOLOGY:
=============
Source: left ___ toe, near distal bone.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
STAPH AUREUS COAG +. RARE GROWTH OF TWO COLONIAL
MORPHOLOGIES.
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.
BETA STREPTOCOCCUS GROUP B. RARE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
----------
___ 3:00 pm TISSUE 3 RD TOE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
TISSUE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
LABS ON DISCHARGE:
==================
___ 06:00AM BLOOD WBC-13.4* RBC-4.00* Hgb-10.2* Hct-32.2*
MCV-81* MCH-25.5* MCHC-31.7* RDW-17.0* RDWSD-49.8* Plt ___
___ 06:00AM BLOOD Glucose-63* UreaN-26* Creat-1.1 Na-141
K-4.3 Cl-100 HCO3-25 AnGap-20
___ 06:20AM BLOOD CRP-152.4*
Brief Hospital Course:
___ with hx IDDM, HFpEF, HTN, OSA, severe anxiety, presenting
with fever and left foot swelling found to have bacteremia due
to left third toe infection now s/p partial toe amputation for
source control.
# STREP SEPSIS:
# TOE INFECTION:
Patient transferred from ___ with gram
positive cocci ___ blood. Speciation of the blood culutres showed
group-b strep. His toe wound was cultured that showed group-b
strep and MRSA. The patient was treated with vancomycin given
MRSA (+) culture. Source control was achieved by partial
amputation of his third toe (pathology pending).
Blood cultures with GBS. Wound cultures GBS and Staph A. ___ this
setting foot wound is likely source of entry. All blood cultures
at ___ were negative. Patient was seen by infectious disease
who arranged for outpatient IV antibiotics. The patient received
a PICC line. He was discharged on vancomycin IV 1250mg Q12H.
Projected End Date: ___ (4wks total). Follow-up by OPAT
will be arranged after discharge by the OPAT program. Patient
will need the following weekly labs: CBC with differential, BUN,
Cr, Vancomycin trough, CRP.
# Hypoxemia
# Pulmonary Edema:
# CHF:
Patient developed pulmonary edema and hypoxemia during his
hospitalization. A chest Xray showed pulmonary edema. The
pulmonary edema and hypoxemia was likely secondary to his home
torsemide being held ___ the setting of sepsis. He was
hemodynamically stable so he was given IV Lasix with adequate
diuresis. His oxygen requirement improved from 6L at its maximum
to room air prior to discharge. He was continued on his home
Torsemide 40mg BID. Discharge weight: 296.3 lb.
# Anxiety: Continued home klonipin TID. Ativan QHS was given as
needed for anxiety.
#CVD risk:
- Increased atorvastatin to 40mg from 20mg
- Continued ASA
#CKD: his baseline Cr is 1.2-1.4. Was at his baseline during
hospitalization. Discharge creatinine: 1.1.
#T2DM: Last A1C 8.6% ___ ___. Was continued on his Humalog
___ 100u TID. He had multiple episodes of low blood glucose at
night to 60-70. The episodes were asymptomatic. Discharged on
reduced dose of 100u, 70u, 80u, at breakfast, lunch and dinner
respectively.
#Venous stasis:
- Continued home saran
#OCD: continued fluoxetine and clonazepam with hold parameters.
#GERD: continued omeprazole
#OSA: Continued CPAP
#Glaucoma:
- continued home eye drop regimen, except those that are
nonformulary.
- Continued home methazolamide
===================
TRANSITIONAL ISSUES
===================
OUTPATIENT ANTIBIOTICS:
[ ] Vancomycin 1250mg IV q12h
Start Date: ___
Projected End Date: ___ (4wks)
[ ] WEEKLY LABS: CBC with differential, BUN, Cr, Vancomycin
trough, [CRP]
ALL LAB RESULTS SHOULD BE SENT TO :
ATTN: ___ CLINIC - FAX: ___
[ ] FOLLOW UP APPOINTMENTS: ID OPAT will arrange
DIURETIC REGIMEN: Torsemide 40mg BID
DISCHARGE WEIGHT: 296.3 lb (standing weight)
MEDICATIONS CHANGED:
[ ] Atorvastatin increased to 40mg from 20mg
[ ] Gabapentin increased from QHS to TID dosing
ITEMS FOR FOLLOW-UP:
[ ] Follow-up final pathology from bone fragment
[ ] Patient should be partial weight bearing on left lower
extremity until specified otherwise from his podiatrist
[ ] Wound care, Site: toe, Type: Surgical, Cleansing agent:
Commercial cleanser, Dressing: Gauze - dry, change every other
day
[ ] Follow-up blood glucose and if hypoglycemia, contact PCP to
adjust insulin dosing
[ ] Leukocytosis: Patient with WBC ___ prior to discharge. No
localizing symptoms or fevers. Please monitor patient for fevers
or other localizing symptoms of infection. If he has diarrhea,
low threshold to test for CDiff.
Name of health care proxy: ___
Phone number: ___
Code: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze
2. Atorvastatin 20 mg PO QPM
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. ClonazePAM 1 mg PO TID:PRN anxiety
5. Diltiazem Extended-Release 240 mg PO DAILY
6. FLUoxetine 80 mg PO DAILY
7. Gabapentin 100 mg PO QHS
8. Humalog ___ 100 Units Breakfast
Humalog ___ 100 Units Lunch
Humalog ___ 100 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: OMR med
9. Methazolamide 50 mg PO BID
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Omeprazole 20 mg PO BID
12. Potassium Chloride 20 mEq PO DAILY
13. Torsemide 40 mg PO BID
14. Travatan Z (travoprost) 0.004 % ophthalmic QHS
15. Aspirin 81 mg PO DAILY
16. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Vancomycin 1250 mg IV Q 12H
RX *vancomycin 500 mg 2.5 vials IV every twelve (12) hours Disp
#*70 Vial Refills:*0
2. Atorvastatin 40 mg PO QPM
3. Gabapentin 100 mg PO TID
4. Humalog ___ 100 Units Breakfast
Humalog ___ 100 Units Lunch
Humalog ___ 100 Units Dinner
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: OMR med
5. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze
6. Aspirin 81 mg PO DAILY
7. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
8. ClonazePAM 1 mg PO TID:PRN anxiety
9. Diltiazem Extended-Release 240 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. FLUoxetine 80 mg PO DAILY
12. Methazolamide 50 mg PO BID
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Omeprazole 20 mg PO BID
15. Potassium Chloride 20 mEq PO DAILY
16. Torsemide 40 mg PO BID
17. Travatan Z (travoprost) 0.004 % ophthalmic QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
--Sepsis
--Cellulitis
--Osteomyelitis
SECONDARY DIAGNOSIS:
--Anxiety
--Congestive Heart Failure, acute exacerbation HFpEF
--Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you. You were admitted to ___
___ because you were found to have bacteria growing
___ your blood. You also had an infection of a toe on your left
foot. The bacteria ___ your blood was thought to be from your toe
infection, so you had part of your left third toe removed.
Since you had bacteria ___ your blood, you will need to be on
antibiotics for a total of four weeks. The antibiotics will need
to be given through your vein so you were given something called
a "PICC" line. This is a line that you will have ___ your arm
until after your antibiotics are completed.
For your toe, it is important that you try and only put your
weight on your heel when standing up. You will be able to stand
on your feet normally once your toe heals.
It is important that you follow-up with your doctors. ___ have
made an appointment for you to see your primary doctor. You also
have an appointment to see your podiatrist (foot doctor).
It was a pleasure caring for you!
Sincerely,
Your Medical Team
Followup Instructions:
___
|
19767462-DS-7
| 19,767,462 | 23,569,057 |
DS
| 7 |
2156-08-09 00:00:00
|
2156-08-09 16:39:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
___ placement ___
Endoscopic ultrasound ___
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a history of
chronic pancreatitis who was found down, taken to OSH, and found
to have a thalamic bleed, so was transferred to ___ for
further
evaluation and treatment.
When Meals on Wheels came to his house today, Mr. ___ did
not come to the door. When the service-providers entered his
house, he was found leaning against the wall with medication
(Maalox?) covering him.
He was taken to ___, where ___ showed thalamic
bleed with intraventricular extension R>L.
On further history with Mr. ___, he describes that he got
up last night at 9:30pm to go to the bathroom, and when he sat
down to dress himself, he felt dizzy and felt that things were
"Going darker," and his vision turned gray. He ate macaroni and
cheese after this episode, and then felt better. Mr. ___
has never had a seizure.
ROS: + Headaches, back of neck and sinuses. Mr. ___
endorses a headache on most days of the week.
Mr. ___ reports that he has had droopy eyelids for many
years, and cataracts. Mr. ___ endorses difficulty
swallowing food or pills for a few months, since he had his
endoscopy.
He says he has bad hearing in his right ___.
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. Mr. ___ has had weight loss over
the past year, or few years. 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:
PUD
gastritis
pernicious anemia
cirrhosis
IBS
HTN
pancreatitis
Social History:
___
Family History:
Father with stomach ulcers. Mother had a stroke in her ___.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 97.2F P: 104 R: 16 BP: 155/91 SaO2: 94% on room
air.
General: Awake, cooperative, NAD. Appears cachectic.
HEENT: NC/AT, no scleral icterus noted, dry mucous membranes.
Neck: Supple.
Pulmonary: Normal work of breathing
Cardiac: warm, well-perfused
Abdomen: soft, ___
Extremities: No ___ edema. Cachectic.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Mostly attentive, able to name ___ backward
until ___, then stopped. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 5
minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: Right eye pupil 3 to 2mm and brisk (left eye
with significant cataract). Full EOM in right eye, left eye did
not track.
V: Facial sensation decreased on left compared to right.
VII: + Left facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Decreased bulk throughout; normal tone.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 3 3 3+ 2- 2 UN 2 2+ 2 2 2
R 5 ___ 5 5 5 5 5 5 5
-Sensory: Decreased sensation to pinprick and temperature on
left
hemibody compared to right.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor on right, extensor on left.
-Coordination: Significant dysmetria in right hand with FNF, and
unable to test left hand ___ weakness.
-Gait: Unable to test.
============================
DISCHARGE EXAM:
General: Awake, cooperative, NAD. Appears cachectic.
HEENT: NC/AT, no scleral icterus noted, dry mucous membranes.
Neck: Supple.
Pulmonary: Normal work of breathing
Cardiac: warm, well-perfused
Abdomen: soft, ___ tube c/d/i
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person and place, says year
is ___. Language is fluent with intact comprehension. Speech
mildly dysarthric. Able to follow both midline and appendicular
commands. Patient with L sided neglect
-Cranial Nerves:
II, III, IV, VI: Right eye pupil 3 to 2mm and brisk (left eye
with significant cataract). EOMs intact, though does not fully
look to L, likely related to visual neglect.
VII: + Left facial droop
VIII: Hearing decreased (chronic)
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline.
-Motor: Decreased bulk throughout; normal tone.
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___
L 3 4 3+ 3 3 2 2 2+ 5- 5-
R 4+ 4+ 4+ 5 5 4 4 4 5 5
*Note: Patient generally deconditioned. Rarely able to cooperate
with formal strength testing. Exam noted represents best exam.
Generally barely antigravity strength in L arm and L leg.
-Sensory: Decreased sensation to on left hemibody compared to
right.
-DTRs: ___ response was flexor on right, extensor on left.
-Coordination: Patient not cooperative with exam.
-Gait: Unable to test due to hemiparesis
Pertinent Results:
___ 08:09PM BLOOD WBC-10.4* RBC-3.07* Hgb-11.8* Hct-32.7*
MCV-107* MCH-38.4* MCHC-36.1 RDW-13.4 RDWSD-53.1* Plt ___
___ 08:09PM BLOOD ___ PTT-33.7 ___
___ 08:09PM BLOOD Glucose-182* UreaN-7 Creat-0.7 Na-131*
K-4.7 Cl-93* HCO3-18* AnGap-20*
___ 12:41AM BLOOD ALT-20 AST-59* LD(LDH)-788* CK(CPK)-409*
AlkPhos-81 Amylase-69 TotBili-0.6
___ 12:41AM BLOOD CK-MB-7 cTropnT-<0.01
___ 12:41AM BLOOD Lipase-28
___ 08:09PM BLOOD Calcium-9.1 Phos-3.0 Mg-2.1
___ 09:43AM BLOOD calTIBC-178* VitB12-1128* Ferritn-427*
TRF-137*
___ 12:41AM BLOOD Triglyc-136 HDL-84 CHOL/HD-2.2 LDLcalc-72
___ 03:53AM BLOOD Osmolal-283
___ 12:41AM BLOOD TSH-0.33
___ 08:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:21AM BLOOD Lactate-2.3*
___ 09:43PM URINE Color-Straw Appear-Clear Sp ___
___ 09:43PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-TR* Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:43PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 05:55AM BLOOD WBC-15.8* RBC-2.55* Hgb-9.4* Hct-28.2*
MCV-111* MCH-36.9* MCHC-33.3 RDW-12.8 RDWSD-51.9* Plt ___
___ 05:55AM BLOOD Glucose-316* UreaN-11 Creat-0.3* Na-134*
K-4.6 Cl-88* HCO3-35* AnGap-11
===============
Diagnostic Studies:
CT Head ___:
-Stable parenchymal hematoma centered in the right thalamus with
stable edema.
-Stable large-volume intraventricular extension of hemorrhage.
-Stable mild enlargement of the temporal and occipital horns of
lateral
ventricles.
MRCP ___:
1. Limited examination due to non-breath hold technique, given
these
limitations a small pancreatic lesion would be difficult to
exclude.
2. Atrophic pancreas with mildly heterogeneous signal intensity,
likely
sequela of chronic pancreatitis. Overall appearance of the
pancreatic duct is
improved from ___.
3. Interval decrease in size of a 0.6 cm vague T2 hyperintense
lesion in the
pancreatic head since ___, likely a resolving/residual small
pseudocyst.
CTA Pancreas ___:
1. Chronic pancreatitis with pancreatic atrophy and
resolving/residual 0.7 cm
small pancreatic head pseudocyst. No acute pancreatitis or
pancreatic
necrosis.
2. Apparent 0.7 cm subtle hyperenhancing lesion within the
pancreatic head
with abrupt main pancreatic duct cutoff and mild upstream
pancreatic duct
dilatation. Findings may be related to normal enhancing
pancreatic parenchyma
on a background of chronic pancreatitis with associated
pancreatic duct
stricture however a small neuroendocrine tumor would be similar
in appearance.
3. 2.5 x 0.7 x 0.3 cm rim enhancing collection within the
corpora cavernosa
may represent focal dilatation of the penile urethra.
4. Distended bladder with large volume intraluminal air.
5. Bilateral lower lobe ground-glass and ___ opacities,
worrisome for
aspiration or early pneumonia
6. 0.3 cm left lower lobe pulmonary nodule.
CXR ___:
Heart size is normal. Mediastinum is normal. Lungs are clear
by
hyperinflated. There is no appreciable pleural effusion. There
is no
pneumothorax.
EUS ___:
A focused EUS was performed using a linear echoendoscope at 7.5
MHz frequency: The head and uncinate pancreas were imaged from
the duodenal bulb and the second / third duodenum. The body and
tail [partially] were imaged from the gastric body and fundus.
Pancreas duct: the pancreas duct measured 4 mm in maximum
diameter in the head of the pancreas. In the head of the
pancreas, there was an abrupt cutoff however no mass or stone
was seen.
Bile duct: The bile duct was imaged at the level of the
porta-hepatis, head of the pancreas and ampulla. The maximum
diameter of the bile duct was 4 mm. The bile duct was normal in
appearance. No intrinsic stones or sludge were noted. The bile
duct and the pancreatic duct were imaged within the ampulla and
appeared normal.
Pancreas parenchyma: The uncinate process, head, body and tail
of the pancreas showed the following parenchymal changes:
hyperechoic foci, hyperechoic strands, atrophy in the tail,
hypoechoic foci, calcifications compatible with chronic
pancreatitis.
Gallbladder: evidence of sludge in the gallbladder was seen
Otherwise normal upper eus to third part of the duodenum
Brief Hospital Course:
#R thalamic IPH w/ IVE
___ gentleman with a PMH of HTN, chronic pancreatitis,
PUD, pernicious anemia, cirrhosis, ETOH abuse (?current). Found
down but alert, L sided weakness, facial droop, and sensory
deficits. ___ showed a R thalamic bleed with IVE R>L with
blood in the ___ ventricle and tracking up throughout the entire
ventricular system. He was admitted to the NeuroICU initially
for hydrocephalus watch. Repeat head CT at 24 hours was stable.
His exam has continued to improve since admission. He did not
require hypertonics or EVD. He was transferred to the floor once
deemed stable from bleed perspective. His bleed was felt to be
hypertensive in etiology given the location.
#Abd pain -continued home regimen, lipase wnl on admission. This
has been a chronic problem for him. Consulted GI, who initiated
workup for cachexia and chronic abdominal pain including MRCP
which did not show any cholangiocacinoma, with further
evaluation of the head of the pancreas with CT, which showed
concern for mass, possible neuroendocrine tumor vs . A decision
was made to undergo EUS on ___. There was no definite tumor
seen, and patient will undergo repeat imaging in 2 months per
advanced endoscopy fellow (Dr. ___. He continued on home
medication regimen, and gabapentin was increased to
1200mg/900mg/900mg.
# Malnutrition - Patient was checked for refeeding syndrome
after tube feeds were started without concerns. ___ was placed
on ___. He received feeds of vital 1.5 @ 40cc/hour. He received
phosphorus supplementation, and potassium supplementation as
needed.
#Urinary retention - He initially had coude placed as foley
unable to be placed. This was removed on ___, and patient was
able to void spontaneously. He has condom cath in place for
comfort.
# Social: SW and multidisciplinary team involved in case.
Patient able to make own decisions. Health care proxy is local
friend ___, determined during admission.
===================
Transitional issues:
- Patient to keep abdominal binder in place x 1 month to avoid
patient pulling out Gtube
- Please titrate anti-hypertensives.
- Patient continues on Neutra-phos supplementation, can be made
PRN if phosphorus levels are stable with feeding.
- Patient requires follow up with GI (Dr. ___/ Dr. ___ in
___ months.
- He should receive GI imaging (to be determined by GI team) in
2 months after discharge
- Patient requires Neurology follow up in ___ months.
===================
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 1 mg PO BID
2. DICYCLOMine 20 mg PO QID:PRN abdominal pain
3. Gabapentin 900 mg PO TID
4. Pancrelipase 5000 1 CAP PO QIDWMHS
5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
6. Pantoprazole 40 mg PO Q24H
7. Venlafaxine XR 150 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
6. Neutra-Phos 2 PKT PO BID hypophosphatemia
7. Nicotine Patch 14 mg TD DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Thiamine 100 mg PO DAILY
10. Gabapentin 900 mg PO BID
11. Gabapentin 1200 mg PO QAM
12. Lisinopril 40 mg PO DAILY
13. ALPRAZolam 1 mg PO BID
14. Cyanocobalamin 1000 mcg PO DAILY
15. DICYCLOMine 20 mg PO QID:PRN abdominal pain
16. Multivitamins 1 TAB PO DAILY
17. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
18. Pancrelipase 5000 1 CAP PO QIDWMHS
19. Pantoprazole 40 mg PO Q24H
20. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hemorrhagic stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized after being found unconscious and were
diagnosed with an ACUTE HEMORRHAGIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
altered due to bleeding in the brain. The brain is the part of
your body that controls and directs all the other parts of your
body, so damage to the brain from being deprived of its blood
supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
high blood pressure
We are changing your medications as follows:
New medications for blood pressure are amlodipine,
hydrochlorothiazide, and atenolol, and we increased your
lisinopril.
We added supplements for nutrition - folic acid, thiamine,
neutral-phos.
You will need insulin for your high blood pressure.
We started tamusolin for inability to urinate (urinary
retention).
We increased your gabapentin for pain.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19767462-DS-8
| 19,767,462 | 22,550,435 |
DS
| 8 |
2156-08-19 00:00:00
|
2156-08-19 14:32:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
___:
1. Exploratory laparotomy.
2. Closure of gastrostomy.
3. ___ gastrostomy with ___ Malecot drain.
History of Present Illness:
Mr. ___ is a ___ yo M with history of hypertension, chronic
pancreatitis, alcohol abuse and ?cirrhosis with recent admission
to the neurology service (___) for R thalamic bleed
who presented to ___ ED on ___ with abdominal pain and
cramping found to have leukocytosis and malpositioned G tube.
Briefly, pt was found down with L sided weakness, facial droop
and sensory deficit. NCHCT showed a R thalamic bleed with
intraventricular extension. He was admitted to the neuroICU
initially for hydrocephalus monitoring. Repeat NCHCT was stable
and he was transferred to the floor. Bleed thought to be
hypertensive in etiology. Course c/b abdominal pain and GI was
csonulted. MRCP notable for atrophic pancreas and decrease in
size of lesion in the pancreatic head. CTA of the pancreas
showed
0.7 cm subtle hyperenhancing lesion within the pancreatic head.
EUS was performed and there was no definite tumor seen, and
patient will undergo repeat imaging in 2 months per advanced
endoscopy fellow (Dr. ___. PEG tube was placed on ___ by
ACS due to severe malnutrition and persistent dysphagia. Pt was
initiated on tube feeds. He was discharged to rehab with
abdominal binder in place x 1 month to avoid
patient pulling out Gtube.
Patient had episode of hypotension and tachycardia and was also
noted to be having issues with G tube and tube feeds so he was
sent back to ___.
In the ED, pt reported abdominal pain and cramping.
Initial VS were: 97.8 88 144/84 98% RA
Exam notable for:
- AOx1
- Thrush?
- No mvmt of LUE or LLE
- Speaks fluently and follows commands
Labs showed: WBC 15.8, Hb 9.4, Platelets 449, Na 134, Glc 316,
lactate 1.4
Imaging showed:
- CT A/P: Percutaneous gastrostomy tube is malpositioned in the
anterior abdominal wall and located outside of the stomach with
adjacent air and fluid collection.
Consults:
- Surgery: recommended consultation with ___ for replacement of G
tube and drainage of collection
- ___: Will rewire G tube and drain collectin
Patient received: IV vancomycin, IV piperacillin-tazobactam
Transfer VS were: 99.0 98 139/70 18 98% RA
On arrival to the floor, when asked why pt is in the hospital,
he
notes that "I've been going to him for awhile." He says he is
feeling okay but has a lot of abdominal pain, which is not a new
problem for him. He tells me that his most recent
hospitalization
was for diarrhea and constipation. He otherwise denies fevers,
chills, vomiting, diarrhea, CP, SOB. He denies weakness,
difficulty swallowing or difficulty speaking. He notes a slight
cough and reports that he has been losing weight for many years.
He is unable to tell me the last time he saw his primary care
doctor.
Past Medical History:
Hemorrhagic stroke- Right thalamic stroke
Hypertension
Chronic pancreatitis
PUD
Gastritis
Pernicious anemia
?Cirrhosis
Alcohol abuse
IBS
Social History:
___
Family History:
Father with stomach ulcers. Mother had a stroke in her ___.
Physical Exam:
ADMISSION EXAM:
VS: 97.4 137 / 87 92 18 97 ra
GENERAL: Very cachetic appearing, appears older than stated age
HEENT: Mouth appears very dry
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTABL, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: thin, G tube with significant erythema, painful to the
touch, otherwise abd with NABS, soft, mildly tender, no rebound
or guarding
EXTREMITIES: Warm, no edema
PULSES: 2+ DP pulses bilaterally
NEURO: Alert to person, hospital, thinks it is ___, PERRL, no
facial droop, tongue mildly deviated to L, unable to lift
shoulder on the L, otherwise CN ___ intact, R UE with ___, ___
with ___, L UE ___, ___ ___, exam somewhat limited by patient
cooperation
DISCHARGE EXAM:
VS: 98.5, 148/87, 67, 18, 97 Ra
Gen: Lying in bed, NAD. +cachexia
CV: HRR
Pulm: LS ctab
Abd: soft, mini-laparotomy site with staples CDI. GT site CDI,
tube sutured in. Abdominal binder in place to prevent pulling.
Ext: No edema
Pertinent Results:
ADMISSION LABS:
___ 09:30PM WBC-16.1* RBC-2.68* HGB-10.1* HCT-29.1*
MCV-109* MCH-37.7* MCHC-34.7 RDW-12.9 RDWSD-51.1*
___ 09:30PM NEUTS-90.4* LYMPHS-3.7* MONOS-4.5* EOS-0.4*
BASOS-0.2 IM ___ AbsNeut-14.49* AbsLymp-0.59* AbsMono-0.73
AbsEos-0.07 AbsBaso-0.04
___ 09:30PM GLUCOSE-248* UREA N-11 CREAT-0.4* SODIUM-129*
POTASSIUM-5.7* CHLORIDE-83* TOTAL CO2-29 ANION GAP-17
___ 09:30PM ALT(SGPT)-32 AST(SGOT)-39 ALK PHOS-184* TOT
BILI-0.3
___ 09:30PM LIPASE-16
___ 09:30PM ALBUMIN-2.9*
___ 09:44PM LACTATE-1.4 K+-5.3*
IMAGING:
CT A/P ___
IMPRESSION:
1. Percutaneous gastrostomy tube is malpositioned in the
anterior abdominal wall and located outside of the stomach.
Adjacent to the tube, there is a rim enhancing fluid containing
air containing collection in the anterior abdominal wall which
measures 0.6 x 5.5 x 10 cm (AP x TV x CC).
2. 2.3 x 0.6 rim enhancing tubular structure in the corporal
cavernosa may
represent focal dilatation of the penile urethra.
3. Distended bladder with intraluminal air is nonspecific in
etiology
___ ___
IMPRESSION:
1. Decrease in size and evolution of the blood products in the
right thalamic region. Evolution of blood products in the
ventricles.
2. Unchanged ventriculomegaly
___ G-Tube Check:
Contrast passed freely through the PEG tube into the stomach
without evidence of leak or obstruction
Brief Hospital Course:
ONE-LINER:
___ yo M with history of hypertension, chronic pancreatitis,
alcohol abuse and ?cirrhosis with recent admission to the
neurology service (___) for R thalamic bleed who
presented to ___ ED on ___ with abdominal pain and cramping
found to have malpositioned G tube and intraabdominal abscess.
MEDICINE COURSE:
Mr. ___ was admitted to the medicine service for
management of malpositioned G-tube and imaging concerning for
rim enhancing fluid containing air containing collection in the
anterior abdominal wall which measures 0.6 x 5.5 x 10 cm. He was
started on broad-spectrum antibiotics with vanc/zosyn. Surgery
and ___ were consulted, and after evaluation Surgery recommended
patient have urgent drainage of the collection. Due to
development of new word-finding difficulty, Neurology was
consulted and he had a head CT which did not show acute change.
He was transferred to the Surgical service after the OR for
ongoing management.
ACS COURSE:
The patient was taken to the operating room on ___ and underwent
exploratory laparotomy, closure of gastrostomy, and placement of
___ gastrostomy with ___ Malecot drain 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 on bowel rest, on IV fluids, and IV
analgesia for pain control. The GT was to gravity. The patient
was hemodynamically stable.
On POD1 a PICC line was placed and TPN was started. The Foley
catheter was removed and the patient voided without difficulty.
Antibiotics were continued for 4 days post-operatively. On POD5
a tube study was done which showed contrast pass freely through
the PEG tube into the stomach without evidence of leak or
obstruction. Tube feeds were started and advanced to goal, which
patient tolerated well.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating tube
feedings at goal, out of bed to the chair with assist, voiding
without assistance into condom catheter, and pain was well
controlled. The patient was discharged to rehab. PICC was
removed prior to d/c. The patient and HCP received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
*Anticipated rehab stay <30 days.
Medications on Admission:
.
1. ALPRAZolam 1 mg PO BID
2. DICYCLOMine 20 mg PO QID:PRN abdominal pain
3. Gabapentin 900 mg PO BID
4. Gabapentin 1200 mg PO QAM
5. Lisinopril 40 mg PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
7. Pancrelipase 5000 1 CAP PO QIDWMHS
8. Venlafaxine XR 150 mg PO DAILY
9. amLODIPine 10 mg PO DAILY
10. Atenolol 100 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Hydrochlorothiazide 25 mg PO DAILY
13. Neutra-Phos 2 PKT PO BID hypophosphatemia
14. Nicotine Patch 14 mg TD DAILY
15. Tamsulosin 0.4 mg PO QHS
16. Thiamine 100 mg PO DAILY
17. Cyanocobalamin 1000 mcg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Pantoprazole 40 mg PO Q24H
20. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H
2. Artificial Tears ___ DROP BOTH EYES PRN Artificial Tears And
Lubricant Single Agents
3. Docusate Sodium 100 mg PO BID
4. OxycoDONE Liquid 10 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg/5 mL ___ mg by mouth every four (4) hours
Refills:*0
5. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using REG Insulin
6. ALPRAZolam 1 mg PO BID
7. amLODIPine 10 mg PO DAILY
8. Atenolol 100 mg PO DAILY
9. Cyanocobalamin 1000 mcg PO DAILY
10. DICYCLOMine 20 mg PO QID:PRN abdominal pain
11. FoLIC Acid 1 mg PO DAILY
12. Gabapentin 900 mg PO BID
13. Gabapentin 1200 mg PO QAM
14. Hydrochlorothiazide 25 mg PO DAILY
15. Lisinopril 40 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Neutra-Phos 2 PKT PO BID hypophosphatemia
18. Nicotine Patch 14 mg TD DAILY
19. Pancrelipase 5000 1 CAP PO QIDWMHS
20. Pantoprazole 40 mg PO Q24H
21. Tamsulosin 0.4 mg PO QHS
22. Thiamine 100 mg PO DAILY
23. Venlafaxine XR 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PEG tube dislodgement with sepsis
OR Findings:
1. Fibrinous exudate along left lobe of the liver and in
upper abdomen.
2. A 1 cm gastrotomy from prior PEG position in the incisura
of the stomach.
3. A ___ Malecot placed in body of the stomach.
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 re-admitted to ___ from rehab with high blood
pressure and altered mental status. You underwent a CT scan
which showed displacement of your PEG tube into the subcutaneous
tissues of the abdominal wall. You were taken to the operating
room and underwent an exploratory laparotomy, repair of the hole
in your stomach, and placement of a new PEG tube. You tolerated
this well. After surgery you received IV nutrition for 5 days
while the surgical site healed. A tube study was done which did
not show any leak. You tube feedings have resumed and you are
tolerating them at goal. You are now ready to be discharged back
to your facility to continue your recovery.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
19767548-DS-14
| 19,767,548 | 29,823,677 |
DS
| 14 |
2188-03-12 00:00:00
|
2188-03-13 13:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, chills
Major Surgical or Invasive Procedure:
-Tunneling of left internal jugular hemodialysis line
-placement of a midline
History of Present Illness:
Mr. ___ is a ___ y/o M with ESRD on HD MWF (anuric), DMII c/b
bilateral neuropathy, PVD and chronic hypotension who p/w fever
and chills. Sx began on ___ at HD when he spiked
fever to 101. He was given vanc after HD and then taken to an
OSH for eval (pt resides in prison). OSH thought pt had viral
syndrome, took cultures, and discharged without further
treatment. Pt felt better initially but then felt bad again on
___ at HD. He was given another course of vanc s/p HD.
Brought to ___ the evening of ___ for continued fevers. Pt
had HD in house today per his usual schedule with blood cultures
drawn prior to HD. He spiked to 103 in HD and developed rigors
and tachycardia to 130s. BP stable. OSH was contacted and BCx
there were found to be positive for GPCs and GNRs. He was
started on vanc, cefepime, and gentamycin and given 1g IV APAP.
ID was consulted in HD and will follow, but prelim recs were for
vanc/zosyn/gent. Pt was nearly done with HD when he spiked; took
off 800mL in HD but then gave back once he spiked. pt not volume
overloaded on exam and probably near euvolemia in HD per renal.
(dry weight is 98. here is ___ s/p HD). pt became hypotensive to
SBP 79 right before transfer. mentating fine. no pain. fluids
running wide open on way over. about 2L up at the time of
transfer.
In the MICU, VS 109/91, P ___, T 103, RR 19, 95% 2LNC. Pt says
he only noticed feeling "jumpy" the past week. Did not notice he
was febrile. Pt has tunneled left IJ for HD and a peripheral 22G
on left wrist. Access needed so attempted right IJ -
unsuccessful x 3 despite gaining access to IJ --> wire would not
advance. Attempted EJ x 2, also unsuccessful. Pt getting IVF and
pressures remained stable in MICU, coming up to 100-110s. Lab
called several hours into admission to say ___ bottles from HD
line growing GNRs. Other Bcx from HD line still pending. Patient
stable so no further IV access attempted overnight. Transplant
surgery consulted and they plan to remove tunneled line tonight.
Review of systems:
(+) Per HPI
(-) Denies f/c/s subjectively, CO, SOB, cough, diarrhea, rashes,
pain at catheter site, dizziness, lightheadedness.
Past Medical History:
- DMII c/b neuropathy
- chronic hypotension
- ESRD on HD w/ 3x failed renal txpt (___), anuric
- PVD
- gout
- s/p parathyroid surgery
- s/p CVA in ___ with speech and facial muscle impairment
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admissions Exam
General: Alert, oriented, no acute distress
HEENT: Sclera injected, MM dry, oropharynx clear, left eye
dysconjugate gaze laterally at rest but EOMI
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, moves all four extremities
Discharge Exam
VS - T 98.1 HR 84 RR 18 BP 116/62 SaO2 96% on RA
GENERAL - obese polite gentleman resting comfortably in bed
NECK - supple, no JVD appreciated
LUNGS - CTAB, respirations unlabored, no accessory muscle use
HEART - RRR, no m/g/r
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, no c/c, 2+ ___ pulses, 1+ lower edema up to
knees b/l
NEURO - awake, A&Ox3, moving all four exremities spontaneously,
follows commands.
Pertinent Results:
ADMISSION LABS
___ 06:00PM BLOOD WBC-8.4 RBC-3.29* Hgb-10.3* Hct-32.5*
MCV-99* MCH-31.4 MCHC-31.7 RDW-15.0 Plt ___
___ 03:24AM BLOOD WBC-8.6 RBC-2.89* Hgb-8.8* Hct-28.8*
MCV-100* MCH-30.4 MCHC-30.4* RDW-14.6 Plt ___
___ 06:00PM BLOOD Glucose-106* UreaN-27* Creat-7.8* Na-140
K-4.8 Cl-98 HCO3-31 AnGap-16
___ 03:24AM BLOOD Glucose-121* UreaN-19 Creat-5.9* Na-139
K-4.9 Cl-102 HCO3-27 AnGap-15
___ 03:24AM BLOOD LD(LDH)-205 TotBili-0.4
___ 07:00AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.2
___ 03:24AM BLOOD VitB12-240 Folate-14.9 Hapto-164
___ 11:23AM BLOOD Vanco-23.0*
___ 06:57PM BLOOD Lactate-0.6
___ 06:10AM BLOOD CRP-77.9*
___ 06:02AM BLOOD ALT-23 AST-17 LD(LDH)-186 AlkPhos-56
TotBili-0.3
___ 06:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
___ 06:00AM BLOOD HCV Ab-NEGATIVE
DISCHARGE LABS
___ 01:00PM BLOOD WBC-10.5 RBC-2.80* Hgb-8.7* Hct-27.7*
MCV-99* MCH-31.2 MCHC-31.6 RDW-15.0 Plt ___
___ 08:09AM BLOOD WBC-9.1 RBC-2.71* Hgb-8.3* Hct-26.6*
MCV-98 MCH-30.5 MCHC-31.1 RDW-14.9 Plt ___
___ 03:15PM BLOOD Glucose-184* UreaN-45* Creat-8.7*# Na-136
K-4.8 Cl-95* HCO3-26 AnGap-20
___ 08:09AM BLOOD Glucose-165* UreaN-56* Creat-9.6* Na-135
K-4.8 Cl-97 HCO3-22 AnGap-21*
___ 08:09AM BLOOD Calcium-8.4 Phos-9.6* Mg-2.0
___ 01:30PM BLOOD PTH-276*
MICRO:
___: BLOOD CULTURE X2: NGTD
___: BLOOD CULTURE: NGTD
___: BLOOD CULTURE:
SERRATIA MARCESCENS
| 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
PIPERACILLIN/TAZO----- S S
TOBRAMYCIN------------ 2 S 2 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
___ MRSA SCREEN: NEGATIVE
___ BLOOD CULTURE: NGTD
___ CATHETER TIP -IV:
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
___ BLOOD CULTURE X2: NGTD
___ BLOOD CULTURE: NGTD
___ BLOOD CULTURE: NGTD
___ STOOL: C. DIFF NEGATIVE
___ BLOOD CULTURE: NGTD
___ EKG: 92bpm, Artifact is present. Sinus rhythm. The P-R
interval is prolonged. No previous tracing available for
comparison.
___ CXR:
Left subclavian central venous catheter tip terminates in the
proximal right atrium. The heart is mildly enlarged. Aorta is
unfolded. The pulmonary vascularity is normal and hilar
contours are within normal limits. The lungs are clear. No
pleural effusion or pneumothorax is present. No acute osseous
abnormalities are seen.
IMPRESSION:
No acute cardiopulmonary abnormality.
___ CXR (portable): In comparison with the study of ___,
there is no evidence of
pneumothorax. There is some increasing opacification at the
left base
suggesting some volume loss and possible pleural fluid. There is
continued
enlargement of the cardiac silhouette with some indistinctness
of engorged
vessels, suggesting some elevated pulmonary venous pressure.
___ TTE
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is normal (LVEF 65%). 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. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: no vegetations seen
___ TEMPORARY LIJ PLACEMENT
1. Placement of a triple-lumen temporary hemodialysis catheter
with a VIP port into the upper right atrium via a collateral
vein in the left neck under fluoroscopic visualization. The
line is ready for use.
2. This patient has tenuous IV access. If this line is
converted to a
tunneled line, and if there is future concern for a line
infection, rather
than pull the tunneled line, please consider converting the
tunneled line into a temporary line for a "line holiday."
___ B/L UPPER EXTREMITIES U/S
FINDINGS: There is a normal respiratory flow pattern in the
bilateral
subclavian veins. There is normal compressibility and flow
demonstrated in the right internal jugular, axillary, brachial,
cephalic, and basilic veins. Incidentally noted there is
irregularity of the wall of one of the brachial veins,
presumably sequelae from a prior infection. Additionally, an
anechoic structure superficial to the right brachial artery is
presumably a tract from a prior AV graft.
In one of the left brachial veins, there is an occlusive
thrombus with
non-compressibility. Only partial flow is detected proximal to
this area in the vein. The second brachial vein is compressible
and patent. There is normal compressibility and flow in the
left internal jugular, axillary,
basilic and cephalic veins.
IMPRESSION:
1. Deep vein thrombosis of one of the left brachial veins.
2. Evidence of prior infection involving one of the right
brachial veins.
___ TUNNELING OF LIJ HD LINE AND PLACEMENT OF MIDLINE:
IMPRESSION:
1. Successful placement of a left brachial venous approach
midline venous
catheter terminating at the left axillary vein. Line is ready
for use.
2. Successful conversion of the left side of temporary
hemodialysis catheter to tunneled hemodialysis catheter. The
tip is located in the right atrium and catheter is ready for
use.
Brief Hospital Course:
___ year old male with ESRD on HD MWF (anuric), DMII c/b
bilateral neuropathy, PVD and chronic hypotension who presents
with five days of fever and chills who became hypotensive and
febrile in HD today.
# Sepsis secondary to Serratia bacteremia from HD line
infection: GNR grew on bcx in house, but GPCs also seen on OSH
bcx which speciated to coagulase negative (coag neg staph likely
contaminant). Likely source was R IJ tunnelled HD line which
was removed on ___. His hypotension was fluid responsive
in the ICU and he never required pressors. He was initially
covered with IV stress dose steroids which were tapered down. He
was then restarted on his home 5mg prednisone. He was
empirically covered with vancomycin/zosyn which was eventually
narrowed to ceftriaxone when blood cultures came back with
serratia sensitive to ceftriaxone (for a total of 14 day course
treatment, last day ___. He had a line holiday on
___ and underwent temporary HD line placement under ___ on
___. TTE did not show vegetations. Temporary L HD line
was tunneled on ___. A PICC was difficult to place by ___ and
a midline catheter was instead placed. Blood cultures from
___ were all negative growth to date. At time of
discharge, patient has been afebrile with stable vital signs for
several days. Should continue to receive antibiotics through
___ (ceftazadime dosed after HD).
#) LUE DVT: On u/s, patient found to have deep vein thrombosis
of one of the left brachial veins. He was started on heparin
drip and bridge to coumadin. Coumadin was increased from 5mg -->
7.5 mg --> 10mg based on INR. INR at time of discharge is 2.1.
He will continue with 10 mg. Patient will need frequent INR
checks initially and appropriate dosage of coumadin. Should be
on anticoagulation as long as HD line in place, or at least 6
months if catheter removed before that time.
# ESRD on HD w/ 3x failed renal txpt (all removed). RIJ HD line
removed. Patient able to receive hemodialysis successfully with
LIJ temporary line. LIJ tunneled on ___. Continued to have
scheduled dialysis MWF without any problems. Last hemodialysis
on ___. Throughout his hospitalization, he was continued on
calcitriol, calcium acetate (dose increased to 2 tabs TID
w/meals), vitamin D, and prednisone 5mg (patient does not know
why he is prescribed prednisone, assumed this is ___ to previous
failed transplants).
#) ANEMIA: Hgb: ___, Hct: ___. Uncertain baseline. Likely
secondary to CKD and HD. Haptoglobin and LDH were normal
excluding a hemolysis process. Retic count was 1.9, which shows
appropriate marrow response. No evidence of bleeding. He
receives darbepoeitin ___
#) DMII c/b neuropathy: at home patient takes NPH 8 units
qbreakfast and qdinner. While hospitalized, his sugars were
elevated >300s during the afternoons and evenings. His NPH
morning dose was increased to 12 units. We also continued his
home gabapentin. He was discharge on his home dose of NPH 8
units qbreakfast and qdinner.
#) CHRONIC ISSUES:
-GOUT: Continued on renally dosed allopurinol
-S/P CVA in ___ with speech and facial muscle impairment:
continued on home ASA
-HTN: his metalozone was beheld during his hospitalization. His
BPs have been 100-120s/70s
#) TRANSITIONAL ISSUES:
-please follow up with INR and dose coumadin appropriately (be
aware that in combination with aspirin, prednisone, and
allopurinol may increase bleeding)
-please give ceftazidime 1mg with HD on ___, and
___
-please be aware that patient is an extremely difficult stick.
If future line becomes infected, will likely need to keep line
in since he is so difficult to maintain access.
-please monitor FSBS and adjust insulin accordingly
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.5 mcg PO DAILY
4. Calcium Acetate 667 mg PO DAILY
5. Vitamin D 400 UNIT PO DAILY
6. Gabapentin 300 mg PO BID
7. Metolazone 10 mg PO DAILY
8. PredniSONE 5 mg PO DAILY
9. NPH 8 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcitriol 0.5 mcg PO DAILY
4. Gabapentin 300 mg PO BID
5. PredniSONE 5 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Nephrocaps 1 CAP PO DAILY
8. Warfarin 10 mg PO DAILY16
9. Metolazone 10 mg PO DAILY
10. CefTAZidime 1 g IV POST HD
11. Calcium Acetate 1334 mg PO TID W/MEALS
12. NPH 8 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis: Sepsis secondary to hemodialysis catheter
infection and Serratia bacteremia, left upper extremity deep
venous thrombosis
Secondary diagnosis: End-stage renal disease on hemodialysis
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 during your hospitalization at
___. You were admitted to the hospital because you had
bacteria growing on your hemodialysis line that spread to your
body. You were treated with antibiotics. Your hemodialysis line
was also removed and replaced with a new one.
Please continue taking antibiotics after dialysis. Last day on
___.
A clot was found on your left arm. You were started on an
anticoagulant to prevent future clots. Please continue to take
coumadin 10 mg daily and follow up with your primary care
physician who will check your INR levels and adjust your dose
accordingly. You will need to continue taking coumadin daily for
as long as your hemodialysis catheter is in place (or at least 6
months if catheter is removed before that time).
Please be aware that while taking coumadin, you are at an
increased risk of bleeding. As a result, it is very important to
continually check your INR with your primary care physician to
make sure your dose is appropriate.
Followup Instructions:
___
|
19767548-DS-16
| 19,767,548 | 20,257,898 |
DS
| 16 |
2188-09-24 00:00:00
|
2188-09-24 13:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w ESRD on HD with multiple failed access attempts, s/p
L axillary loop AVG ___, transferred from his correctional
facility after experiencing fever to 101 and chills during HD
today. He is presently dialyzing ___ via tunneled R IJ HD
catheter. Of note, he also had a recent R great toe amputation
and is currently receiving vancomycin with HD on M/F in
treatment
of this. He had had several prior admissions for line
infections, most recently Enterococcal bacteremia in ___
treated with ampicillin, and the present catheter was not
removed
at that time secondary to extraordinarily difficult access
history. Mr. ___ does report that it was "exchanged" two
weeks
ago while he was admitted to another hospital for his toe
amputation.
He received a full run of HD today and a dose of gentamycin
prior
to transfer. He does not void.
Upon interview in the ED, Mr. ___ reports that he feels well
now, but endorses an episode of chills with the fever at HD
earlier today. He ate ___ fries for lunch and denies nausea,
vomiting, dizziness, headache, or shortness of breath. He
endorses mild, ___ pain at the ___ surgical site, controlled
with oxycodone.
ROS:
(+) per HPI
(-) Denies night sweats, unexplained weight loss,
fatigue/malaise/lethargy, changes in appetite, trouble with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
# ESRD DUE TO: lead poisoning (per patient); 3x failed renal
txpt (___), anuric
# ON RENAL REPLACEMENT SINCE: ___ s/p renal transplant ___
failed, ___ failed)
# ACCESS HISTORY AND COMPLICATIONS: Right forearm AVF ___
(s/p transplant ___ & ___, both failed), right UE AV graft
___ -> removed for infection in ___, left UE AVG ___ ->
removed for infection in ___, left leg AVG ___
transplant in ___ but failed in ___, re-initiated HD
in ___ through lumbar catheter -> removed in ___
___ due to infection, Left tunneled IJ placed in ___ in
___ -> removed ___ at ___ -> New left sided tunneled
IJ placed ___. -> ?Date? left tunneled IJ removed at OSH, new
right tunneled IJ placed.
# DMII c/b neuropathy
# chronic hypotension
# PVD
# gout
# s/p parathyroid surgery
# s/p CVA in ___ with speech and facial muscle impairment
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: 103.4 115 97/49 20 97% RA
GEN: A&O, nontoxic, appropriate and conversant. Guards at
bedside.
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R. R chest tunneled HD
line insertion site intact without induration, erythema, or
drainage.
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
LUE: Upper arm surgical incisions clean, dry, and intact with
mattress sutures. The loop graft is palpable with minimal,
focal, overlying edema. There is no erythema or induration and
no palpable thrill. Palpable radial pulse. Multiple prior
surgical incisions well-healed. Motor function intact, sensory
exam at baseline (neuropathy).
RUE: Many well-healed surgical incisions, no edema.
LLE: 1+ pitting edema with mild chronic skin changes.
RLE: s/p great toe amputation with 3cm wound healing by
secondary
intention. Single prolene suture visible on plantar surface.
No
drainage, induration, erythema, or tenderness at the site. 1+
pitting edema. Shackles on.
Laboratory:
Lactate:2.2
8.8 > 34.4 < 151
MODERATELY HEMOLYZED SPECIMEN
141 96 17 < 95 AGap=21
------------
5.9 30 5.8 ___
(Repeat K+ 4.7)
N:60.2 L:23.8 M:5.7 E:9.7 Bas:0.6
Imaging:
CXR: No acute process.
LUE U/S: Occluded left arteriovenous graft. Overlying soft
tissue
edema without organized fluid collection. Patent native vessels.
Pertinent Results:
___ 08:30PM BLOOD WBC-8.8 RBC-3.58* Hgb-10.6* Hct-34.4*
MCV-96 MCH-29.6 MCHC-30.8* RDW-16.0* Plt ___
___ 05:44AM BLOOD WBC-5.2 RBC-2.96* Hgb-8.5* Hct-27.9*
MCV-94 MCH-28.8 MCHC-30.5* RDW-15.7* Plt ___
___ 07:25AM BLOOD ___ PTT-36.8* ___
___ 08:30PM BLOOD Glucose-95 UreaN-17 Creat-5.8*# Na-141
K-5.9* Cl-96 HCO3-30 AnGap-21*
___ 05:44AM BLOOD Glucose-64* UreaN-22* Creat-6.4*# Na-138
K-4.7 Cl-105 HCO3-28 AnGap-10
___ 05:44AM BLOOD Calcium-8.4 Phos-4.8* Mg-2.1
___ 05:44AM BLOOD Vanco-16.8
___ 2:42 pm Rapid Respiratory Viral Screen & Culture
Site: NASOPHARYNGEAL SWAB
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Refer to respiratory viral antigen screen and respiratory
virus
identification test results for further information.
Respiratory Viral Antigen Screen (Final ___:
Positive for Respiratory viral antigens.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to Respiratory Virus Identification for further
information.
Respiratory Virus Identification (Final ___:
Reported to and read back by ___ ___ 1105.
POSITIVE FOR PARAINFLUENZA TYPE 3.
Viral antigen identified by immunofluorescence.
___ Blood culture-negative
___ Blood Culture-pending
___ Blood Culture-pending
___ Blood Culture-pending
___ Blood Culture-pending
___ Blood Culture-pending
Brief Hospital Course:
___ w ESRD on HD with multiple failed access attempts, s/p L
axillary loop AVG ___, presented with fever. He was
nontoxic and without evidence of infection at the clotted LUE
AVG site or the recent RLE toe amputation site. Blood cultures
were sent. IV Vancomycin which had been started on ___ for
osteomyelitis was continued. The LUE AVG was found to be
occluded. This was noted on U/S on ___. No fluid collection or
edema was noted. CXR was negative for pneumonia.
On ___ he was febrile to 102.3. Repeat blood cultures were
sent peripherally and via HD cath. IV Zosyn was added to
empirically cover him. He had a hemodialysis session via the
right tunneled line on ___ with 1900cc removed. Vancomycin was
held for random level of 43.9. He continued to have temps up to
101.2. A TTE was done to evaluate for vegetations. This study
was suboptimal study. However, no vegetations were seen. Mild
pulm HTN was unchanged.
On ___ he was febrile to 103.2 and was pan cultured. Vanc
level was 28.5. On ___, CXR demonstrated increasing increasing
prominence to the interstitium in right mid, lower lobe, and
retrocardiac area. The right subclavian catheter remains in
place with its tip in the distal SVC.
___ d/ced zosyn, started imipenem, cough x2-3 days, sent
flu/resp cxs
On ___ resp cultures were sent for flu/respiratory cultures
for cough, and nasal congestion. He was placed on droplet
precautions. Cultures were negative to date. Zosyn was switched
to Imipenem.
On ___, Tamiflu was started. Nasal culture isolated
parainfluenza 3. Tamiflu was discontinued as it is not effective
for parainfluenza. He remained afebrile. Imipenem was
discontinued. Dialysis was performed via the HD line.
On ___, vital signs were stable. Blood cultures ___ were
still unfinalized. He was well enough to go back to ___.
Coumadin was resumed at 4mg daily. Coumadin had been held for
possible procedures. No procedures were done.
He will continue on Vancomycin at dialysis until ___ for right
toe osteo which had started on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcium Acetate 667 mg PO TID W/MEALS
3. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral BID
4. darbepoetin alfa in polysorbat *NF* 1000 units Injection
Weekly
5. Gabapentin 300 mg PO BID
6. NPH 8 Units Breakfast
NPH 8 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. OxycoDONE (Immediate Release) 10 mg PO Q 8H
8. Vancomycin 1000 mg IV ___
9. Nephro-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg Oral
Daily
10. Warfarin 4 mg PO DAILY16
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Acetate 667 mg PO TID W/MEALS
3. Gabapentin 300 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. NPH 8 Units Breakfast
NPH 5 Units Dinner
Insulin SC Sliding Scale using REG Insulin
6. Vancomycin 1000 mg IV HD PROTOCOL
continue until ___ on hemodialysis days.
7. Acetaminophen 650 mg PO Q6H:PRN pain/fever
8. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
10. Glucose Gel 15 g PO PRN hypoglycemia protocol
11. Guaifenesin ___ mL PO Q6H:PRN cough
12. Nephro-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg
Oral Daily
13. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral BID
14. darbepoetin alfa in polysorbat *NF* 1000 units Injection
Weekly
15. Warfarin 4 mg PO DAILY16 h/o DVT
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ESRD
h/o right ___ toe osteomyelitis
para influenza
h/o DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You will be returning to ___
Please call the access clinic at ___ for fever > 101,
chills, nausea, vomiting, increased left arm pain, left arm
incision redness, drainage or bleeding, increased circumference
of the left arm, cold blue or numb fingers of the left hand,
catheter site redness or drainage, catheter failure or other
concerns regarding hemodialysis access.
Comtinue hemodialysis via catheter q ___
Continue all home medications, dietary and fluid restrictions
You will be on IV Vancomycin until ___
Followup Instructions:
___
|
19767548-DS-17
| 19,767,548 | 21,116,299 |
DS
| 17 |
2189-02-12 00:00:00
|
2189-02-13 10:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___ Right tunneled IJ catheter replacement over guidewire.
History of Present Illness:
___ yo male w/ h/o ESRD ___ ___ s/p 3 failed kidney transplants
and many HD access failures due to infections, presents with
fevers and rigors since noon today. Tmax at ___ was 103.7.
He reports that he was feeling fine during his HD session on
___ and has not been having any problems accessing the line.
He denies using the line for anything else and denies poor
hygiene.
Denies headaches, sore throat, cough, chest pain, dyspnea,
abdominal pain, diarrhea, nausea, vomiting, back pain. He is
anuric.
In the ED, initial vitals were 102.3 43 133/92 22 95% RA. He
recieved Tylenol, 2L IVF, and vancomycin for fevers and rigors,
with suspected CLABSI. BC x3 (including from line) were done.
He was found to be hyperkalemic and EKG demonstrated peaked Ts.
So, he was given Insulin 8U, glucose CaGluconate, Kayaxelate PO.
However, repeat K was still elevated so the renal team decided
to start a short emergent HD session through the existing HD
line tonight.
On arrival to the MICU, he is having rigors while on the HD
session through his existing right IJ line. He has no other
complaints. Post HD, he was hemodynamically stable and was
transferred to the general medicine floor.
Initial Blood cultures grew ___ GNR (later speciated to
Enterobacter). He started on daptomycin and cefepime initially
and then narrow to cefepime. He remained stable on antibiotics
and had his right tunneled IJ replaced over guidewire. His
first negative blood culture was on ___. He recieved four
days of IV cefepime and was discharged on oral cipro for 10 more
days. He remained afebrile, asymptomatic, and hemodynamically
stable on discharge.
Past Medical History:
# ESRD DUE TO: lead poisoning (per patient); 3x failed renal
txpt (___), anuric
# ON RENAL REPLACEMENT SINCE: ___ s/p renal transplant ___
failed, ___ failed)
# ACCESS HISTORY AND COMPLICATIONS: Right forearm AVF ___
(s/p transplant ___ & ___, both failed), right UE AV graft
___ -> removed for infection in ___, left UE AVG ___ ->
removed for infection in ___, left leg AVG ___
transplant in ___ but failed in ___, re-initiated HD
in ___ through lumbar catheter -> removed in ___
___ due to infection, Left tunneled IJ placed in ___ in
___ -> removed ___ at ___ -> New left sided tunneled
IJ placed ___. -> ?Date? left tunneled IJ removed at OSH, new
right tunneled IJ placed.
# DMII c/b neuropathy
# chronic hypotension
# PVD
# gout
# s/p parathyroid surgery
# s/p CVA in ___ with speech and facial muscle impairment
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
HEENT: Sclera anicteric, MMM
Neck: supple, no stiffness, no LAD
Lungs: clear to auscultation bilaterally
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Abdomen: soft, non-tender, non-distended, bowel sounds present,
surgical scars from previous transplants noted.
Ext: warm, 1+ edema. L arm swollen; numerous scars from previous
AVG/AVF. L axillary loop graft without thrill/bruit/pulse.
right leg with slightly more swelling than left (he reports this
is chronic) and with 3 amputated toes.
Skin: no splinter hemorrhages, ___ nodes, ___
lesions.
Discharge Physical Exam:
Afebrile
Right IJ: Line without purulence or fluctuance; no discharge or
tenderness.
Rest of exam unchanged from admission.
Pertinent Results:
ADMISSION LABS:
___ 02:13PM WBC-7.7 RBC-4.33*# HGB-12.8*# HCT-41.9#
MCV-97 MCH-29.6 MCHC-30.7* RDW-16.1*
___ 02:13PM NEUTS-77.4* LYMPHS-12.3* MONOS-5.8 EOS-3.8
BASOS-0.6
___ 02:01PM GLUCOSE-75 UREA N-33* CREAT-8.3*# SODIUM-140
POTASSIUM-6.4* CHLORIDE-100 TOTAL CO2-24 ANION GAP-22*
___ 02:01PM ___ PTT-39.6* ___
___ 02:14PM LACTATE-2.1*
___ 04:45PM GLUCOSE-173* UREA N-34* CREAT-8.6* SODIUM-140
POTASSIUM-6.2* CHLORIDE-101 TOTAL CO2-27 ANION GAP-18
___ 04:56PM LACTATE-2.1*
MICU LABS:
___ 03:30AM BLOOD WBC-7.8 RBC-4.02* Hgb-11.7* Hct-37.8*
MCV-94 MCH-29.2 MCHC-31.0 RDW-16.1* Plt ___
___ 10:23AM BLOOD ___ PTT-48.6* ___
___ 03:30AM BLOOD Glucose-67* UreaN-22* Creat-6.4*# Na-142
K-5.0 Cl-102 HCO3-23 AnGap-22*
MICROBIOLOGY:
___ 10:35 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
___ 2:05 pm BLOOD CULTURE #2.
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
___ 4:45 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON ___ -
___.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
___ 10:22 am BLOOD CULTURE Source: Venipuncture #1.
Blood Culture, Routine (Pending):
IMAGING:
CXR (___): FINDINGS: Right-sided central venous catheter
tip terminates in the lower SVC. The heart size is normal.
Mediastinal and hilar contours are unremarkable. There is no
pulmonary vascular congestion. Streaky opacity within the left
lung base likely reflects atelectasis. There is no focal
consolidation, pleural effusion or pneumothorax. "Rugger
___ spine is compatible with renal osteodystrophy.
TTE:
The left atrium is elongated. 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. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: No vegetations seen. Normal global and regional
biventricular systolic function. Mild mitral regurgitation.
Moderate tricuspid regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
the findings appear similar.
DISCHARGE LABS:
___:00AM BLOOD WBC-5.0 RBC-3.63* Hgb-10.8* Hct-34.4*
MCV-95 MCH-29.8 MCHC-31.4 RDW-15.7* Plt ___
___ 07:00AM BLOOD ___ PTT-36.0 ___
___ 07:00AM BLOOD Glucose-60* UreaN-52* Creat-8.4*# Na-137
K-4.8 Cl-100 HCO3-24 AnGap-18
___ 07:00AM BLOOD Calcium-8.3* Phos-6.6* Mg-2.2
ENTEROBACTER AEROGENES. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER AEROGENES
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ year old male with end stage renal disease (ESRD) on
hemodialysis (HD) with tunnelled RIJ and diabetes mellitus, type
2 (DM2) presents with fever and rigors x 8 hours and found to
have Enterobacter bacteremia from hemodialysis catheter-related
infection.
# Bacteremia: Pt. has a history of multiple line infections
including VRE and pan-sensitive serratia. Blood cultures grew
___ enterobacter. Pt. started on cefepime and daptomycin ___
with narrowing to cefepime ___. After consultation with renal,
transplant, and infectious disease, right tunneled IJ catheter
exchanged over guidewire ___. TEE did not reveal any
vegetations. Daily surveillance blood cultures have had no
growth since ___. Pt. has remained hemodynamically stable. He
was discharged on 500mg PO Cipro once a day. His last day is
___. On HD days, he should take the Cipro after dialysis. If
possible, it would be recommended if patient can get gentamicin
2.5mg/mL +4% NaCitrate (2mL) locks after HD.
# ESRD on HD: Per patient, ESRD related to lead poisoning and
type 2 DM. HD scheduled MWF. Right tunneled IJ changed over a
wire ___. Pt. has been continued on his home meds.
# H/O DVT: Medical records state that patient is on warfarin for
history of DVT. Per chart review, however, pt. does not have
documented DVT. On discharge, INR was low at 1.3. We did not
feel that a bridging regimen was necessary. Will continue
warfarin to maintain INR ___ and defer to outpatient PCP for
further management.
# Diabetes, Type II uncontrolled with complications: Pt. was
maintained on outpatient insulin regimen. On this regimen, he
had some fasting hypoglycemia in the AM. We would recommend
switching him to once daily Glargine with humalog meal time
sliding scale. He was continued on codeine and gabapentin for
neuropathy
TRANSITIONAL ISSUES:
- Adjusting insulin regimen
- Evaluate for neccesity of continued anticoagulation with
warfarin
- Continue ciprofloxacin 500mg PO daily to complete course (last
day ___
- Consider doing Gentamicin 2.5mg/mL + 4% sodium citrate dwell
2mL after HD if able to get the solution
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcium Acetate 667 mg PO TID W/MEALS
3. Gabapentin 300 mg PO BID
4. NPH 5 Units Dinner
Insulin SC Sliding Scale using REG Insulin
5. Acetaminophen 650 mg PO Q6H:PRN pain/fever
6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
8. Glucose Gel 15 g PO PRN hypoglycemia protocol
9. Guaifenesin ___ mL PO Q6H:PRN cough
10. Nephro-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg
Oral Daily
11. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral BID
12. darbepoetin alfa in polysorbat *NF* 1000 units Injection
Weekly
13. Warfarin 4 mg PO DAILY16 h/o DVT
14. Doxercalciferol 2 mcg IV MWF WITH HD
15. Vitamin D 50,000 UNIT PO QMONTH
16. Ferric Gluconate 125 mg IV QMOWEFR
17. sevelamer CARBONATE 800 mg PO TID W/MEALS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Acetate 667 mg PO TID W/MEALS
3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
4. Gabapentin 300 mg PO BID
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. Guaifenesin ___ mL PO Q6H:PRN cough
8. NPH 5 Units Dinner
Insulin SC Sliding Scale using REG Insulin
9. Warfarin 4 mg PO DAILY16 h/o DVT
10. Acetaminophen 650 mg PO Q6H:PRN pain/fever
11. darbepoetin alfa in polysorbat *NF* 1000 units Injection
Weekly
12. Doxercalciferol 2 mcg IV MWF WITH HD
13. Ferric Gluconate 125 mg IV QMOWEFR
14. Nephro-Vite *NF* (B complex-vitamin C-folic acid) 0.8 mg
Oral Daily
15. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral BID
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
17. Vitamin D 50,000 UNIT PO QMONTH
18. Ciprofloxacin HCl 500 mg PO Q24H Duration: 10 Days
Please give after HD on dialysis days. last day ___
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Catheter-Related Infection
SECONDARY DIAGNOSIS:
Bacteremia
End-stage renal disease on hemodialysis
Diabetes Melitus
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 fevers and chills. You were found
to have an infection in your blood, most likely related to your
hemodialysis line. You were started on antibiotics and your
line was replaced. The antibiotics have been working well and
there is no longer evidence of active infection. You have been
switched to oral antibiotics and will need to continue them
until ___.
Followup Instructions:
___
|
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