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19767823-DS-15
| 19,767,823 | 22,814,819 |
DS
| 15 |
2152-10-28 00:00:00
|
2152-10-30 20:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with squamous cell carcinoma, recent porcine
aortic valve replacement and one-vessel CABG to the LAD who
presents as transfer from ___ for tachycardia, and
with concern for a pericardial effusion. The patient initially
presented to ___ today after being referred by his visiting
nurse for tachycardia. This was refractory to home metoprolol,
however it is unclear if patient skipped doses. Patient had
previously been on Metop succinate, but was discharged from his
last hospitalization on Metop Tartrate. He finished his initial
prescription, but then he mistakenly refilled his Metop
succinate again. He continued taking this 3 times a day, but
reports that he stopped taking it the day prior to admission.
At ___, he was tachycardic and received 10 mg of
IV diltiazem and metoprolol without significant improvement in
his heart rate. He was noted to be in atrial flutter on EKG. A
CT angiogram of the chest was obtained and showed a small
pericardial effusion and bilateral, left greater than right
pleural effusions. There was no evidence of infection identified
on imaging. Patient was transferred here for cardiac surgery
evaluation following an echocardiogram which showed no evidence
of tamponade.
On arrival to the CCU: patient is resting comfortably and denies
any complaints. He specifically denies dyspnea, orthopnea,
palpitations, chest pain, dizziness, fever/chills.
Past Medical History:
Aortic stenosis
Coronary artery disease
Anemia
Asthma
Carotid Artery Stenosis
Cerebrovascular Accident, ___
Chronic Obstructive Pulmonary Disease
Depression
Hypertension
Hypothyroid
Non-Hodgkin's Lymphoma s/p radiation
Orthostatic Hypotension
Peripheral Vascular Disease
Squamous Cell Carcinoma of head and neck
Carotid Endarterectomy, bilateral
Laparotomy with Appendectomy and Splenectomy
Social History:
___
Family History:
Father HF CAD MI in late ___
Mother CAD MI in late ___
Brother CAD MI ~___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T 98.3F HR 130 BP 112/63 RR 20 O2SAT 97% on RA
GENERAL: Well developed, thin man in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL. EOMI. Conjunctiva pink. No
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple. JVP flat. Well-healed carotid endarterectomy scars
b/l.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Tachycardic, regular rhythm. Normal S1, S2. I/VI SEM.
LUNGS: Midline scar well-healed. No chest wall tenderness.
Respiration is unlabored with no accessory muscle use. No
crackles, wheezes or rhonchi. Diminished breath sounds in the
left lower lung field. with associated dullness to percussion.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
=======================
VS: ___ 0810 Temp: 98.7 PO BP: 114/80 HR: 115 RR: 18 O2
sat:
92% O2 delivery: ra
GENERAL: Thin pleasant male. lying in bed in NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL. EOMI. no conjuctival
pallor
NECK: Supple. JVP flat. Well-healed carotid endarterectomy scars
b/l.
CARDIAC: Tachycardic, irregular rhythm. Normal S1, S2. +I/VI
SEM.
LUNGS: Midline scar well-healed. No chest wall tenderness.
Respiration is unlabored with no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS
==============
___ 06:45PM BLOOD WBC-12.7* RBC-3.71* Hgb-10.6* Hct-34.1*
MCV-92 MCH-28.6 MCHC-31.1* RDW-14.6 RDWSD-49.4* Plt ___
___ 06:45PM BLOOD Neuts-71.5* Lymphs-16.2* Monos-10.7
Eos-0.5* Baso-0.9 Im ___ AbsNeut-9.12* AbsLymp-2.06
AbsMono-1.36* AbsEos-0.06 AbsBaso-0.11*
___ 06:45PM BLOOD ___ PTT-28.0 ___
___ 06:45PM BLOOD Glucose-118* UreaN-9 Creat-0.6 Na-139
K-4.3 Cl-101 HCO3-24 AnGap-14
___ 06:45PM BLOOD CK(CPK)-23*
___ 06:45PM BLOOD CK-MB-<1
___ 06:45PM BLOOD cTropnT-<0.01
___ 04:05AM BLOOD Calcium-8.7 Phos-3.8 Mg-1.8
___ 06:45PM BLOOD TSH-1.6
DISCHARGE LABS
==============
___ 07:35AM BLOOD WBC-8.9 RBC-3.49* Hgb-10.0* Hct-32.0*
MCV-92 MCH-28.7 MCHC-31.3* RDW-14.8 RDWSD-50.0* Plt ___
___ 07:35AM BLOOD ___ PTT-28.0 ___
___ 07:35AM BLOOD Glucose-101* UreaN-19 Creat-0.7 Na-140
K-4.2 Cl-101 HCO3-28 AnGap-11
___ 07:35AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.3
STUDIES
=======
___ CXR
Compared to postoperative chest radiographs since ___,
most recently ___.
Moderate left and small right pleural effusions are new.
Midline position of the mediastinum indicates that opacification
at the base of the left lung is atelectasis. Upper lungs clear.
Heart size normal.
Patient has had AVR. Chronic prevascular mediastinal
calcification projecting over the right tracheobronchial angle
is probably in a lymph node.
___ TTE
The estimated right atrial pressure is ___ mmHg. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF = 65%). The right ventricular
free wall is hypertrophied. The right ventricular cavity is
dilated with profound global free wall hypokinesis. There is
abnormal septal motion/position. A bioprosthetic aortic valve
prosthesis is present. The mitral valve leaflets are moderately
thickened. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. At least moderate tricuspid
regurgitation is seen but may be grossly underestimated due to
the technically suboptimal imaging. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion. A left pleural effusion is present.
Compared with the prior study (images reviewed) of ___,
the findings are grossly similar but the technically suboptimal
nature of both studies precludes definitive comparison.
___ Barium Swallow
No evidence of an esophageal mass or stricture in the mid to
upper esophagus. The patient had large volume aspiration into
the right bronchial tree, and the study was therefore
terminated.
Brief Hospital Course:
___ male with a history of squamous cell carcinoma,
recent porcine aortic valve replacement and one-vessel CABG to
the LAD on ___, who presented to ___ with
tachycardia on routine check, transferred to ___ for bilateral
pleural effusions and tachycardia.
# CORONARIES: 70-80% of the ostium of the LAD. RCA: Totally
occluded with collaterals to the distal RCA but non-dominant.
# PUMP: EF 50-55%
# RHYTHM: HR 120s. aflutter vs. atrial tachycardia
ACUTE ISSUES
=============
# Supraventricular tachycardia: Likely atrial
flutter/tachycardia with variable block. Patient's home
metoprolol was incorrectly re-filled as Succinate 1 week prior
to admission. Patient reports that he did not take any
Metoprolol since 2 days prior to admission. His metoprolol dose
was increased. He was rate controlled with metoprolol succinate
150mg BID. He was started on rivaroxaban for anticoagulation.
# Pleural effusion: New left pleural effusion as compared to
discharge CXR in ___. Likely ___ diastolic dysfunction in
setting of tachycardia. Patient was diuresed with subsequent
improvement in the pleural effusion.
# CAD s/p CABG: CABGx 1 ___, LIMA to LAD. Continued ASA
81mg. Metoprolol as above.
# Aortic Stenosis s/p bioprosthetic valve: Aortic valve
replacement ___ with a 25 mm ___ Magna
Ease valve. Per TTE post-op, valve well-seated.
# Squamous Cell Carcinoma of Tongue: Initially diagnosed by ENT
at ___. Planning to follow at ___ although unclear if he
has seen anyone there yet. Barium swallow indicates no overt
mass in upper esophagus, and evidence of aspiration right
tracheal endobronchial tree.
CHRONIC ISSUES
===============
# Hypothyroidism: Continued home Levothyroxine Sodium 100 mcg
daily.
# BPH: Continued home Tamsulosin 0.4 mg PO QHS.
# Depression: Continued on Paroxetine 30 mg PO daily.
***TRANSITIONAL ISSUES:***
- F/U with cardiologist and PCP ___ 1 week
- Metoprolol tartrate changed to metoprolol succinate 150 mg
BID; monitor heart rate and adjust beta blockade as needed
- Follow-up resolution of pleural effusion
- Patient should follow-up with oncology as previously scheduled
for Squamous Cell Carcinoma of Tongue
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Levothyroxine Sodium 100 mcg PO DAILY
4. PARoxetine 30 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Simvastatin 40 mg PO QPM
7. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
8. Ranitidine 150 mg PO BID
9. Metoprolol Tartrate 25 mg PO TID
10. Tamsulosin 0.4 mg PO QHS
11. Cyanocobalamin 50 mcg PO DAILY
12. fluticasone-vilanterol 100-25 mcg/dose inhalation Q6H:PRN
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
Discharge Medications:
1. Metoprolol Succinate XL 150 mg PO BID
RX *metoprolol succinate 50 mg 3 tablet(s) by mouth twice a day
Disp #*180 Tablet Refills:*0
2. Rivaroxaban 20 mg PO DINNER
RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
4. Aspirin EC 81 mg PO DAILY
5. Cyanocobalamin 50 mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. fluticasone-vilanterol 100-25 mcg/dose inhalation Q6H:PRN
8. Levothyroxine Sodium 100 mcg PO DAILY
9. PARoxetine 30 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN
12. Ranitidine 150 mg PO BID
13. Simvastatin 40 mg PO QPM
14. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Supraventricular tachycardia
Pleural effusion
SECONDARY DIAGNOSES:
Squamous Cell Carcinoma of Tongue
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 ___
___!
Why was I admitted to the hospital?
- You were admitted because you were feeling short of breath and
your heart rate was elevated.
What happened while I was in the hospital?
- You were admitted to the intensive care unit to closely
monitor your heart rate. The dose of metoprolol, the medication
that regulates the heart rate, was increased with subsequent
improvement in the heart rate.
- You were started on a blood thinner (Rivaroxaban, also known
as Xarelto). Make sure to take this medication every day with
the largest meal. This medication thins the blood and prevents
strokes from the abnormal heart rhythm.
- You were found to have fluid in the lungs, you were given
medications to help get rid of the fluids off the lung. The
fluid in the lungs subsequently decreased.
What should I do after leaving the hospital?
- Please take your medications as listed and follow up at the
listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team
Followup Instructions:
___
|
19768128-DS-11
| 19,768,128 | 28,337,226 |
DS
| 11 |
2181-12-08 00:00:00
|
2181-12-08 17:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none this admission
History of Present Illness:
This is a ___ year old female who is s/p Suboccipital
craniotomy for vestibular schwannoma by Dr ___ on ___
with
discharge to home on ___. The patient presents to the Emergency
room this morning with progressive worsening headache. She
reports headache at 0230 at which time she took Tylenol followed
by worsening headache at 4:30 am for which she took oxycodone.
At 0600 the patient had headache ___ and the patients husband
and daughter took her to the Emergency Department at ___
___
for evaluation by Neurosurgery. The patient had a ___ upon
arrival that was suspicious for dural venous sinus thrombosis
and MRI/MRV was ordered for further evaluation.
Past Medical History:
Anxiety
Depression
Vestiibular schwannoma s/p craniotomy for resection ___
(___)
Social History:
___
Family History:
no history of CAD, DM, Cancer
Physical Exam:
-------------
on admission and stable at discharge
-------------
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-3mm bilat EOMs: intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: ___ objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: dense left facial, incomplete left eyelid closure,
inability to puff out left cheek, facial droop
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue deviation to the right
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger
Pertinent Results:
see OMR
Brief Hospital Course:
Mrs. ___ is s/p cranitomy for resection of vestibular
schwannoma ___, presenting with headache, found to have was
acute left transverse thrombosis
# acute left transverse sinus thrombosis
MRI/MRA confirmed acute left transverse sinus thrombosis
extending to left jugular vein proximally within the visualized
portions. Neurology was consulted. She was started on heparin
drip without bolus with PTT goal 50-60. PTT was therapeutic ___.
Head CT showed no acute hemorrhage. She was started on Aspirin
325 mg ___ and heparin drip was discontinued. Headaches improved
on oral medications. Neurology was consulted and recommend
anticoagulation with Coumadin, however Aspirin 325 was preferred
by Neurosurgeon attending. She remained stable and was
discharged home on ___.
# Vestibular schwannoma
She was continued on her decadron taper. Incision looked well
healed. Patient will follow up as scheduled next week for wound
check.
#Left eye ptosis
Patient has persistent left facial droop since postop. She was
continued on artificial tears and given an eye patch due to
incomplete closure of eye. She c/o blurry vision in left eye and
ophthalmology was consulted to evaluate for papilledema. Exam
showed no optic disc swelling and eye drops/gel was recommended
eye weakness.
Medications on Admission:
Acetaminophen 325-650 mg PO Q6H:PRN Pain,
Artificial Tears 2 DROP LEFT EYE TID Left facial,
dextran 70-hypromellose [Artificial Tears (PF)] 2 drops left
eye three times a day
Bisacodyl 10 mg PO/PR DAILY
Dexamethasone 3 mg PO Q8H x 9 doses, 2mg q8 h x 9 doses, then
1mg q8 hours x9 doses
1 mg PO Q8H,Docusate Sodium 100 mg PO BID Famotidine 20 mg PO
BID
OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN
Senna 8.6 mg PO BID
Discharge Medications:
1. Artificial Tears GEL 1% ___ DROP BOTH EYES QHS
apply once at bed time then tape eyelids of the
left eye
2. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
3. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild/Fever
4. Artificial Tears Preserv. Free ___ DROP LEFT EYE QID waking
hours
5. Dexamethasone 2 mg PO Q8H Duration: 4 Doses
This is dose # 2 of 3 tapered doses
Tapered dose - DOWN
RX *dexamethasone 1 mg taper tablet(s) by mouth every 8 hours
Disp #*17 Tablet Refills:*0
6. Dexamethasone 1 mg PO Q8H Duration: 9 Doses
after completing 2mg every 8 hours
This is dose # 3 of 3 tapered doses
Tapered dose - DOWN
7. Docusate Sodium 100 mg PO BID
8. Famotidine 20 mg PO BID
9. Senna 8.6 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute left transverse sinus thrombosis
vestibular schwannoma
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:
Activity
· We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· You should take Aspirin 325 mg daily. Please do NOT take any
blood thinning medication (Ibuprofen, Plavix, Coumadin) until
cleared by the neurosurgeon.
· You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication and
oxycodone for severe pain.
· Continue decadron taper 2mg every 8 hours x 4 doses, then 1mg
every 8 hours x 9 doses.
What You ___ Experience:
· You may experience headaches and incisional pain.
· You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and
mostnoticeable on the second and third day of surgery. You
apply ice or a cool or warm washcloth to your eyes to help with
the swelling. The swelling will be its worse in the morning
after laying flat from sleeping but decrease when up.
· You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foodsmay be
easier during this time.
· Feeling more tired or restlessness is also common.
· Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics
(prescriptionpain medications), try an over-the-counter stool
softener.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the incision
site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Roomif you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason
Followup Instructions:
___
|
19768190-DS-20
| 19,768,190 | 20,688,808 |
DS
| 20 |
2150-01-22 00:00:00
|
2150-01-24 10:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Oxycodone
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with PMH of achilles tendon repair in ___ (off
Lovenox x 1 month) and breast cancer (remission since ___ who
was brought to ED by EMS for 2 hours of sudden onset substernal
chest pain and dyspnea. The pain started on the morning of
presentation while the patient was bending down in the shower.
The patient had never had pain like this previously. She
described it as sharp, pleuritic, and associated with mild
dyspnea and tachypnea. She denied feeling of palpitations,
lightheadedness, or dizziness.
On arrival to the ED, EKG showed sinus tachycardia, with Q wave
in III. CXR was normal. The patient was started on heparin gtt
empirically. CTA chest was performed that showed bilateral,
large PEs. RV was slightly enlarged. LENIs and/or TTE was not
performed. Trop was 0.09, BNP was 845.
On speaking with the patient, she says that her chest pain has
resolved. She denies a personal h/o clots. She says that her
mother had a blood clot, without hypercoaguable workup. Patient
is a non-smoker, not on OCPs. She has no active malignancy. She
has had limited mobility due to recent surgery.
Review of systems:
(+) Per HPI
Past Medical History:
- Pulmonary embolism/left poplieal DVT (___): Provoked in the
setting of breast cancer and recent surgery
- Left achilles tendon rupture s/p repair ___
- Left breast invasive carcinoma with both ductal and lobular
features, grade 3, ER/PR negative, HER-2 positive diagnosed in
___
* ___: 1. Partial mastectomy for left breast cancer. 2.
Sentinel node mapping and biopsy left axilla.
* Treatment plan: dose dense Adriamycin/Cytoxan followed by
weekly Herceptin/Taxol x12 and year long Herceptin -> completed
___
- Polyneuropathy secondary to chemotherapy
- s/p TAH-BSO for fibroids
- Glaucoma
- Osteoarthritis
- Hypercholesterolemia
- Tenosynovitis of the foot and ankle
- Overactive bladder
Social History:
___
Family History:
Family Psychiatric History:
Half or step brother: ___ disorder, committed suicide.
Family History:
Step or Half sister: breast cancer at ___ (deceased).
Second half or step sister: AIDS, stroke age:___ (deceased).
Maternal cousin: ___ cancer
Father with prostate cancer in his ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- afebrile, 117, 114/88, 100% NC
General- NAD, AOx3
HEENT- anicteric, MMM, no elevation of JVD
CV- tachycardic, regular, no murmurs, no RV heave
Lungs- CTAB
Abdomen- soft, NT, ND
GU- no Foley
Ext- left leg with 2 incision sites with clean steri strips,
dry skin over foot, slight increased warmth of left calf, no
palpable cords or Homans sign, no livedo, palpable pulses
bilaterally
Neuro- nonfocal
Discharge Physical Exam
Vitals- 97.6 114/71 86 18 98%/RA
General- Alert, oriented, no acute distress
HEENT- NCAT, PERRL, Sclera anicteric, MMM, oropharynx clear
Neck- supple, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rhythm, tachycardia without murmurs
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no pitting edema. mild left
ankle swelling, staples on achilles and left calf in place,
clean dry intact, limited mobility, no calf tenderness
Neuro- CNs2-12 intact, motor function grossly normal
Psych - rapid, pressured speech, sometimes repetitive. Denies
insomnia
Pertinent Results:
--------------------
Admission labs
--------------------
___ 01:00PM BLOOD proBNP-845*
___ 01:00PM BLOOD cTropnT-0.09*
___ 01:00PM BLOOD Glucose-139* UreaN-14 Creat-0.9 Na-136
K-3.6 Cl-105 HCO3-15* AnGap-20
___ 03:21AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-143
K-3.7 Cl-112* HCO3-22 AnGap-13
___ 01:00PM BLOOD WBC-10.1 RBC-4.63 Hgb-13.6 Hct-41.4
MCV-89 MCH-29.3 MCHC-32.9 RDW-13.1 Plt ___
___ 03:24PM BLOOD WBC-6.8 RBC-3.85* Hgb-11.4* Hct-34.3*
MCV-89 MCH-29.6 MCHC-33.2 RDW-13.3 Plt ___
Discharge Labs
___ 07:10AM BLOOD WBC-6.6 RBC-4.05* Hgb-11.9* Hct-35.7*
MCV-88 MCH-29.3 MCHC-33.2 RDW-13.1 Plt ___
___ 07:10AM BLOOD ___ PTT-33.0 ___
___ 07:10AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-142
K-4.1 Cl-108 HCO3-26 AnGap-12
___ 01:00PM BLOOD ALT-18 AST-22 AlkPhos-81 TotBili-0.4
___ 07:10AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.0
Imaging, Other Studies
CTA CHEST (___)
1. Central pulmonary emboli involving the left and right
pulmonary arteries extending into the lobar branches of the all
lobes. Enlargement of the right ventricular diameter compared
to the left suggesting component of right heart strain.
2. Up to 4 mm bilateral pulmonary nodules for which a follow-up
can be
performed in ___ year if the patient has risk factors, such as
smoking or
malignancy, otherwise no additional imaging is necessary.
**
___ (___)
1. Left leg DVT with occlusive thrombus seen involving the
popliteal vein and calf veins. In addition there is occlusive
thrombus in the left lesser
saphenous vein.
**
TTE (___)
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The right ventricular cavity is mildly
dilated with moderate global free wall hypokinesis. Tricuspid
annular plane systolic excursion is depressed (1.3 cm)
consistent with right ventricular systolic dysfunction. There is
abnormal systolic septal motion/position consistent with right
ventricular pressure overload. 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 moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Dilated right ventricle with mild-moderate systolic
dysfunction. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of ___,
RV has dilated and RV systolic function has deteriorated
Brief Hospital Course:
This is a ___ yo F with recent immobility ___ achilles tendon
repair who presented with chest pain and was found to have
bilateral PEs.
# PULMONARY EMBOLISM: She was found to have large bilateral
pulmonary emboli. It was likely provoked by her recent
orthopedic surgery and subsequent immobility. Her case was
discussed with her oncologist, who felt that this was not likely
related to her malignancy as she has been in remission for the
last year. Her Chest CT and subsequent TTE showed some evidence
of right heart strain with dilation of the right ventricle.
However, LV function was not impaired and the patient did not
have any clinical evidence of hemodynamic compromise (no
hypotension, tachycardia only with exertion). She had lower
extremity venous dopplers that also showed DVT. She was started
on therapeutic lovenox to bridge to warfarin.
# Achilles repair (___): She was evaluated by physical
therapy who recommended the patient continue with ___, wear
bearing on LLE with boot. She will require ambulance or lift
assistance with the stairs to her apartment and will need to be
homebound for now.
# Pulmonary nodule: The patient was incidentally found to have a
4mm pulmonary nodule on Chest CT. She will need follow-up
imaging in one year.
# Glaucoma: Continued eye drops
TRANSITIONAL ISSUES
===================
[] Pulmonary nodule (4mm): Need f/u CT in ___ year to trend.
[] Anticoagulation f/u (titration of warfarin)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. travoprost 0.004 % ophthalmic QD
2. Acetaminophen 500 mg PO BID:PRN Pain
3. Docusate Sodium 100 mg PO BID:PRN Constipation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN fever
2. Docusate Sodium 100 mg PO BID:PRN Constipation
3. Enoxaparin Sodium 80 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 80 mg/0.8 mL 0.8 ml subcut twice a day Disp #*28
Syringe Refills:*0
4. travoprost 0.004 % ophthalmic QD
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Laxative PEG 3350] 17 gram 1
packet by mouth daily prn Disp #*30 Packet Refills:*0
6. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*50 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis: pulmonary embolism
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 to participate in your care here at the ___
___. You were admitted for chest
pain and found to have large blood in your lungs. We started you
on blood thinners to treat this. You will need to be on Lovenox
(injectable blood thinners) while we transition you to the pill
form (coumadin or warfarin). You will need to follow up with
your PCP to adjust the dose.
Please follow-up with your outpatient providers as outlined
below.
We wish you the best,
Your ___ team
transitional issues:
- please make sure your visiting nurse checks your blood on
___.
Followup Instructions:
___
|
19768422-DS-15
| 19,768,422 | 23,522,497 |
DS
| 15 |
2126-02-12 00:00:00
|
2126-02-13 17:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
low back, left leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with h/o hypertension and herniated lumbar disc with
sciatica x 6 months presents with worsening low back pain
radiating down left leg similar to previous sciatica. Pt
reports overnight was turning in bed and felt "pop" and sudden
onset pain left low back/buttock radiating down lateral leg.
Has had intermittent numbness in left toe but otherwise no
paresthesias or loss of bowel or bladder. Worse with movement.
Has difficulty weight bearing but doesn't feel he has focal
weakness. No fevers or chills. No difficulty urinating,
subjective perianla anesthsia. No trauma. Oxycodone at home gave
minimal relief. Has gotten cortisol injections x2, last one 3
weeks ago. Has trialed NSAIDs, flexiril, and oxycodone at home.
Has not see a specialist yet.
In the ED, he had the following vitals: pain 8, 98.6F, HR68,
BP180/90, RR16, O2 100%RA. EXAM: no TTP along spinous processes,
TTP mid-left buttock musculature, reflexes symmetric, downgoing
babinski's bl,, sensation grossly intact to soft touch, motor-
4+/5 strenght LLE plantar flexion (?limited by pain), normal
perianal sensation and rectal tone. Patient was given 5mg IV
morphine, 5mg morphine sc, oxycodone 10mg PO, and diazepam 5mg.
Plain film L spine done with arthrosis in lumbar and sacral
areas, no subluxation.
Currently, resting in bed in NAD. Family at bedside.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
HTN
Sciatica
Alcohol use
Social History:
___
Family History:
No significant family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.3F, BP 170/83, HR 64, R 18, O2-sat 98% RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, slightly dry MM,
OP clear
NECK - supple, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
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, unable to
elicit DTRs in bilateral LEs. Toes downgoing. Straight leg raise
mildly positive in left leg. No saddle anesthesia
DISCHARGE PHYSICAL EXAM:
unchanged
Pertinent Results:
LABS:
On admission:
___ 03:05PM BLOOD WBC-8.1 RBC-4.50* Hgb-14.9 Hct-42.8
MCV-95 MCH-33.1* MCHC-34.7 RDW-12.8 Plt ___
___ 03:05PM BLOOD Neuts-79.1* Lymphs-13.1* Monos-4.8
Eos-2.4 Baso-0.6
___ 03:05PM BLOOD Glucose-115* UreaN-26* Creat-0.8 Na-140
K-4.5 Cl-104 HCO3-23 AnGap-18
MICRO:
none
IMAGING:
___ Lumbo-sacral xray:
FINDINGS: Frontal and lateral views of the lumbar spine were
obtained. Five non-rib-bearing vertebral bodies are identified.
No fracture is present and vertebral body heights are
preserved. Multilevel lumbar spine degenerative changes are
present, most severe at L4-5 and L5-S1, with moderate-to-severe
facet arthrosis. No alignment abnormality. No focal lytic or
sclerotic lesion. Chain sutures are present in the right lower
quadrant.
IMPRESSION: Multilevel degenerative change, worst in lower
lumbar spine.
___ MRI Lumbar Spine:
IMPRESSION: Underlying dextroscoliosis with associated
alignment
abnormalities, as well as congenitally abnormal spinal canal
geometry and
prominent epidural lipomatosis, result in:
1. L4-L5: Most severe spinal canal and left more than right
subarticular
zone stenosis with traversing L5 neural impingement; bilateral
neural
foraminal stenosis with exiting L4 neural impingement.
2. L3-L4: Multifactorial moderate canal stenosis with central
crowding of
the traversing nerve roots; right more than left neural
foraminal stenosis
with possible impingement upon the exiting right L3 nerve root.
3. L5-S1: Grade 1 anterolisthesis, likely spondylolytic, with
bilateral
neural foraminal narrowing and possible exiting L5 neural
impingement, left
more than right.
4. T11-T12: Disc degeneration with right paracentral/proximal
foraminal
protrusion which may impinge upon the exiting right T11 nerve
root,
incompletely imaged.
COMMENT: Given the numerous findings, close correlation should
be made with the nature, level and side of the patient's
symptoms. In addition, comparison with any previous (outside)
MR imaging study would be helpful.
Brief Hospital Course:
___ yo M with h/o hypertension and herniated lumbar disc with
sciatica x 6 months presents with worsening low back pain
radiating down left leg similar to previous sciatica.
# Lumbar radiculopathy: History and exam consistent with
exacerbation of known herniated disc leading to worsening
radicular pain down left leg. No evidence of cord compression
or cauda equina on exam. Xray did not show any bony
deformities. MRI confirmed severe degenerative disc disease with
lumbar disc herniation resulting in multilevel moderate to
severe spinal stenosis and nerve impingement, worst at left L5
(consistent with symptoms). His pain was fairly well-controlled
with standing tylenol and ibuprofen with PRN oxycodone, so he
was discharged on this regimen for pain control. He was
encouraged to continue physical therapy and establish care with
an orthopedic spine specialist for further evaluation and care.
# Hypertension: increased lisinopril to 20mg daily
TRANSITION OF CARE ISSUES:
- Lumbar radiculopathy: pain control with tylenol, ibuprofen,
and oxycodone. He was discharged with a CD of his MRI images
and encouraged to establish care with a back surgeon for further
evaluation.
- HTN: increased lisinopril to 20mg daily
- FULL CODE
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Ibuprofen 800 mg PO Q8H
2. Lisinopril 10 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
4. Indomethacin 50 mg PO TID
Discharge Medications:
1. Ibuprofen 800 mg PO Q8H
RX *ibuprofen 800 mg 1 tablet(s) by mouth every 8 hours Disp
#*90 Tablet Refills:*0
2. Lisinopril 20 mg PO DAILY
Hold for SBP <110
RX *lisinopril 10 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
3. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
Hold for RR <12 or sedation
RX *oxycodone 5 mg 2 tablet(s) by mouth every 6 hours Disp #*30
Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp
#*120 Tablet Refills:*0
5. Outpatient Physical Therapy
722.1 Displacement of thoracic or lumbar intervertebral disc
without myelopathy
Evaluate and treat for lumbar radiculopathy from degenerative
disc disease with disc herniation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
L5 lumbar radiculopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure being involved in your care at ___
___. ___ were admitted to the hospital due to acute
worsening of your chronic low back pain. An MRI showed that ___
have a herniated disc in your back that is starting to press on
some nerves and causing your symptoms. There was no sign of
infection or masses in the back.
We started ___ on some pain medications to help control your
symptoms. ___ should continue to take ibuprofen and tylenol
scheduled around the clock, with oxycodone available as a
stronger medicine when the pain is bad. Do not drink alcohol,
drive or operate heavy machinery while taking oxycodone.
Avoid doing any lifting or twisting motions that may worsen your
symptoms. Physical therapy will be an important part of your
recovery, so please bring this ___ prescription to your local
physical therapy office to begin sessions. ___ also should make
an appointment with a back surgeon for evaluation for possible
surgery in case your symptoms continue unabated.
Your lisinopril was also increased to 20mg to help better
control your blood pressure.
Followup Instructions:
___
|
19768542-DS-8
| 19,768,542 | 23,814,040 |
DS
| 8 |
2123-07-01 00:00:00
|
2123-07-03 22:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with PMH of HTN and POD ___ s/p
laminectomy for disk herniation who presents from home for
hypotension. He was discharged from the hospital on ___
after a disk laminectomy on ___. Discharge medications
included Diazepam 5 mg PO Q6H:PRN pain, spasm and OxycoDONE
(Immediate Release) ___ mg PO Q4H:PRN Pain. ED referral states
that he was taking oxycodone 15mg q 3 hours and diazepam 10mg q
6 hours.
On the day of presentation, he was found at home by ___ to have
pressures ranging from 60/40 to 78/60 at home. Pulse Ox was 93%.
By report he had pinpoint pupils at home. He was asymptomatic by
report though his wife states that she has noticed that he is
sleepier than usual.
In the ED intial vitals were: 3 98.6 68 114/62 18 98%
Physical exam with no saddle anesthesia and normal rectal tone
by report. He experienced RLE swelling and ___ was negative for
clot though peroneal veins were not visualized. Labs were
significant for Na 127 and Cr 1.9 from baseline 0.9. He was seen
by ortho spine and the surgical wound appeared uninfected and
clean. A bedside ultrasound showed a distended bladder
post-voiding and a foley catheter was placed resulting in 1.8L
of urine returned.
Patient was given: 1LNS, 10mg diazepam and 15mg oxycodone.
He was admitted to medicine for hyponatremia and ___.
Vitals on transfer: 98.3 73, 107/47, 20, 96%RA
On the floor VS 98.5, RR 20, O2sat 93%RA, HR80, BP84/44 with a
well-fitted BP cuff. BP was rechecked at 70/doppler and
74/doppler. A clinical trigger was called. 2LNS were bolused
with recovery of BP to 105 systolic. The patient was sleepy but
easily arousable and mentating well the entire time. He denies
chest pain, shortness of breath, or light-headedness. ECG
revealed sinus rhythm with 1st degree AV delay and no ischemic
changes. The patient was placed on maintenance fluids overnight.
Review of Systems:
(+) leg swelling R>L, back pain, bladder distension now
relieved, constipation
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
HTN
HLID
Carpal Tunnel Syndrome
___
___ on CPAP
Morbid Obesity
Impotence
neuropathy
sciatica
Elevated HbA1c->6.1
Social History:
___
Family History:
Father had a CABG at age ___
No CVA in the family
Mother had breast cancer
Physical Exam:
ON ADMISSION
Vitals-98.6 68 114/62 18 98%
General- sleepy but easily arousable, oriented, no acute
distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- limited by distant heart sounds, regular rate and rhythm,
normal S1 + S2, no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
ON DISCHARGE
Vitals: 98.6 139/68 69 18 98%RA
General: Initially sleeping with CPAP in place but arousable,
oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation
CV: Distant heart sounds, secondary to body habitus. Regular
rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops
appreciated.
Abdomen: Mildly distended, soft, non-tender, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Ext: Warm and well perfused, no clubbing, cyanosis. Trace
pitting edema on LLE, 1+ pitting edema on RLE. No calf
tenderness
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ON ADMISSION:
___ 05:00PM BLOOD WBC-10.8 RBC-4.25* Hgb-11.8* Hct-35.6*
MCV-84 MCH-27.7 MCHC-33.1 RDW-15.0 Plt ___
___ 05:00PM BLOOD Neuts-76.5* Lymphs-12.9* Monos-5.6
Eos-4.4* Baso-0.5
___ 05:00PM BLOOD Plt ___
___ 05:00PM BLOOD Glucose-104* UreaN-54* Creat-1.9* Na-127*
K-4.3 Cl-88* HCO3-23 AnGap-20
___ 10:05PM BLOOD Calcium-8.7 Phos-5.2* Mg-2.5
___ 10:48PM BLOOD ___ pO2-137* pCO2-40 pH-7.40
calTCO2-26 Base XS-0
___ 05:13PM BLOOD Lactate-2.2*
ON DISCHARGE:
___ 06:25AM BLOOD WBC-10.3 RBC-3.86* Hgb-10.8* Hct-32.0*
MCV-83 MCH-28.1 MCHC-33.9 RDW-14.7 Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-122* UreaN-15 Creat-0.8 Na-139
K-4.6 Cl-105 HCO3-26 AnGap-13
___ 06:25AM BLOOD Calcium-9.1 Phos-5.2*# Mg-1.9
IMAGING:
___
LENIs: IMPRESSION: Nonvisualization of the peroneal veins,
otherwise, no right lower extremity deep vein thrombosis.
___
CXR: FINDINGS: The lung volumes remain low. Moderate
cardiomegaly. No overt pulmonary edema. No evidence of
pneumonia. No larger pleural effusions.
Brief Hospital Course:
Mr. ___ is a ___ male with history of morbid obesity and
hypertension who presents to the hospital 10 days post-op s/p
lumbar laminectomy with hypotension, ___, and hyponatremia.
#Hypotension: Mr. ___ was hypotensive from 60/40 to 78/60 with
pinpoint pupils on ___ visit at his home. On arrival to the ED
his BP normalized at 114/62. The etiology of his symptoms was
determined to be secondary to a combination of hypovolemia and
medication effect from high doses of oxycodone and diazepam. He
was monitored on telemetry with no evidence of arrhythmia. A
foley was placed in the ED with 1.8 L of diuresis. He arrived to
the floor hypotensive, likely a vagal response from rapid
bladder decompression in addition to the mentioned etiologies.
His blood pressure recovered s/p 2L IVF on arrival to the floor.
During his hospitalization he required IVF to keep up with
post-obstructive diuresis as detailed below. On the day prior to
discharge he demonstrated the ability to keep up with his UOP
with PO intake alone. His blood pressures remained stable after
his initial hypotensive episode on the floor and throughout the
duration of the rest of his hospital stay. His home blood
pressure regimen was restarted prior to discharge.
___: Mr. ___ presented with ___ of 1.9 from a baseline of
0.8-0.9. This was thought likely secondary to obstructive
uropathy from high dose diazepam/oxycodone he was taking at home
s/p his laminectomy. His oxycodone dose was reduced during his
hospitalization. He was started on standing Tylenol and on the
days leading up to his discharge was not requiring oxycodone and
his back pain level was stable at ___. His kidney injury
resolved with IVF and foley drainage. His electrolytes were
monitored throughout his hospitalization given post-obstructive
diuresis and were stable during his hospitalization.
#Urinary Retention: Secondary to obstructive uropathy from high
dose oxycodone/valium. A foley catheter was placed with
post-obstructive diuresis of 500cc per hour. He was started on
IVF to keep up with his urine output. By discharge, his UOP had
decreased to 160cc per hour and he had no difficulty keeping up
with PO intake to compensate for urinary losses. He passed a
voiding trial on day of discharge and was sent home without a
foley.
#Hyponatremia: FeNa was consistent with pre-renal ___ and
resolved with IVF. with IVF.
#Pain control: Mr. ___ was placed on standing Tylenol with
Oxycodone Q6H PRN and was not requiring narcotics for pain
relief in the days leading up to his discharge.
#Neuropathy: His Gabapentin was held on admission given ___, but
restarted when his creatinine returned to his baseline.
#OSA: Mr. ___ was monitored on telemetry overnight and was
placed on CPAP overnihgt.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 10 mg PO Q6H:PRN pain, spasm
2. Docusate Sodium 100 mg PO BID
3. Doxycycline Hyclate 100 mg PO DAILY
4. Gabapentin 300 mg PO TID pain
5. Hydrochlorothiazide 50 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. OxycoDONE (Immediate Release) 15 mg PO Q3H:PRN Pain
9. Senna 1 TAB PO BID
10. Aspirin 81 mg PO DAILY
11. Niacin SR Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Doxycycline Hyclate 100 mg PO DAILY
5. Senna 1 TAB PO BID
6. Gabapentin 300 mg PO TID pain
7. Hydrochlorothiazide 50 mg PO DAILY
8. Lisinopril 40 mg PO DAILY
9. Niacin SR 0 mg PO Frequency is Unknown
10. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary retention
Hyponatremia
Hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted because of low blood pressure, low sodium, and
evidence of injury to your kidney. You were found to be
retaining a significant amount of fluid in your bladder. This is
likely due to high doses of the Oxycodone and Diazepam you were
taking at home. We placed a foley and administered IVF to keep
up with your high urine output. Your elecrolyte abnormalities
resolved with fluids and your blood pressure returned to your
baseline. You were ultimately able to keep up with your urinary
output just with oral fluid intake and no longer required IV
supplementation. The foley catheter was discontinued prior to
discharge and you were able to urinate without problems.
Please try to avoid oxycodone for pain control as much as
possible as high doses of this medication can cause urinary
retention. If you are requiring Tylenol for pain control, please
do not exceed 4 g in 24 hours. Discuss with your primary care
physician whether an evaluation for benign prostatic hypertrophy
should be undertaken in the future.
It was a pleasure to be a part of your care!
Your ___ treatment team.
Followup Instructions:
___
|
19768844-DS-10
| 19,768,844 | 25,644,729 |
DS
| 10 |
2134-07-19 00:00:00
|
2134-07-19 17:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right facial pain and swelling
Major Surgical or Invasive Procedure:
___ surgery ___
History of Present Illness:
Mr. ___ is a ___ male with the past medical
history of CAD s/p CABG, HTN, HLD, hypothyroidism, a-fib on
Coumadin, systolic CHF who presents with R facial pain and
swelling, found to have masseter abscess. Patient had dental
extraction 2 months ago which was relatively uncomplicated.
Completed a course of abx at that time. Several weeks ago, he
developed R cheek pain and swelling which has progressively
worsened. He presented to his dentist, X-rays negative for acute
process. Patient presented to his PCP last week and was given a
4
day course of abx (he is unsure which abx) and vicodin. He
reports the antibiotics improved his pain - he did not like the
narcotics as they gave him palpitations. Soon after he completed
the abx, pain returned which prompted him to present to the ED.
He reports he has not been able to open his mouth ___ pain and
swelling therefore has only been eating liquids. Denies f/c,
vision changes, numbness or tingling in the area. Denies SOB or
sensation of throat closing.
Patient is not sure the exact reason he is on warfarin, thinks
it
is because of a "low ventricle." Denies history of stroke,
a-fib.
Reports he is able to walk the golf course without CP or SOB.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
HTN
Hypothyroidism
CAD s/p CABG
Systolic heart failure
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
ADMISSION EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: R mandibular/maxillary area with swelling and warmth, large
area of induration, mildly TTP, unable to open mouth widely due
to swelling and pain
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 HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE exam
97.6
PO 95 / 59
R Sitting 68 18 97 Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: R mandibular/maxillary area
enduration and tenderness better mildly TTP, able to open mouth
now
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 HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 04:16AM BLOOD WBC-7.5 RBC-3.34* Hgb-10.3* Hct-29.8*
MCV-89 MCH-30.8 MCHC-34.6 RDW-12.4 RDWSD-39.8 Plt ___
___ 05:02AM BLOOD WBC-13.7* RBC-3.80* Hgb-11.7* Hct-34.2*
MCV-90 MCH-30.8 MCHC-34.2 RDW-12.3 RDWSD-40.1 Plt ___
___ 05:05AM BLOOD WBC-11.3* RBC-3.64* Hgb-11.2* Hct-32.5*
MCV-89 MCH-30.8 MCHC-34.5 RDW-12.4 RDWSD-40.5 Plt ___
___ 04:16AM BLOOD Neuts-68 Bands-0 Lymphs-17* Monos-10
Eos-5 Baso-0 ___ Myelos-0 AbsNeut-5.10 AbsLymp-1.28
AbsMono-0.75 AbsEos-0.38 AbsBaso-0.00*
___ 04:16AM BLOOD Plt Smr-NORMAL Plt ___
___ 04:16AM BLOOD ___
___ 04:16AM BLOOD Glucose-100 UreaN-20 Creat-0.8 Na-134*
K-3.6 Cl-96 HCO3-26 AnGap-12
___ 05:02AM BLOOD Glucose-103* UreaN-17 Creat-0.9 Na-136
K-4.6 Cl-97 HCO3-24 AnGap-15
___ 04:16AM BLOOD Calcium-8.2*
Ct maxillofacial
IMPRESSION:
1. Inflammatory changes surrounding an enlarged right master
muscle containing
a 2.3 cm centrally hypodense area concerning for intramuscular
abscess.
2. Periapical lucency around an adjacent right mandibular molar
with
disruption of the lateral cortex is suggestive of periodontal
source of
infection.
3. Enlargement of the adjacent right submandibular gland is also
concerning
for infection.
Pre Operative Diagnosis:
1. Right submasseteric, vestibular space infection.
2. Impacted tooth #32
Post operative diagnosis: Same
Procedure:
1. Incision and drainage of the right submasseteric space
infection
2. incision and drainage of right vestibular space infection.
3. Extraction of full bony impacted tooth #32.
BLood cultures : NGTD
Intra -op cultures
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
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
in this
culture.
Brief Hospital Course:
Mr. ___ is a ___ male with the past medical history
of CAD s/p CABG, HTN, HLD, hypothyroidism, remote hx of
perioperative a-fib on Coumadin, systolic CHF who presents with
R facial painand swelling, found to have R masseter abscess.
ACUTE/ACTIVE PROBLEMS:
#Masseter muscle abscess - evaluated by ___, likely secondary
to impacted
tooth, recent dental extraction. Pt was afebrile and
hemodynamically stable.
- ___ wanted INR < 2.5 prior to surgery. warfarin was held and
reveresed with IV vitamin K (see below). Patient was started on
IV unasyn. Patient underwent I&D of the abscess on ___
-now being discharged on po augmentin and chlorheixine wash for
14 days
-___ will arrange for a outpatient appointment for him
Patient underwent Procedure:
1. Incision and drainage of the right submasseteric space
infection
2. incision and drainage of right vestibular space infection.
3. Extraction of full bony impacted tooth #32.
#Hyponatremia - likely related to low solute intake given
history of decreased PO intake due to difficulty opening the
jaw, Resolved quickly with gentle IV fluids
Recommend monitoring of sodium outpatient
#Chronic warfarin use: in the setting of ventricular aneurysm
(without documented thrombus) and perioperative afib per PCP. no
afib detected after hospitalization for CABG (remote), no PE,
DVT, LV thrombus, but was continued on warfarin as pt has
tolerated it well
-hx of aflutter/NSVT with cardiology per notes in ___
-okay with holding/reversing, no need for perioperative
bridging as patient is low risk
-restarted on 2 mg of Coumadin on 1012. will take 4 mg Coumadin
till gets blood work on ___ and PCP aware of the need for inr
check on ___
CHRONIC/STABLE PROBLEMS:
#HTN - on Lisinopril/aldactone at home
#hypothyroidism - continue synthroid
#CAD s/p CABG:resumed home ASA, resume after surgery
#Chronic Systolic EF
-TTE in ___ with EF 35-40%
-continued BB, ACEI
-euvolemic. continue to monitor volume status
needs close f/u with PCP and ___
___ spent in d/c 40 mins
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 4 mg PO DAILY16
2. Levoxyl (levothyroxine) 50 mcg oral DAILY
3. lisinopril-hydrochlorothiazide ___ mg oral DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Rosuvastatin Calcium 40 mg PO QPM
6. Spironolactone 25 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Fish Oil (Omega 3) 1200 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1 tab
by mouth twice a day Disp #*28 Tablet Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
4. Aspirin 81 mg PO DAILY
5. Fish Oil (Omega 3) 1200 mg PO DAILY
6. Levoxyl (levothyroxine) 50 mcg oral DAILY
7. Lisinopril 20 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Rosuvastatin Calcium 40 mg PO QPM
11. Spironolactone 25 mg PO DAILY
12. Warfarin 4 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Masseter Abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for abscess in the masseter muscle. You were
treated with surgery and IV antibiotics. Weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
You need to finish a course of antibiotics as prescribed and get
blood work on ___ for INR check
Followup Instructions:
___
|
19769211-DS-9
| 19,769,211 | 23,490,499 |
DS
| 9 |
2134-06-18 00:00:00
|
2134-07-14 13:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
encephalopathy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year old female with a history of
cutaneous T-cell lymphoma, chronic lymphocytic leukemia,
___ disease, bipolar disorder, prior right lacunar
stroke
in ___, hypertension now transferred from ___ after
presenting with a period of unresponsive, possible left sided
weakness and right eye deviation. History is obtained from
Neurology consult note as well as the patient. Per neurology,
"Patient does not remember any details about this morning and no
staff from rehab available tonight. Per written records, had
vomiting and nausea all day yesterday which patient confirms.
GI virus is reportedly going
around rehab facility. Evidently Ms. ___ was at baseline
this
AM and then early this afternoon became unresponsive, staring
straight ahead with eyes open. At some point later, paramedics
note eye deviation rightward and no verbal output. Blood
glucose=140. At ___, she was initially very lethargic
and
exam was limited. Afebrile and labs with increasing WBC (42)
but
otherwise unrevealing (listed below). CXR with question of
pneumonia so started on cefepime and vancomycin. Head CT
unrevealing and abdominal/pelvic CT showed worsening
lymphadenopathy. Discussion of LP with family but they deferred
per records. On re-examination [in the ER], markedly more alert
and able to follow commands. Per records (and subsequent phone
conversation with daughter ___ ___, family
thought she had returned to her baseline. Transferred to ___
ED for further
evaluation for possible seizure and admission to oncology
service."
On arrival to the floor at 3am, when asked how she was feeling,
she responded, "I feel great!" She acknowledges that she was
nauseous and vomiting for ___ days and does not fully remember
the events of the day, but has no physical symptoms that concern
her at this time.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies blurry vision,
diplopia, loss of vision, photophobia. Denies headache, chest
pain or tightness, palpitations, lower extremity edema. Denies
cough, shortness of breath, diarrhea, constipation, abdominal
pain, melena, hematemesis, hematochezia. Denies dysuria,
arthralgias or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. All other systems negative.
Past Medical History:
1. ___ Disease
2. Cutaneous T Cell Lymphoma
- diagnosed in ___
- treated with rituxan
- completed pentostatin from ___ after receiving 8 cycles
- received radiation therapy to nodular lesion on left arm
- started maintenace oral methotrexate in ___
- PO methotrexate stopped ___
- Now treated with clobetasol topical
3. CLL
- diagnosed in ___, asymptomatic
4. Bipolar Disorder
- required multiple psychiatric admissions
5. Stroke
- resulting left-sided weakness
- ___
6. Degenerative Joint Disease
7. Benign Hypertension
8. GERD
Social History:
___
Family History:
Colon Cancer
Hypertension
Sister - CLL
2 Brothers - Cancer, unsure what type
Physical Exam:
VS: T 96.9 HR 74 bp 143/72 RR 16 SaO2 95 RA
GEN: NAD, awake, alert, making jokes, baseline tremor
HEENT: EOMI, no gaze deviation, sclera anicteric, conjunctivae
clear, OP moist and without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, obese, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone and bulk
EXT: No c/c/e, 2+ ___ bilaterally
SKIN: warm skin
NEURO: oriented x 2 (knows name of hospital but cannot recall
season or year - says she is too tired) normal attention, CN
II-XII intact, ___ strength on right, slightly weaker on the
right, intact sensation to light touch
PSYCH: appropriate
.
Discharge:
VS: T afebrile bp 138/88, 80, 20, 92-96% RA
GEN: awake, alert
HEENT: no sinus tenderness, op clear
CV: rrr no mrg
CHest: ctab
neuro: aox2
Pertinent Results:
___ 01:30AM ___ PTT-33.4 ___
___ 01:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 01:00AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 01:00AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 09:24PM LACTATE-0.9
___ 09:13PM GLUCOSE-110* UREA N-14 CREAT-0.5 SODIUM-141
POTASSIUM-3.7 CHLORIDE-109* TOTAL CO2-25 ANION GAP-11
___ 09:13PM ALT(SGPT)-7 AST(SGOT)-12 ALK PHOS-74 TOT
BILI-0.3
___ 09:13PM cTropnT-<0.01
___ 09:13PM ALBUMIN-3.3* CALCIUM-8.0* PHOSPHATE-3.6
MAGNESIUM-1.9
___ 09:13PM VALPROATE-42*
___ 09:13PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Laboratory Data (from ___:
WBC-42.8, Hgb-13.3, Hct-40.9, Plts-209
Na-136, K-4.0 Cl-98, CO2-29, BUN-19, Cr-0.6, Glu-110
Ca-8.6
Alb-3.2, ALP-101, AST-13, ALT-21, Lipase-63
UA: negative.
Serum Tox: negative
Blood Culture pending.
EKG: normal sinus rhythm, left bundle branch block
Radiologic Data:
Head CT: chronic small vessel disease, hyperostosis of frontalis
CT Abdomen/Pelvis: Diffuse lymphadenopathy that has increased in
size and extent.
CXR: low lung volumes. There may be a small left-sided pleural
effusion. There is no focal consolidation or pneumothorax. The
cardiomediastinal silhouette is within the range of normal.
EEG at ___ ___: I spoke with the Senior Neurology resident
who relayed that the EEG did not identify active seizure nor
epliptiform activity. It showed diffuse slowing which is
non-specific and consistent with an encephalopathy. Based on
these findings, there is no indication for antiepeleptics.
.
___:
Head MRI:
IMPRESSION:
1. No acute intracranial pathologic process, with no acute
ischemia or
intracranial enhancing lesion.
2. Pan-sinus inflammatory disease, as described.
3. Cervical lymphadenopathy, in keeping with known CLL.
.
___
CXR
FINDINGS: In comparison with the study of ___, the patient
has taken a
much better inspiration. Areas of increased opacification
persist at the
bases, most likely representing atelectasis. Elevation of the
right
hemidiaphragm is again seen.
No evidence of vascular congestion.
.
Micro:
___: blood cultures pending
Discharge labs:
.
___ 06:47AM BLOOD WBC-32.7* RBC-3.68* Hgb-11.7* Hct-35.4*
MCV-96 MCH-31.8 MCHC-33.1 RDW-14.3 Plt ___
___ 06:47AM BLOOD Neuts-36* Bands-0 Lymphs-57* Monos-1*
Eos-2 Baso-0 Atyps-2* Metas-2* Myelos-0
___ 06:47AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL Ovalocy-1+
___ 06:47AM BLOOD Plt Smr-NORMAL Plt ___
___ 06:47AM BLOOD ___ PTT-36.9* ___
___ 06:47AM BLOOD Glucose-117* UreaN-7 Creat-0.5 Na-142
K-3.4 Cl-107 HCO3-26 AnGap-12
___ 06:47AM BLOOD ALT-8 AST-18 LD(LDH)-150 AlkPhos-88
TotBili-0.2
___ 06:47AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.9
.
___ 01:00AM URINE Color-Straw Appear-Clear Sp ___
___ 01:00AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:00AM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
Brief Hospital Course:
___ is a ___ year old female with a history of
cutaneous T-cell lymphoma, chronic lymphocytic leukemia,
___ disease, bipolar disorder, prior lacunar stroke in
___, hypertension now transferred from ___ after
presenting with a period of unresponsive, possible left-sided
weakness and right eye deviation.
#Encephalopathy: Initially concern that pt had seizure activity
or stroke, however EEG was more consistent with encephalopathy
and MRI did not show any evidence of mass lesion. Pt did not
have any significant electrolyte abnormalities, and initially
had a leukocytosis of 30, which is consistent with her baseline
CLL. She remained afebrile, CXR did not show evidence of pna
and pt had no other localizing signs of infection with the
exception of diffuse sinusitis on head MRI. Combination of
bacterial sinusitis, dehydration and history or dementia likely
contributed to encalopathy. On HD2, pt was back to her baseline
MS, pt's sister visited hospital and confirmed that she was at
her ___ MS, which is AOx2 (person and place). Pt will be
followed up in Neurology clinic with Dr. ___ on ___.
.
# Acute bacterial sinusitis: Pt did not complain of frontal
headache and did not have tenderness to palpation over sinuses,
but had significant sinusitis on MRI, as evidenced air fluid
levels in frontal sinus and T1 signal enhancement. There was no
evidence of extension of sinusitis past dura. Given that she is
technically immunocompromised from CLL, it was decided to treat
pt for bacterial sinusitis for 10 day course with augmentin xr
BID.
.
# Leukocytosis: from CLL. No change from pt's baseline WBC.
.
# CLL: Stable disease without treatment. Quantitative
immunoglobulins adequate.
.
# Cutaneous T-cell lymphoma: Normal LDH. PO methotrexate
stopped ___. Now treated with clobetasol topical.
.
# ___ disease: Continued outpatient carbidopa-levodopa,
pramipexole.
.
# HTN: Continued outpatient metoprolol, lisinopril
.
# Bipolar disease: Continued outpatient valproate, quetiapine,
and clonazepam. Valproate is used as a mood stabalizer; level
of 48 is acceptable but not sufficient enough to prevent seizure
(50-100 goal for this intent). Usually levels for BPAD are kept
on the high side, so pt's psychiatrist might want to adjust her
dosing.
.
# CODE: DNR/DNI.
.
Transitional:
- follow up with Dr. ___ on ___, Dr. ___ ___
- consider adjusting valproate dosing
- 10 treatment with augmentin for sinusitis
Medications on Admission:
-mirapex 0.125mg TID
-seroquel 50mg qHS
-vitamin D2 50,000 units q2weeks
-calcium carbonate 500mg daily
-clonazepam 0.25mg BID
-lisinopril 2.5mg daily
-prilosec 20mg daily
-lopressor 100mg BID
-sinemet 25mg-100mg QID
-sinemet long-acting 25mg-100mg BID
-divalproex SR 250mg BID
-folic acid 2mg daily
-clobetasol BID
Discharge Medications:
1. pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
2. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO q 2
weeks.
4. calcium carbonate 500 mg calcium (1,250 mg) Capsule Sig: One
(1) Tablet PO DAILY (Daily).
5. clonazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
6. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
9. divalproex ___ mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
10. folic acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. carbidopa-levodopa ___ mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
12. carbidopa-levodopa ___ mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
13. Augmentin XR 1,000-62.5 mg Tablet Extended Release 12 hr
Sig: One (1) Tablet Extended Release 12 hr PO twice a day for 10
days.
Disp:*20 Tablet Extended Release 12 hr(s)* Refills:*0*
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
15. clobetasol
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. altered mental status
2. acute bacterial sinusitis
.
secondary:
- CLL
- ___ dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
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 care of you at ___. You were
admitted to the hospital for altered mental status. We were
initially concerned that you might have had a seizure, but our
workup with an EEG and MRI did not show evidence of active
seizure activity or any abnormality in your brain that might
cause seizures. We were also concerned that you might have an
infection and found that you have sinusitis, which was
identified on your MRI. We are treating you with a 10 day
course of antibiotics for the sinusitis.
.
We have made the following medication changes:
1. start augmentin XR every 12hrs for 10 days
2. start colace 100mg by mouth every twelve hours for
constipation
.
We have made follow up appointments for you with neurology as
outlined below. Please also follow up with Dr. ___ on
___.
Followup Instructions:
___
|
19769235-DS-2
| 19,769,235 | 27,247,434 |
DS
| 2 |
2152-12-29 00:00:00
|
2153-01-01 17:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
- CT-guided thrombin injection of pseudoaneurysm (not completed
because aneurysm was no longer seen)
- Interventional radiology coiling of pseudoaneurysm (not
completed because aneurysm was not found during the procedure)
History of Present Illness:
Ms. ___ is a ___ year old woman with chronic pancreatitis
following acute episode 6 months ago, who presents with one day
of worsening abdominal pain.
She first developed pancreatitis 6 months ago and was treated at
___ for approximately 1 week. She is unsure the etiology of
her episode, but suspects it may have been gallstones. Since
that time, she has had intermittent flares of abdominal pain
once or twice weekly which are generally mild and resolve after
a few days. However, at 2pm on the day of presentation, she
developed acutely worsened flare of epigastric and LUQ abdominal
pain. She describes it as a flooding pain, up to ___ associated
with nausea and dry heaves. She denies associated fevers or
chills, and no change to her chronic diarrhea for which she
takes Creon. Due to the severity of this flare, she presented to
the ED. Notably, she is scheduled for ERCP on ___ here at
___.
Initial VS in the ED: T 98.8, HR 51, BP 178/71, RR 18, O2 96%RA.
Exam notable for nontoxic appearing and convesational with soft
abdomen diffusely TTP throughout epigastrium with voluntary
guarding but no rebound. Initial labs were notable for Lipase
476, AP 126, Tbili 0.5, WBC 11.2 with 79%N, Ca 8.9. CT abdomen
showed pancreatitis with 5x5x3 hypodensity in the head
concerning for either necrosis of pseudocyst formation with 1cm
hemorrhagic blush and occluded splenic vein. Patient was given
IV zofran and dilaudid for symptom control and 2L NS prior to
admission to medicine for further managament.
On the floor, patient notes ___ abdominal pain, but is
otherwise wihtout complaint and in good spirits.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, 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. No recent change in bowel or bladder
habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
-HTN
-Depression/anxiety
-Chronic pancreatitis
-Gastric bypass surgery ___
Social History:
___
Family History:
Dad with CAD. No known history of GI cancers.
Physical Exam:
Physical Exam on admission:
Vitals: T:97.8 BP:148/72 P:52 R: 20 O2:95%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, bowel sounds present. TTP over
epigastrum and into LUQ. Volunary guarding without rebound
tenderness. No HSM
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, moving all extremities equally with
good strength
Pertinent Results:
Labs on Admission:
___ 04:50PM BLOOD WBC-11.2* RBC-4.66 Hgb-13.6 Hct-41.2
MCV-89 MCH-29.2 MCHC-33.0 RDW-13.5 Plt ___
___ 04:50PM BLOOD Neuts-78.8* Lymphs-15.2* Monos-3.4
Eos-2.3 Baso-0.2
___ 04:50PM BLOOD ___ PTT-32.8 ___
___ 04:50PM BLOOD Glucose-103* UreaN-16 Creat-0.5 Na-142
K-3.5 Cl-101 HCO3-31 AnGap-14
___ 04:50PM BLOOD ALT-23 AST-24 AlkPhos-126* TotBili-0.5
___ 04:50PM BLOOD Lipase-476*
___ 04:50PM BLOOD Albumin-4.3 Calcium-8.9 Phos-3.7 Mg-2.1
.
Studies:
CT Abd/Pelvis ___:
IMPRESSION:
1. Acute-on-chronic pancreatitis with a complex collection
replacing the pancreatic parenchyma within the neck and proximal
body compatible with walled-off necrosis. 12-mm bilobed
pseudoaneursym is identified within this area of walled-off
necrosis, and chronic splenic venous occlusion with collateral
formation is noted.
2. Age-indeterminate T12 compression deformity; correlate with
clinical exam to assess for acuity.
.
RUQ US ___: IMPRESSION:
1. Small dependent sludge within the gallbladder without
evidence for shadowing stone. No evidence of cholecystitis.
2. Mildly dilated common bile duct measuring up to 1.1 cm.
.
CTA Abdomen ___:
FINDINGS:
VASCULAR:
The celiac origin is patent. The splenic artery and common
hepatic artery are patent. A bilobed blush of contrast is noted
adjacent to the junction of the common hepatic artery and
gastroduodenal artery, measuring approximately 1.2 x 0.8 cm,
consistent with a pseudoaneurysm. A direct connection with the
vasculature can not be clearly visualized.
The superior mesenteric artery is patent. Moderate
atherosclerotic calcifications are noted predominantly in the
distal aorta and proximal common iliac arteries.
NONVASCULAR:
There are trace bilateral pleural effusions, left greater than
right. There is minimal bibasilar atelectasis. There is no
pericardial effusion.
The liver demonstrates mild intrahepatic biliary ductal
dilatation, similar to the previous exam. Two small hypodense
areas are again noted in the porta hepatis and portacaval
region, likely representing small pseudocysts from prior bouts
of pancreatitis. There is vicarious excretion of contrast within
the gallbladder.
There is extensive inflammatory/hemorrhagic change in the region
of the neck and body of the pancreas with an ill-defined complex
collection measuring approximately 6.4 x 5.6 x 4.2 cm (AP x TV x
CC). This collection demonstrates hyperdense material,
consistent with hemorrhage from the previously identified
pseudoaneurysm. There is occlusion of the splenic vein as noted
on the prior
exam.
Post-surgical changes from previous gastric bypass are noted.
The remainder of the visualized bowel appears unremarkable,
without evidence of obstruction. There is edema surrounding the
distal stomach and proximal duodenum, but no evidence of
obstruction.
The adrenal glands are normal. The kidneys demonstrate
symmetric nephrograms, without evidence of hydronephrosis.
There are tiny low attenuating lesions within the right kidney,
which are too small to characterize, but likely represent cysts.
An age indeterminate compression deformity at T12 is again
noted.
IMPRESSION:
1. Extensive inflammatory change involving the pancreatic neck
and proximal body with hemorrhage and bilobed pseudoaneurysm,
likely arising from the gastroduodenal artery.
2. Splenic vein occlusion.
3. Two small hypodense areas in the porta hepatis and
portacaval region, likely representing small pseudocysts from
prior bouts of pancreatitis.
.
Arteriogram with Attempted Embolization ___:
IMPRESSION:
1. Normal-appearing celiac axis. Specifically, despite multiple
superselective catheterizations, no vessels feeding the
pseudoaneurysm could be identified.
2. Normal appearance of the superior mesenteric artery.
3. Normal appearance of a right common femoral angiogram
performed via the vascular sheath.
4. Findings are suggestive of possible interval thrombosis of
the pseudoaneurysm or feeding on the pseudoaneurysm from tiny
arterial branches.
If it remains patent the pseudoaneurysm could possibly be
accessed percutaneously via an ultrasound or CT guided approach.
.
Limited CT for Thrombin Injection into Pseudoaneurysm ___:
IMPRESSION:
1. No evidence of previously seen pseudoaneurysm within the
evolving lesser sac pseudocyst. Thrombin injection was not
performed due to this reason.
2. Otherwise, findings in the remaining upper abdomen were
unchanged since ___.
.
Labs on Discharge:
___ 05:00AM BLOOD WBC-7.8 RBC-3.49* Hgb-9.9* Hct-30.2*
MCV-87 MCH-28.2 MCHC-32.6 RDW-13.5 Plt ___
___ 08:05AM BLOOD ___ PTT-31.7 ___
___ 07:40AM BLOOD Ret Aut-2.0
___ 05:00AM BLOOD Glucose-130* UreaN-20 Creat-0.4 Na-138
K-4.3 Cl-99 HCO3-31 AnGap-12
___ 06:18AM BLOOD Amylase-37
___ 08:05AM BLOOD ALT-14 AST-18 AlkPhos-100 TotBili-0.6
___ 06:18AM BLOOD Lipase-29
___ 05:00AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.0
___ 07:40AM BLOOD calTIBC-199* Ferritn-331* TRF-153*
___ 08:05AM BLOOD Triglyc-96
Brief Hospital Course:
Ms. ___ is a ___ year old woman with chronic pancreatitis
following acute episode 6 months ago, who presents with one day
of worsening abdominal pain found to have acute on chronic
pancreatitis.
.
Acute Issues:
# Acute on Chronic Pancreatitis: Walled off area of necrosis
with pseudoaneurysm present in pancreas and with splenic vein
thrombosis on CT. However, BISAP score of 1 indicating low
probability of mortality. RUQ US without cholelithiasis, but
biliary sludge present and dilated CBD. Patient was initially
treated with NPO for bowel rest, IVFs, and IV narcotics for pain
control. CTA abdomen was obtained on HOD 3 to better
characterize pseudoanerysm and showed that it was likely arising
from the gastroduodenal artery. Interventional Radiology
attempted embolization via coiling of pseudoaneurysm, but it was
not completed because aneurysm was not found during the
procedure. ___ then attempted CT-guided thrombin injection of
the pseudoaneurysm, but the procedure was not completed because
the aneurysm was not visualized in the CT on the ___ (HOD 6).
We attempted to advance the patient's diet, but pain worsened
when she took toast and even clears, so we returned to bowel
rest. Panc/Bili surgery and GI were consulted and followed the
patient throughut her hospitalization. They recommended PICC
placement and TPN. PICC was placed, and TPN was initiated. She
was transitioned to fentanyl patch and PO oxycodone for pain.
The patient will follow up with Dr. ___ in panc/biliary surgery
for ongoing management of nutrition/pain. She will also get an
endoscopic U/S by Dr. ___ in the weeks after discharge to
evaluate if ERCP or surgery might be appropriate and helpful.
.
# Anemia of chronic disease: Hct drop from 41 on admission to 35
on HOD 2. Patient not hypotensive, no evidence acute blood loss.
Likely factor of dilution in setting of IVFs. Guaiac stools were
negative. Iron/anemia labs were c/w anemia of chronic
inflammation. HCT on discharge was 30.
.
Chronic Issues:
# HTN: Patient was mostly normotensive, but sometimes
hypertensive (with SBPs into 160s) during the hospital course.
Home amlodipine, metoprolol, and benazepril were continued.
.
# Depression/anxiety: well controlled, home paxil 40mg daily was
continued.
.
# Chronic Diarrhea: since gastric bypass in ___, no recent
changes. Home creon was discontinued in the setting of decreased
PO intake and lack of diarrhea.
.
Transitional Issues:
- Patient will follow up with Dr. ___ nutrition, pain
managment, and further management of pancreatitis.
- Patient will follow up with Dr. ___ primary care.
- Patient will follow up with Dr. ___ EUS and further
evaluation of the pancreas and the area of necrosis.
- Prior to discharge, grade 3 phlebitis was diagnosed on the
patient's left forearm, at a site of prior peripheral IV.
Nursing instructed the patient in proper care of the area, and
she was instructed to contact a physician with development of
fever or other new symptoms.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. M-Vit *NF* (PNV w/o calcium-iron fum-FA) ___ mg Oral daily
2. Paroxetine 40 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Potassium Chloride 20 mEq PO BID Duration: 24 Hours
Hold for K >
5. amlodipine-benazepril *NF* ___ mg Oral daily
6. Cyanocobalamin 1000 mcg IM/SC MONTHLY
7. Creon 12 4 CAP PO QIDWMHS
8. Aspirin 325 mg PO DAILY
9. Diclofenac Sodium ___ 50 mg PO DAILY
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Acetaminophen 325 mg PO Q6H:PRN pain
12. Ascorbic Acid ___ mg PO DAILY
13. calcium carbonate-vitamin D2 *NF* 600 mg calcium- 200 unit
Oral daily
14. ___ *NF* (ferrous sulfate) 325 mg (65 mg iron) Oral
daily
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Paroxetine 40 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. amlodipine-benazepril *NF* ___ mg Oral daily
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
hold for sedation or RR < 10
RX *oxycodone 5 mg ___ capsule(s) by mouth Q4H PRN Disp #*360
Capsule Refills:*0
6. Fentanyl Patch 25 mcg/h TP Q72H
RX *fentanyl 25 mcg/hour Apply 1 patch to the skin Q72H Disp
#*10 Transdermal Patch Refills:*0
7. Outpatient Lab Work
weekly on ___: CBC w/ diff, chem 7, Ca, Magnesium, Phos,
ALT, AST, AlkPhos, Albumin, Total protein, Tbili
8. TPN
Daily TPN: Volume(ml/d) 1800, Amino Acid(g/d) 90, Dextrose(g/d)
290, Fat(g/d) 45. Trace Elements added daily. Standard Adult
Multivitamins added daily. NaCL 80, NaAc 0, NaPO4 30, KCl 15,
KAc 0, KPO4 10, MgS04 10, CaGluc 8. Cycle over 12 (hrs.) Start
at 1800, Stop at 0600.
9. DiphenhydrAMINE 25 mg PO Q6H:PRN itching
RX *diphenhydramine HCl [Diphenhist] 25 mg 1 capsule(s) by mouth
Q6H PRN Disp #*120 Capsule Refills:*0
10. Docusate Sodium 100 mg PO BID
patient may refuse
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
11. Line Flush
Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute on Chronic Pancreatitis
Secondary:
Hypertension
anemia of chronic 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 with abdominal pain and found
to have pancreatitis. You were seen by Surgery and
Gastroenterology, but admitted to the General Medicine service.
You were treated with bowel rest, which means not taking
anything to eat or drink. You were also treated with IV fluids
and pain medication. When you tried taking liquid or solid food
by mouth, your pain worsened. Therefore, we put in a PICC (a
type of IV) and started you on TPN, which is nutrition in IV
form.
Please follow up with Dr. ___ (Surgery) about if and when
you should try drinking or eating. You have an appointment with
her listed below. You may call her office with any questions.
In addition, you should call her office immediately if you have
a sharp increase in your pain, increased nausea, vomiting, or
the development of any new symptoms.
Please continue to use the fentanyl patch (to be changed once
every three days) for pain. In addition, you may take oxycodone
as needed for pain. However, it is very important that you DO
NOT DRIVE while taking oxycodone. Driving while taking this
medication can be very dangerous. If you feel more forgetful or
confused while taking this medicine, please contact Dr. ___
Dr. ___.
Please follow up with Dr. ___. You will be called by her
office with an appointment time.
Finally, you will have an appointment with Dr. ___
(Gastroenterology) to have an endoscopic ultrasound in about ___
weeks time. His office is in the process of arranging that
appointment, and someone should be calling you within the next
few days with the appointment time. If you do not hear from
someone by ___, please call Dr. ___ office at
___.
Thank you for allowing us to take part in your care.
Followup Instructions:
___
|
19769235-DS-4
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DS
| 4 |
2154-02-14 00:00:00
|
2154-02-14 18:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea and abdominal pain
Major Surgical or Invasive Procedure:
___: Percutaneous transhepatic cholangiogram and placement
of an internal-external 8 ___ biliary catheter.
History of Present Illness:
___ h/o gastric bypass, pancreatitis complicated by
pseudocyst and cholelithiasis s/p cholecystectomy and pancreatic
pseudocyst gastrostomy (___), now presents with abdominal
pain
and nausea. Reportedly, she has had symptoms for approximately 4
weeks, which have progressively worsened. Until yesterday, these
symptoms could be lessened / alleviated by dietary change and
pain control (oxycodone). However, her abdominal pain has
worsened - typically mild and diffuse, subsequently more
pronounced in the right lower abdomen in association with nausea
and emesis x1. She additionally reports recent night sweats and
intermittent flushing. No dysuria, diarrhea or fevers. She feels
the pain is similar to prior episodes of pancreatitis.
Past Medical History:
-HTN
-Depression/anxiety
-Chronic pancreatitis
-Gastric bypass surgery ___
Social History:
___
Family History:
Dad with CAD. No known history of GI cancers.
Physical Exam:
Admission Physical Exam:
T 97.5, HR 65, BP 141/77, RR 16, O2 saturation 97%RA
Gen: NAD, A+Ox3
CV: RRR
Pulm: lungs clear to auscultation, bilaterally
Abd: soft, minimally diffusely tender to palpation,
non-distended; incisions well-healed
Ext: warm, well-perfused
Pertinent Results:
___ 11:28AM LACTATE-1.0
___ 11:10AM ALT(SGPT)-144* AST(SGOT)-225* ALK PHOS-267*
TOT BILI-1.2
___ 11:10AM LIPASE-182*
___ 11:10AM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-4.9*#
MAGNESIUM-2.6
___ 11:10AM WBC-7.7# RBC-4.81 HGB-13.9 HCT-44.0 MCV-92
MCH-29.0 MCHC-31.6 RDW-12.8
___ 11:10AM NEUTS-78.1* LYMPHS-14.6* MONOS-4.4 EOS-2.2
BASOS-0.6
___ 11:10AM PLT COUNT-220
Brief Hospital Course:
The patient was admitted on ___ to the General Surgical
Service for evaluation and treatment of her nausea and
progressive abdominal pain. The patient was started on IV
fluids for hydration, provided oxycodone PRN, and placed on a
clear liquid diet. On HD#2, the patient had persistent RUQ,
small volume emesis, and her LFTs had risen from admission and
so she was scheduled for ___ intervention. On HD#4, the patient
went to the ___ suite and underwent a percutaneous transhepatic
cholangiogram and placement of an internal-external 8 ___
biliary catheter. The patient was monitored closely on HD#5,
the drain was capped, however, she had persistent epigastric and
back pain. In the morning of HD#6, the drain was uncapped, her
abdominal pain resolved, and the patient tolerated a diet
without problems. The patient remained afebrile and
hemodynamically stable throughout her admission
Neuro: The patient received oxycodone with good effect and
adequate pain control. CV: The patient remained stable from a
cardiovascular standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: 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.
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 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:
Medications: pantoprazole 40mg daily, metoprolol ER 50mg daily,
Vit E, Vit B12, Vit D, Vit C, omega 3 fatty acids, Creon
12,000-38,000-60,000 unit: 4 capsules w/meals, paxil 40mg daily,
oxycodone 5mg prn pain,
Discharge Medications:
1. Creon 12 4 CAP PO TID W/MEALS
2. 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
3. Metoprolol Succinate XL 50 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ capsule(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q24H
6. Paroxetine 40 mg PO DAILY
Discharge Disposition:
Home with Service
Discharge Diagnosis:
pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
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).
*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.
___ Drain Care Rx:
Drain Catheter: To gravity drainage. Cleanse insertion site with
___ strength hydrogen peroxide and rinse with saline moistened
q-tip or with mild soap and water. Apply a drain sponge if
needed. Change dressing daily and as needed. Monitor for s/s
infection or dislocation. Check the patency of tube and that the
tube and drainage bag are secured to the patient. Monitor and
record quality and quantity of output.
Followup Instructions:
___
|
19769430-DS-5
| 19,769,430 | 20,715,800 |
DS
| 5 |
2160-08-02 00:00:00
|
2160-08-02 16:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R tibial plateau frx
Major Surgical or Invasive Procedure:
___: R tibial plateau fx ORIF, prophylactic fasciotomy
ant/lat
History of Present Illness:
___ recovering alcohol who presents after drinking for the first
time since ___ and falling down a flight of stairs to her
basement. She did strike her head, denies LOC. She is
complaining of some back pain, and severe R leg pain. Xrays at
OSH demonstrated a R tibial plateau fracture for which
Orthopaedics is consulted.
Past Medical History:
Depression, alcoholism
Social History:
___
Family History:
NC
Physical Exam:
Right lower extremity:
- Skin intact, inc cdi
- Passively able to range toes and ankle without pain
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R tibial plateau frx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for R tibial plateau ORIF and ppx anterior and lateral
fasciotomies, 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 <<>> 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
NWB in the right lower extremity in unlocked ___, and will
be discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ trauma team per routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
Effexor
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN PRN
wheezing/hypoxia
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin [Lovenox] 40 mg/0.4 mL 1 syringe at bedtime Disp
#*24 Syringe Refills:*0
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
7. Multivitamins 1 TAB PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN constipation
11. Venlafaxine XR 75 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R tibial plateau fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- non weight bearing, unlocked ___
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet (if applicable)
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Non weight bearing
Encourage turn, cough and deep breathe q2h when ___
unlocked<br>Strict NWB, ROMAT
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: To be changed DAILY by ___ starting POD ___. RN - please
overwrap any dressing bleedthrough with ABDs and ACE
Followup Instructions:
___
|
19769430-DS-6
| 19,769,430 | 29,538,202 |
DS
| 6 |
2160-09-03 00:00:00
|
2160-09-06 04:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
wound dehiscence
Major Surgical or Invasive Procedure:
I+D of right tibial wound dehiscence
History of Present Illness:
Ms. ___ is a ___ lady who is nearly 5 weeks status
post open reduction and internal fixation of a right bicondylar
tibial plateau fracture with associated four compartment
fasciotomy with primary wound closure. She sustained the injury
as a result of falling down stairs while intoxicated. She was
discharged from the ___ on ___ to rehab and was
discharged home from rehab on ___. She had been doing well
both at rehab and at home until ___ when she noticed
feeling a stabbing pain in the front of her left leg, as well as
feeling a bump about the right leg. ___ came to change her
dressing on ___ ___ and thought the wound looked somewhat
concerning. Ms. ___ then presented to her PCP's office on
___, at which point the wound was open distally and
leaking purulent fluid. She was seen and evaluated at the ___
___ ED before being transferred to the ___ ED. Ms. ___
denies fever, shaking chills, nausea, vomiting, diarrhea, cough,
and any other associated symptoms.
Past Medical History:
Depression, alcoholism
Social History:
___
Family History:
NC
Physical Exam:
Gen: NAD, aaox4
Cv: rrr
Pulm: lungs ctab
RLE: anterior tibial wound c/d/i, staples in place to skin.
Minimal drainage. 2+ distal pulses. SILT s/s/spn/dpn/tn, fires
___.
Pertinent Results:
___ 03:56PM BLOOD WBC-6.1 RBC-3.45* Hgb-9.9* Hct-31.7*
MCV-92 MCH-28.7 MCHC-31.2* RDW-13.9 RDWSD-47.0* Plt ___
___ 11:05PM BLOOD WBC-7.5 RBC-3.60*# Hgb-10.5*# Hct-32.9*#
MCV-91 MCH-29.2 MCHC-31.9* RDW-14.2 RDWSD-47.4* Plt ___
___ 11:05PM BLOOD Neuts-46.3 ___ Monos-9.0 Eos-2.5
Baso-0.5 Im ___ AbsNeut-3.48 AbsLymp-3.11 AbsMono-0.68
AbsEos-0.19 AbsBaso-0.04
___ 03:56PM BLOOD Glucose-107* UreaN-9 Creat-0.5 Na-139
K-3.9 Cl-105 HCO3-25 AnGap-13
___ 11:05PM BLOOD Glucose-115* UreaN-15 Creat-0.7 Na-138
K-3.5 Cl-103 HCO3-30 AnGap-9
___ 03:56PM BLOOD Calcium-8.8 Phos-4.1# Mg-1.8
___ 11:05PM BLOOD CRP-3.4
___ 12:45PM BLOOD Vanco-7.4*
___ 11:05PM BLOOD LtGrnHD-HOLD
___ 11:07PM BLOOD Lactate-1.0
Brief Hospital Course:
The patient presented as a same day admission for surgery. The
patient was taken to the operating room on ___ for I+D of
right tibial wound dehiscence, which the patient tolerated well.
For full details of the procedure please see the separately
dictated operative report. The patient was taken from the OR to
the PACU in stable condition and after satisfactory recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NVI and TDWB in the right lower extremity, and will be
discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
venlafaxine
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain
2. Enoxaparin Sodium 40 mg SC QPM Duration: 4 Weeks
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe every evening Disp #*28
Syringe Refills:*0
3. Ondansetron 8 mg PO Q8H:PRN nausea
only fill if needed as this is an expensive medication
RX *ondansetron 8 mg 1 tablet(s) by mouth every 8 hours Disp
#*15 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
please wean as pain improves
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
5. Venlafaxine XR 75 mg PO DAILY
6. Vancomycin 1.25 g IV Q 12H
RX *vancomycin 1 gram 1.25 g iv every 12 hours Disp #*105 Vial
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right tibial wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- TDWB, no brace needed
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
RLE: TDWB, ROMAT, no brace needed
Treatments Frequency:
Wound care: change dressing once per day; abd pad or dry gauze
over incision, wrap with kerlix and ACE. OK for patient to
shower after 48 hours, just do not submerge wound.
Followup Instructions:
___
|
19769489-DS-2
| 19,769,489 | 28,712,243 |
DS
| 2 |
2140-06-07 00:00:00
|
2140-06-14 09:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with multiple sclerosis c/b chronic pain
and quadriplegia/spasticity with chronic indwelling baclofen
pump last revised ___ and suprapubic catheter who initially
presented to ___ ___ with confusion and
poor PO intake, transferred for hyponatremia and concern for
infection at the site of recent baclofen pump revision. Ms.
___ recollection of the events of the past several days is
limited, and her caretaker ___ offers collateral information.
She has had a baclofen pump in place for some ___ years, with
most recent uncomplicated revision 8 days prior to admission by
Dr. ___ neurosurgery, requiring procedural intubation and
sedation. She was in her usual state of health until 6 days
prior to admission, when she developed intermittent chills and
sweats without objective fevers accompanied by nausea,
wretching, and poor PO intake, consuming only occasional Ensures
and soup. She had been prescribed hydrocodone-acetaminophen for
postoperative pain, and her caretaker recalls that nausea seemed
to be associated at least in part with narcotic use, prompting
change to Fioricet, with adequate pain relief and some
symptomatic improvement. Her caretaker also describes confusion
over the same period, noting that she provided tangential
responses to simple questions and was able to state her year of
birth, but not date. At baseline, she is reportedly completely
cognitively intact, requiring assistance with ADLs due to
quadriplegia/spasticity, but performing IADLs, such as shopping,
independently with the assistance of a wheelchair; she lives at
home with her husband and caretaker. She also experienced 2
frontal headaches without accompanying neurologic symptoms
distinct from baseline and relieved by
hydromorphone-acetaminophen, as well as 2 instances of transient
shortness of breath while supine, alleviated by repositioning.
She endorses constipation for 9 days prior to BMs in the 2 days
prior to admission, but denies lightheadedness, chest pain,
cough, URI symptoms, abdominal pain, loose stools, BRBPR/melena,
cloudy/bloody/malodorous urine, or new rashes; her suprapubic
catheter was changed 11 days prior to admission without
incident. Her caretaker has been inspected surgical site daily
and has not observed significant erythema or purulent drainage.
At ___, labs were notable for Na of 115,
normal CBC, and UA with 3+ leukocytes, ___ Wbc, and 1+
bacteria. Rapid influenza testing was negative. CXR was
unremarkable, as was noncontrast head CT. CT abdomen/pelvis with
PO/IV contrast revealed cholelithiasis with mild probable wall
thickening, 1.2cm hyperdensity in the urinary bladder likely
calculus, bilateral ovarian cystic lesions, bulky and hypodense
uterine cervix, and small pancreatic lesions. She received
ceftriaxone 2g IV, vancomycin 1g IV, and levofloxacin 750mg IV,
as well as 2L of IVNS prior to transfer to ___ for further
care. She remained normotensive (140s-150s systolic) at the
outside hospital with initial tachycardia to 110s improved with
IV fluids.
In the ED, initial vital signs were as follows: 98.5 88 152/85
18 95% NC. Admission labs were notable for Na of 123, normal CBC
and coagulation panel, unremarkable LFTs, lactate of 1.5, and UA
with large leukocytes and 75 Wbc. VBG was 7.43/47/59/32 with Na
of 125. Blood Cx x1 and urine Cx were obtained. RUQ ultrasound
revealed cholelithiasis, normal CBD, and a previously recognized
pancreatic neck cyst measuring up to 1.3cm. She was evaluated by
neurosurgery, with low suspicion for infection related to her
baclofen pump, prompting admission to the MICU for further
infectious work-up and correction of hyponatremia. Vital signs
at transfer were as follows: 99.8, 87, 124/72, 15, 96% RA.
On arrival to the MICU, she is entirely comfortable without
nausea. She is alert and oriented x3 and feels
"discombobulated," but is aware that her caretaker brought her
to the hospital, given concern for confusion. She states that
her baseline Na may be low.
Past Medical History:
Multiple sclerosis c/b chronic pain and quadriplegia/spasticity
with chronic indwelling baclofen pump and suprapubic catheter
Hypertension
Noninsulin-dependent diabetes mellitus
Gout
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
GENERAL: Alert, oriented x3, no acute distress
HEENT: Sclerae anicteric, MM dry, oropharynx clear
NECK: Supple, JVP not elevated
LUNGS: Breathing nonlabored, clear to auscultation anteriorly,
no wheezes, rales, rhonchi
CV: Regular rate and rhythm, no murmurs, rubs, gallops
ABD: Soft, non-tender, mildly distended/tympanitic (reportedly
baseline), LLQ indwelling baclofen pump palpable without
tenderness or overlying warmth, erythema, healing LLQ linear
incision with minimal associated erythema, no warmth,
tenderness, or purulent drainage, indwelling suprapubic catheter
draining clear urine, unable to reposition to inspect
EXT: Warm, well perfused, trace pedal edema
NEURO: Alert, oriented x3, flaccid extremities x4
DISCHARGE PHYSICAL EXAM
========================
VITALS: 98.1 124/68 97 20 100% 35 hum O2
GENERAL: sleeping but arousable, in no acute distress, snoring
HEENT: mouth open during sleep w/dry mucous membranes
NECK: large neck
LUNGS: clear to auscultation anteriorly
CV: Regular rate and rhythm, no murmurs, rubs, gallops
ABD: Soft, non-tender, mildly distended, LLQ indwelling baclofen
pump palpable without tenderness or overlying warmth, erythema,
clean, intact LLQ linear incision w/ staples, indwelling
suprapubic catheter draining clear urine
EXT: Warm, well perfused, trace pedal edema
NEURO: Sleepy, oriented x3, flaccid arms and legs, ___ strength
bilaterally in upper extremities. ___ strength in lower
extremities; sustained clonus in feet.
Pertinent Results:
ADMISSION LABS
===============
___ ___, 12:46am):
Chem7: 115/4.2/75.3/8/0.3/115
CBC: 7.7/36/356
UA: Trace protein, 1+ blood, 3+ leukocytes, ___ Wbc, 1+
bacteria
___ 05:30AM BLOOD WBC-7.0 RBC-4.18* Hgb-12.6 Hct-38.1
MCV-91 MCH-30.1 MCHC-33.1 RDW-13.7 Plt ___
___ 05:30AM BLOOD Neuts-80.2* Lymphs-10.9* Monos-7.0
Eos-1.7 Baso-0.2
___ 05:30AM BLOOD ___ PTT-29.4 ___
___ 05:30AM BLOOD Glucose-167* UreaN-6 Creat-0.3* Na-123*
K-4.3 Cl-86* HCO3-29 AnGap-12
___ 05:30AM BLOOD ALT-14 AST-15 AlkPhos-68 TotBili-0.3
___ 05:30AM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.2 Mg-1.5*
___ 05:41AM BLOOD Lactate-1.5
___ 06:37AM BLOOD O2 Sat-89
DISCHARGE LABS
=========================
___ 05:50AM BLOOD WBC-7.3 RBC-3.96* Hgb-12.6 Hct-38.2
MCV-96 MCH-31.8 MCHC-33.0 RDW-13.7 Plt ___
___ 05:45AM BLOOD Glucose-208* UreaN-11 Creat-0.4 Na-131*
K-5.1 Cl-85* HCO3-36* AnGap-15
___ 05:45AM BLOOD Calcium-8.9 Phos-4.9* Mg-1.9
MICROBIOLOGY
=============
URINE CULTURE (Final ___: <10,000 organisms/ml.
Blood culture ___: no growth
RADIOLOGY
===========
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
5:29 AM
1. Cholelithiasis without definite evidence of cholecystitis.
2. Cystic lesion within the neck of the pancreas, likely
secondary to a
side-branch IPMN. An MRCP is recommended in six months for
further
evaluation.
ECG ___:
Sinus rhythm. Right bundle-branch block. Non-specific inferior T
wave
changes. Compared to the previous tracing of ___ ventricular
premature contractions are no longer present. The heart rate is
slightly slower.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 ___ 34 38 3
CXR ___:
No change as compared to the previous image. The lung volumes
are low, but there is no evidence of pulmonary edema or
pneumonia. No pleural effusions. Normal size of the cardiac
silhouette. Normal hilar and mediastinal structures.
CT L-spine ___:
Severe degenerative changes and scoliosis.
2 intrathecal catheters the superior extent of which are not
visualized on this examination
No large fluid collection within the posterior soft tissues.
Brief Hospital Course:
Ms. ___ is a ___ with multiple sclerosis c/b chronic pain
and quadriplegia/spasticity with chronic indwelling baclofen
pump last revised ___ and suprapubic catheter who initially
presented to ___ ___ with confusion and
poor PO intake, transferred for hyponatremia and concern for
infection at the site of recent baclofen pump revision.
ACTIVE ISSUES
==============
# Toxic-metabolic encephalopathy:
Encephalopathy at presentation was likely multifactorial in the
setting of hyponatremia, suprapubic-catheter-associated UTI, and
postoperative narcotic use. Noncontrast head CT and CXR were
unremarkable at the outside hospital and there was no evidence
of intra-abdominal infection on outside hospital CT
abdomen/pelvis or RUQ US in the ___ ED. She was evaluated by
neurosurgery in the ___ ED, with low suspicion for local
infection at the site of her recently revised baclofen pump. Her
mental status improved to baseline after treatment of her UTI
and hyponatremia.
# Hyponatremia:
She presented to an outside hospital with Na of 115. Na improved
to 125 at the time of admission to ___ after 2L of IV NS at
the outside hospital. Hyponatremia is likely hypovolemic in
etiology in the context of nausea and poor oral intake. There
may be some degree of chronic hyponatremia per her report for
unclear reasons; indeed, Na was 128 on ___, though there are
no other measurements available.
# Intermittent hypoxia:
Patient was found to be intermittently hypoxic on monitors
during sleep. Hypoxia was consistently in the ___ but at
times decreased as low as ___. Most likely is a chronic issue
and is due to obstructive sleep apnea in the setting of her
multiple sclerosis and anatomy. She was seen by the sleep team
and will follow up outpatient for a sleep study for definitive
sleep apnea diagnosis. She was discharged with oxygen to wear at
night.
# Bradycardia:
Patient was noted to have intermittent episodes of bradycardia,
as low as 30. ECGs show junctional rhythm although patient is
generally in normal sinus rhythm. EP was consulted. Because she
is asymptomatic and bed-bound at baseline these episodes are low
risk and likely from autonomic dysfunction in setting of likely
OSA and MS. ___ her dose of diltiazem and set up
outpatient sleep follow up to treat her OSA.
# Suprapubic-catheter-associated UTI:
Although pyuria is difficult to interpret in the setting of
chronic indwelling urinary catheter, complicated UTI is presumed
in the setting of associated constitutional symptoms and mental
status changes. Treatment is indicated per current ___
guidelines. There was no evidence of SIRS/sepsis (tachycardia
only).
She was treated with ceftriaxone and later transitioned to
levofloxacin based on outside hospital sensitivity data of
citrobacter. After discharge, the patient called in to ___
complaining of diaphoresis but was afebrile. She felt this was a
side effect and asked to switch antibiotic agents. She was
switched to ciprofloxacin to complete her antibiotic course.
# Nausea:
Nausea at home was perhaps opioid-induced, given temporal
association with hydrocodone use and improvement following
transition to opioid-sparing analgesics. Nausea also may reflect
underlying catheter-associated UTI. There was low suspicion for
intraabdominal pathology in the setting of normal LFTs and
unrevealing CT abdomen/pelvis and RUQ US. Noncontrast head CT
was negative at the outside hospital, hence low suspicion for
centrally mediated nausea, at least due to large intracranial
mass. Her nausea resolved after discontinuation of opioids.
CHRONIC ISSUES
================
# Multiple sclerosis:
She is quadriplegic due to multiple sclerosis with chronic
indwelling baclofen pump and suprapubic catheter. According to
the neurosurgery consult note, she is not receiving intrathecal
baclofen yet post-op.
# Incidental radiographic findings:
Bilateral ovarian cysts and bulky uterus were noted on outside
hospital CT abdomen/pelvis, and IPMN was observed on admission
RUQ US.
# Hypertension:
She was mildly hypertensive to 150s-160s systolic on arrival.
Continued home diltiazem XR 240mg daily and valsartan 320mg
daily
# Noninsulin-dependent diabetes mellitus:
Hold home metformin in favor of Humalog insulin sliding scale.
# Gout:
Continued home allopurinol ___ daily.
TRANSITIONAL ISSUES
====================
- Obtain pelvic US in the outpatient setting for further
evaluation of ovarian cysts and bulky uterus
- Obtain MRCP in 6 months for further evaluation of IPMN
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Vitamin D Dose is Unknown PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Valsartan 320 mg PO DAILY
6. Ascorbic Acid ___ mg PO DAILY
7. lactobacillus acidophilus Dose is Unknown mg oral Daily
8. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN pain
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Valsartan 320 mg PO DAILY
3. Diltiazem Extended-Release 120 mg PO DAILY
RX *diltiazem HCl 120 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
4. Levofloxacin 500 mg PO Q24H
last day ___
RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
5. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN pain
6. Ascorbic Acid ___ mg PO DAILY
7. lactobacillus acidophilus 1 unit ORAL DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Vitamin D 800 UNIT PO DAILY
10. Outpatient Lab Work
Chem 10. Diagnosis hyponatremia (276.1). Fax results to:
___ - Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
hypovolemic hyponatremia
urinary tract infection (catheter associated)
bradycardia
sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure meeting you during your recent
hospitalization. You came to the hospital with confusion and
were found to have low sodium levels in your blood
(hyponatremia) and a urinary tract infection. Your sodium levels
improved with hydration; it is important that you keep hydrated
at home. You should have your sodium checked outpatient next
week and the results will be faxed to your PCP. For your UTI,
you will complete your course of antibiotics as an outpatient.
While in the hospital, our monitors showed that your heart rate
becomes slow intermittently and your oxygen saturations become
low when you sleep. The cardiology team saw you and your
diltiazem dose was decreased. Please take the first dose
tomorrow ___. The sleep team also saw you and recommend that
you have a sleep study outpatient; this is the way to diagnose
sleep apnea. In the meantime, you will be discharged with oxygen
to use at home while you sleep. We will send a nurse, physical
therapy, and speech therapy to visit you at home.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19769905-DS-2
| 19,769,905 | 28,437,873 |
DS
| 2 |
2162-09-29 00:00:00
|
2162-09-29 16:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
NG tube placement
History of Present Illness:
Mr. ___ is an ___ year old gentleman with ___ (non
verbal, bed-bound) who presents with several days of
constipation, vomiting, found to have SBO vs ileus, UTI, and
pancreatitis at ___.
He lives at home with wife who has help to care for him. At home
she been treating for constipation with miralax last 2 days and
decreased appetite. Pt had 2 episodes of vomiting at home on day
of presentation.
He was initially evaluated at ___ and ___ there were
notable for initial lactate of 9.4, lipase of 1656. CT of
abd/pelvis revealed massive gastric distension and multiple
air-fluid levels consistent with SBO. A transition point was
noted per wet read in the right lower quadrant. Surgical team at
___ recommended transfer for further evaluation at ___.
Patient received 4L NS and 1g ceftriaxone for UTI at ___ (UA
was positive for Leuk esterase, negative for nitrite, ___ WBC,
2+ bacteria). NG tube placement failed twice there. CXR revealed
bilateral infiltrates and there was concern for aspiration.
In the ED of ___ initial vitals were: 99.0 64 116/82 16 95%
NRB. Exam was notable for distended and tender abdomen. Repeat
lactate was 4.6. Other labs were notable for Cr 1.1 (baseline
0.9-1.2 ___, Na 147, K 4.3, Mg 2.2 with normal LFT. CBC
was notable for WBC 4.8, 80% PMN, 9% band, 1 % atypicals.
Portable CXR showed no free air, bilateral areas of
consolidation. Pt received Vancomycin, cefepime and flagyl in
the ED for presumed HCAP. Pt was seen by surgical team whose
impression was small bowel and colonic dysmotility and
constipation secondary to ___. They recommended
admission to medicine with NGT that was placed in ED with
brownish output about 2.5 L, NPO, IVF and Foley. Blood and urine
culture drawn and pending. UA at ___ not impressive for UTI.
Pt is being admitted for pancreatitis and possible
ileus/dysmotility.
Vitals prior to transfer were: 89 141/83 13 92% 4 L Nasal
Cannula.
On the floor, he was lying in bed, non-verbal, was sleeping,
could not elicit response in terms of pain.
Overnight, spoke to his wife, ___, who relates that he does not
take many medications but is no longer on home hospice (per ACS
is on home hospice). Patient had been on hospice in ___
but was dc'ed as his health improved.
Review of Systems: unable to obtain
Past Medical History:
- ___
- History of urosepsis
- HTN
- HLD
- Prostate cancer
Social History:
___
Family History:
Mother had DM2. Father died of complications of ___
disease. No known FH of stroke.
Physical Exam:
ADMISSION
Vitals: 98 - 137/75 - 60 - 16 - 94 on 3L
GENERAL: No respiratory distress, non-verbal gentleman,
cachectic, lying on back w/ NC on
HEENT: AT/NC, does not track for EOMs, anicteric sclera, MM
slightly dry, nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: no acc muscle use, breathing comfortably, diminished
breath sounds bilateral bases, pt w poor resp effort
ABDOMEN: soft distension, firm, bowel sounds present but
distant, pt does not groan w/ palpation
EXTREMITIES: thin, cachectic
PULSES: 2+ DP pulses bilaterally
NEURO: pt not compliant with CN exam - unable to determine if
EOMi, but does squeeze eyes shut against opening, appears to
blink to threat. limbs with decreased bulk, pt groans w flexion
of upper extremities (severe rigidity of bilateral elbow joints,
cogwheeling bilateral wrist joints)
SKIN: no rashes
DISCHARGE
Vitals: 98.6 139/68 109 18 99%
I/O 24 hr ___ NGT 300 BMx1
GENERAL: moaning quietly, non-verbal gentleman, cachectic, NAD
HEENT: AT/NC, eyes open to voice and tracks, MM slightly dry,
NGT to suction
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: no acc muscle use, diminished breath sounds at bilateral
bases anteriorly
ABDOMEN: mildly distended but softer, active bowel sounds, pt
does not appear uncomfortable with deep palpation
EXTREMITIES: thin, cachectic, warm with no edema
PULSES: 2+ DP pulses bilaterally
NEURO: limbs with decreased bulk, severe rigidity of bilateral
elbow joints, cogwheeling bilateral wrist joints
Pertinent Results:
ADMISSION LABS
___ 10:30PM BLOOD WBC-4.8 RBC-4.36* Hgb-13.1* Hct-41.2
MCV-95 MCH-30.1 MCHC-31.9 RDW-13.2 Plt ___
___ 10:30PM BLOOD Neuts-80* Bands-9* Lymphs-6* Monos-4
Eos-0 Baso-0 Atyps-1* ___ Myelos-0
___ 10:30PM BLOOD Glucose-169* UreaN-31* Creat-1.1 Na-147*
K-4.3 Cl-103 HCO3-27 AnGap-21*
___ 10:30PM BLOOD ALT-6 AST-17 AlkPhos-71 TotBili-0.6
___ 10:30PM BLOOD Lipase-803*
___ 10:30PM BLOOD Albumin-3.7 Calcium-8.5 Phos-3.0 Mg-2.2
___ 08:00AM BLOOD Triglyc-148
___ 10:40PM BLOOD Lactate-4.6*
___ 09:51AM BLOOD Lactate-3.9*
DISCHARGE LABS
___ 08:05AM BLOOD WBC-6.6 RBC-3.68* Hgb-11.2* Hct-34.4*
MCV-94 MCH-30.3 MCHC-32.4 RDW-13.2 Plt ___
___ 08:05AM BLOOD Glucose-94 UreaN-11 Creat-0.7 Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
___ 07:30AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.1
MICRO
___ urine culture ___ >100k ESBL E.coli, sensitive to
augmentin, ceftaz, imi/erta, tobra/gent, zosyn, macrobid
IMAGING
RUQ U/S ___
Limited study, secondary to difficulty in patient positioning,
with no
evidence of cholelithiasis or cholecystitis. The pancreas and
midline
structures are not visualized secondary to overlying bowel gas.
CXR ___. Nasogastric tube extends below the diaphragm with the tip
located within the body of the stomach. Distention of the
stomach and visualized small bowel loops is consistent with
patient's known small bowel obstruction as seen on the CT of the
abdomen performed on ___ at 7:30 p.m.
2. Bibasilar atelectasis, while due in part to elevated
diaphragm, could also be due to aspiration.
Brief Hospital Course:
ASSESSMENT & PLAN: ___, with PMH of parkinsonism, admitted for
abdominal pain and distension with concern for small bowel
obstruction likely secondary to UTI.
# Small bowel obstruction: Patient presented with abdominal pain
and emesis with OSH imaging consistent with small bowel
obstruction, likely related to underlying dysmotility secondary
to parkinsonism. Lipase was somewhat elevated on presentation as
well though unclear if this contributed to his presentation. He
was not a surgical candidate and so was treated medically with
NGT to suction, bowel rest and IVF. He improved somewhat and
started having small volume stools so NGT was clamped. After
discussion with wife about little chance of meaningful recovery,
patient was discharged home with hospice with morphine and
tylenol for pain control.
# Urinary tract infection: Urine culture at OSH growing >100k
ESBL Ecoli and patient with significant bandemia on
presentation. Blood cxs negative. He completed a 7-day course of
meropenem.
# Aspiration pneumonitis: CXR on admission raised question of
right middle lobe opacity that could be consistent with
atelectasis vs pneumonia vs pneumonitis. He had no respiratory
symptoms on admission so was not treated for pneumonia. He
developed some respiratory secretions later in his stay but this
improved with deep suctioning. After discussion regarding goals
of care, he was advanced to a regular diet despite his risk for
aspiration. He was on room air and comfortable at discharge.
CHRONIC ISSUES
# Anemia: Stable, likely related to chronic disease.
# Atrial fibrillation: First noted on exam ___ontrolled. CHADS is 2 but given poor overall prognosis and
goals of care, anticoagulation was not pursued.
# ___ disease - End stage. Continued home ___
meds as tolerated.
TRANSITIONAL ISSUES
# Code: DNR/DNI, CMO confirmed with wife/HCP
# Emergency Contact: ___, HCP/wife, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 2 TAB PO Q2.5H
2. Comtan (entacapone) 200 mg oral q2.5h
3. Acetaminophen 500 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PR Q8H
2. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q1H:PRN
pain
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth
q1h Refills:*0
3. Carbidopa-Levodopa (___) 2 TAB PO Q2.5H
4. Comtan (entacapone) 200 mg oral q2.5h
5. Bisacodyl ___AILY
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*30
Suppository Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Small bowel obstruction
ESBL E.coli Urinary tract infection
Secondary
End-stage ___ disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to ___ for an obstruction in your bowels and
a urinary tract infection. Your urinary tract infection was
treated with a strong intravenous antibiotic. Your bowel
obstruction improved somewhat after placement of a tube in your
nose which helped to drain a lot of fluid from your stomach.
However, as surgery is not an option for you, it is unclear if
it will ever completely resolve. After discussion with your
wife, we decided to focus on making you comfortable and sending
you home to be with your loved ones.
Followup Instructions:
___
|
19769933-DS-17
| 19,769,933 | 26,478,172 |
DS
| 17 |
2152-11-08 00:00:00
|
2152-11-16 17:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine Sulfate / Pronestyl / Quinidine-Quinine Analogues /
Mexiletine / Captopril / Sulfa (Sulfonamide Antibiotics) / Latex
/ Nitrofurantoin
Attending: ___
Chief Complaint:
progressive dyspnea
Major Surgical or Invasive Procedure:
right heart cath
PICC placement
History of Present Illness:
Mrs. ___ is a ___ year old woman with a history of severe
dilated cardiomyopathy with an EF of ___ (?viral vs
post-partum) s/p ICD placement who was admitted on ___ for
severe shortness of breath and PND, presumably due to worsening
congestive heart failure. Given the lack of edema or hypoxia,
the patient was continued on her home regimen fo torsemide 30mg
PO QAM and 10mg PO QPM. Notable findings during her stay
included a BNP >4000 (baseline of 1000), trigger for severe
dyspnea/orthopnea, and an echo that showed profoundly worsened
EF now down to 5% from ___, with severe dilation of the LV.
At the behest of her cardiologist, Dr. ___ underwent a
right heart cath with plans for a trial of milrinone therapy.
RHC revealed markedly elevated left and right heart filling
pressures that significantly improved with milrinone infusion.
If this milrinone trial fails, she would likely be transferred
to ___ for a heart transplant evaluation.
.
On arrival to the CCU, the patient subjectively felt much better
after milrinone infusion. She had by that point made nearly
700cc of urine.
.
REVIEW OF SYSTEMS
On review of systems, she 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. She denies recent fevers, chills or
rigors. She 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,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
- Idiopathic vs post partum cardiomyopathy atleast since ___,
EF of ___
- ___ year old female with post-partum dilated cardiomyopathy s/p
abdominal ICD implantation for NSVT and inducible VT in EP ___
in ___. She had an abdominal ICD generator change on ___.
In ___ she had abdominal ICD explantation and lead capping
due to discomfort. She had first transvenous ICD implant on
___ in the L pectoral region and had a device change
___. Implantation of a ___ Secura VR Single Chamber
ICD in ___.
3. OTHER PAST MEDICAL HISTORY:
- Incidental finding noted on chest CT scan of a 6 mm nodule,
mild restriction on PFTs
- status post cholecystectomy, status post appendectomy, two
C-sections
- remote asthma and multiple allergies
- anxiety
- ovarian cysts
- Lyme disease seeing specialists in ___.
Social History:
___
Family History:
Father died suddenly at age ___. She reports he may have had a
heart attack and had diabetes near the end of his life. Mother
is alive and fairly healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.8 HR 90 BP 95/63 RR 25 O2 95%RA
GENERAL: Chronically ill appearing woman in NAD, AOx3 and
appropriate but mildly drowsy
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD
CARDIAC: large palpable precordial heave RRR, normal S1, S2. No
m/r/g. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Warm extremities with good cap refill. No c/c/e
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PHYSICAL EXAM ON DISCHARGE:
VS: T97.4, HR:95, BP99/50, RR18, O2sat:97%RA
General: less drowsiness
Extremities: PICC in place
Exam otherwise unchanged from admission
Pertinent Results:
ADMISSION LABS:
WBC-8.9 RBC-4.82 Hgb-14.3 Hct-42.6 MCV-88 MCH-29.7 MCHC-33.6
RDW-13.1 Plt ___
Neuts-74.3* ___ Monos-3.1 Eos-0.7 Baso-0.7
Glucose-120* UreaN-27* Creat-0.9 Na-140 K-3.4 Cl-98 HCO3-31
AnGap-14
proBNP-4779*
cTropnT-<0.01
.
STUDIES:
.
CXR (___): PA and lateral views of the chest are compared to
previous exam from ___. Again seen is cardiomegaly
which is essentially stable from prior. The lungs remain clear.
There is a small left pleural effusion. Pacemaker wires are in
stable position. There are surgical clips in the upper abdomen,
potentially from prior cholecystectomy.
IMPRESSION: Small left pleural effusion. Stable cardiomegaly.
.
RIGHT HEART CATH (___):
1. Resting hemodynamics revealed severely elevated filling
pressures
with a mean PCPW of 39mmHg and an RVEDP of 25mmHg. There was
severe
pulmonary hypertension with a PA pressure of 71/41mmHg. Cardiac
output
was diminished at 2.4L/min with an index of 1.3L/min/m2.
2. Following milrinone bolus and infusion of 0.5mcg/kg/min,
PCWP
decreased to mean of 30mmHg. PA pressure fell to 60/42mmHg, and
cardiac
output increased to 3.4L/min with an index of 1.9L/min/m2.
FINAL DIAGNOSIS:
1. Severe right- and left-sided heart failure with elevated
filling
pressures at rest.
2. Positive response to milrinone infusion with decrease in PA
pressure,
PCWP, and increase in cardiac output.
.
ECHO (___):
Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is profoundly depressed (LVEF= 5 %). The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with severe global free wall hypokinesis. The
mitral valve leaflets are structurally normal. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. AT LEAST
moderate [2+] tricuspid regurgitation is seen. [Due to acoustic
shadowing from the ICD coil, the severity of tricuspid
regurgitation may be significantly UNDERestimated.] There is no
pericardial effusion.
Compared to the prior ___ of ___, the left
ventricular ejection fraction is even further reduced, and now
severe right ventricular contractile dysfunction is present,
with markedly increased tricuspid regurgitation and at least
moderate pulmonary hypertension.
.
LENIs (___): Normal appearance of the deep venous structures
of the right and left lower extremities. No evidence of deep
venous thrombosis.
.
Radiology Report CHEST (PORTABLE AP) ___ Date of ___ 7:30
AM
FINDINGS: As compared to the previous radiograph, the patient
has received a right internal jugular vein device, in addition
to the left pacemaker.
The size of the cardiac silhouette is still substantially
enlarged and the
presence of a small pleural effusion on the left cannot be
excluded.
Otherwise, there are signs of minimal fluid overload but no
overt pulmonary edema with no evidence of pneumonia. Unchanged
retrocardiac atelectasis.
.
Radiology Report CHEST PORT. LINE PLACEMENT ___ Date of
___ 2:00 ___
Radiology Report -___ BY DIFFERENT PHYSICIAN ___ of
___ 2:00 ___
The right PICC line tip is at the level of cavoatrial junction.
Right
internal jugular line tip is at the level of superior SVC. The
rest of the
findings are unchanged.
.
Cardiovascular Report ECG ___ Date of ___ 10:29:02 AM
Sinus rhythm with ventricular premature depolarizations.
Compared to the
previous tracing heart rate is reduced. Otherwise, no
significant change.
TRACING #2
.
Cardiovascular Report ECG ___ Date of ___ 9:53:36 AM
Sinus tachycardia. Left atrial abnormality. Non-specific QRS
widening. Left axis deviation. Left anterior fascicular block.
Diffuse non-diagnostic repolarization abnormalities. Compared to
the previous tracing of ___ heart rate is increased.
Otherwise, no diagnostic change.
TRACING #1
.
Lab Results on Discharge:
___ 07:38AM BLOOD WBC-6.3 RBC-3.98* Hgb-11.8* Hct-34.9*
MCV-88 MCH-29.7 MCHC-33.9 RDW-13.2 Plt ___
___ 05:50AM BLOOD Neuts-72.7* ___ Monos-3.8 Eos-1.3
Baso-0.5
___ 09:00AM BLOOD ___ PTT-28.4 ___
___ 09:00AM BLOOD Glucose-115* UreaN-17 Creat-0.6 Na-136
K-3.5 Cl-102 HCO3-28 AnGap-10
___ 04:47AM BLOOD ALT-59* AST-29 AlkPhos-85 TotBili-0.4
___ 11:00AM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:38AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.2
___ 12:30AM BLOOD Type-ART pO2-91 pCO2-38 pH-7.49*
calTCO2-30 Base XS-5 Intubat-NOT INTUBA
___ 12:30AM BLOOD Glucose-105 Lactate-1.7 Na-137 K-3.5
Cl-100
___ 05:19AM BLOOD Hgb-12.4 calcHCT-37 O2 Sat-64
___ 12:30AM BLOOD freeCa-1.20
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is a ___ year old
woman with a history of severe dilated cardiomyopathy with an EF
of 5% (?viral vs. post-partum) s/p ICD placement who was
admitted on ___ for severe SOB and PND, secondary to
worsening chronic systolic CHF. She was started on milrinone
drip and had improvement in symptoms and functional capacity
in-house. She was discharged home on milrinone drip with
follow-up with transplant cardiology at ___.
.
ACUTE CARE:
1. Chronic Systolic CHF: Patient presented with severe
dypspnea/orthopnea. This was especially bad at night when she
would have paroxysms of symptoms. Her EF was found to be 5%, BNP
elevated to 4000 from baseline of 1000, and left and right sided
pressures were markedly elevated (40s and ___ systolic
respectively) on right cath performed on admission. Patient was
subsequently admitted to CCU for initiation of milrinone. She
improved significantly on milrinone 0.5/hr infusion: CI rose
from 1 to 1.9, CO improved and trans-pulmonary gradient
decreased, which dramatically improved her pulmonary
hypertension. She was transiently hypotensive on milrinone ___
milrinone's vasodilatory effects, which subsequently resolved
with MAPs consistently >55 afterward. Given her profoundly
reduced LV function, she was also started on Coumadin. Home
torsemide was restarted once pt was normotensive. Beta blocker
was initiated per patient's cardiologist. ___ was placed for
home milrinone infusion. She was transferred back to the floor,
where ___ eval on milrinone showed asymptomatic during ADL's and
even climbing stairs. She was discharged home on the milrinone
drip. Patient will ultimately require heart transplant at ___
after optimization of hemodynamics with milrinone.
.
# ARRYTHMIA: Patient went into multifocal ATach on HD#4 likely
___ discontinuation of her beta blocker after initiation of
milrinone. This resolved and she returned to ___ after
metoprolol 5mg IV. Per patient request and with her
cardiologist's permission, she was restarted on low-dose
metoprolol without recurrence of MAT.
.
# Left wrist Superficial Thrombophlebitis: Patient developed
superficial thrombophelbitis of left wrist since peripheral line
removal in the ICU. There was a superficial 3x3cm area of
erythema, warmth, and tenderness to palpation with a palpable
cord on the lateral aspect of patient's left wrist. This
initally improved with warm packs and elevation alone, but then
developed increasing erythema, tenderness, and induration. She
was started on a 7-day course of keflex to complete at home but
noted some improvement after 2 days on antibitics in the
hospital.
.
CHRONIC CARE
1. H/O LYME DISEASE, FUNGAL INFECTIONS: Per patient report, she
has history of chronic Lyme disease for which she is followed by
integrative medicine specialist at an OSH. She also reports h/o
fungal infections (no further details available). Per ID
consult, no further workup needed at this time as these issues
are unlikely related to her chronic heart failure.
.
2. ABNORMAL LFTs: Most likely secondary to congestive
hepatopathy. Iron studies and hepatitis viral studies WNL. They
were downtrending to normal range and monitoring was stopped
when they approached normal.
.
3. DEPRESSION/ANXIETY: Patient endorsed depression and SI
without a plan in the ED. She later denied suicidality. She
underwent psych eval in CCU where she was found to be mildly
delirious and it was recommended that home benzos be limited.
They also feel that she would benefit from talk therapy and
possibly antidepressant therapy as an outpatient. Also followed
by social work. Her mood and affect improved on HD#2, although
she did remain significantly anxious requiring frequent
reassurance and low-dose klonopin throughout.
.
4. ASTHMA: Patient has a remote history of asthma and is on prn
ipratropium at home. This was continued during hospitalization
with no issues.
.
TRANSITIONS IN CARE:
1. Medication Changes:
1. START milrinone infusion at home. The rate is
0.5mcg/kg/minute.
2. START cephalexin 500mg by mouth every 6 hours for six days
3. START saline nasal spray and fluticasone nasal spray as
directed while having nasal congestion.
4. START warfarin 5mg by mouth daily and adjust for INR under
direction of the ___ clinic. This medication is
important in lowering the risk of stroke.
5. START a daily multivitamin
6. START acyclovir 5% ointment. Apply to the affected area on
the lips every two hours while awake for three days.
7. START metoprolol succinate 50mg by mouth once daily
8. STOP taking metoprolol tartrate
9. STOP taking losartan as your blood pressure is not
tolerating this medication
10. CHANGE torsemide dosing to 40mg by mouth once daily.
11. START fexofenadine 60mg by mouth twice daily.
12. STOP nattokinase
13. START potassium chloride 20meq by mouth daily
2. FOLLOW-UP:
You will be contacted by an NP that works with Dr. ___
___ at ___ for an initial appointment in
evaluation for heart transplant. If you do not hear from them
within a week, they can be reached at: ___
Please keep the following other appointments:
Department: CARDIAC SERVICES
When: ___ at 10:00 AM
With: ___
Building: ___
Campus: ___ Parking: ___
Department: CARDIAC SERVICES
When: ___ at 12:00 ___
With: ___
Building: ___
Campus: ___ Best Parking: ___
Department: CARDIAC SERVICES
When: ___ at 11:00 AM
With: ___
Building: ___
Campus: ___ Parking: ___
Please make an appointment to see your PCP ___ 2 weeks of
discharge.
3. OUTSTANDING CLINICAL ISSUES:
-maintenance of coumadin therapy
-evaluation for heart transplant
-follow-up TTE's
-titration of milrinone with cardiologist
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
CLONAZEPAM - (Prescribed by Other Provider; Dose adjustment - no
new Rx) - 1 mg Tablet - ___ Tablet(s) by mouth three times a
day as needed
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol Inhaler - ___ puffs inhaled twice a day for wheezing
LOSARTAN [COZAAR] - 25 mg Tablet - one Tablet(s) by mouth twice
a day
METOPROLOL TARTRATE - 25 mg Tablet - 1 Tablet(s) by mouth two
times a day
NATTOKINASE - (Prescribed by Other Provider) - - one capsule
twice a day
NYSTATIN - 100,000 unit/gram Powder - apply to inflammed area
twice a day
TERCONAZOLE [TERAZOL 7] - 0.4 % Cream - insert in vagina once a
day
TORSEMIDE - 20 mg Tablet - 1.5 Tablet(s) by mouth every morning,
0.5 tablets by mouth every evening
Medications - OTC
ASPIRIN - (Prescribed by Other Provider; ___) (Not Taking as
Prescribed: forgets) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day (not taking because she forgets)
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - 2,000 unit Capsule - 1 Capsule(s) by mouth
COENZYME Q10 [CO Q-10] - (Prescribed by Other Provider; ___;
Dose adjustment - no new Rx) - 300 mg Capsule - 1 Capsule(s) by
mouth twice a day
Discharge Medications:
1. milrinone in D5W 40 mg/200 mL Piggyback Sig: 0.5 mcg/kg/min
Intravenous continuous: OK to substitute 400mcg/mL strength
formulation.
___ weight:74.8kg.
Disp:*30 day supply* Refills:*5*
2. clonazepam 1 mg Tablet Sig: ___ Tablet PO three times a day
as needed for anxiety: do not drive or operate machinery while
taking this medication.
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation BID (2 times a day) as needed for wheezing.
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days.
Disp:*28 Capsule(s)* Refills:*0*
7. nystatin 100,000 unit/g Powder Sig: One (1) application
Topical twice a day.
8. terconazole 0.4 % Cream Sig: One (1) Appl Vaginal DAILY
(Daily) as needed for vaginal itching for 7 days.
9. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Vitamin D-3 2,000 unit Capsule Sig: One (1) Capsule PO once
a day.
11. coenzyme Q10 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
12. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day) as needed for nasal congestion.
Disp:*1 bottle* Refills:*2*
13. sodium chloride 0.65 % Aerosol, Spray Sig: ___ Sprays Nasal
QID (4 times a day) as needed for dryness.
Disp:*1 bottle* Refills:*5*
14. acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR (AS
DIRECTED) for 3 days: apply to affected area on lip every two
hours while awake for four days.
Disp:*1 unit* Refills:*0*
15. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
Disp:*30 Tablet(s)* Refills:*2*
16. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
17. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO once a day.
Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*2*
18. Outpatient Lab Work
Chem-10, ___ on ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Chronic Systolic Heart Failure
Secondary: Chronic pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking part in your care. You were admitted
for shortness of breath. You underwent cardiac catheterization
which showed worsening heart failure. We started some new
medications and adjusted others and your symptoms improved. You
also developed skin infection in your forearm for which we
started antibiotics. You are now discharged home to await
evaluation for heart transplant.
.
Please make the following changes to your medications:
.
1. START milrinone infusion at home. The rate is
0.5mcg/kg/minute.
2. START cephalexin 500mg by mouth every 6 hours for six days
3. START saline nasal spray and fluticasone nasal spray as
directed while having nasal congestion.
4. START warfarin 5mg by mouth daily and adjust for INR under
direction of the ___ clinic. This medication is
important in lowering the risk of stroke.
5. START a daily multivitamin
6. START acyclovir 5% ointment. Apply to the affected area on
the lips every two hours while awake for three days.
7. START metoprolol succinate 50mg by mouth once daily
8. STOP taking metoprolol tartrate
9. STOP taking losartan as your blood pressure is not tolerating
this medication
10. CHANGE torsemide dosing to 40mg by mouth once daily.
11. START fexofenadine 60mg by mouth twice daily.
12. STOP nattokinase
13. START potassium chloride 20meq by mouth daily
.
Please take all other medications as prescribed
.
Please keep all follow-up appointments.
.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19770161-DS-2
| 19,770,161 | 29,377,022 |
DS
| 2 |
2184-02-29 00:00:00
|
2184-02-29 17:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
glyburide
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o gentleman with PMH notable for multiple
CV risk factors including PVD, T2DM, CAD s/p LAD stent, and
Stage
3 CKD, as well as legal blindness, presenting with confusion.
Per patient and review of prior records, he presented to clinic
for follow-up of abnormal LFTs (which after extensive work-up in
atrius system had actually normalized). At this appointment with
GI, he endorsed feeling weak and confused and had a blood
glucose
in the 60's. At this point, he was given juice and sent to
urgent
care for further assessment. At urgent care, the patient further
endorsed difficulty speaking and was sent to ___ for further
evaluation of possible stroke. At this visit, he was noted to
have possible left-sided facial droop with flattening of the
left
nasolabial fold.
Per discussion with patient, he has been feeling very much at
his
baseline recently, up until his appointment today. He states
that
he simply felt confused starting during the appointment, in the
sense what he was saying was not making sense. He denies any
particular difficulty producing speech, but did not feel that he
could articulate exactly what he meant. He felt like the entire
episode lasted about a couple hours and denies any headache, LH,
N/V, chest pain/pressure, SOB, diaphoresis, limb
weakness/tingling, or LOC throughout. He also denies any recent
headaches, N/V, abdominal pain, diarrhea, or constipation
recently. He is able to walk at baseline with a cane without
feeling any unsteadiness on his feet. He denies any issues with
swallowing. He does have baseline lower extremity edema, which
is
actually improving on Lasix. With regards to his blood sugars,
he
manages insulin on his own at home and does not frequently check
his FSBG so does not know if he has frequent low sugars. He has
had his insulin changed from 18u lantus at night to 16u, which
he
is currently taking (although listed as 15u in atrius records).
He denies feeling this way ever in the past. He also denies any
recent fevers, chills, nightsweats. However, he does have
increasing anorexia and potentially associated poor PO over the
past few months, losing ___ pounds over this duration.
In the ED, initial VS were:
-97.1 62 161/82 18 97% RA with FSBG of 69
Initial evaluation in the ED was notable for ongoing mild,
confusion endorsed by patient but exam showing A&Ox3. He denied
any numbness or tingling in his extremities, headache, chest
pain, shortness breath, abdominal pain, nausea, vomiting, or
diarrhea. Visual change was unable to be assessed as patient is
legally blind. His initial ___ stroke scale was 0 and no obvious
facial droop was seen. However, code stroke was called and
neurology evaluated the patient recommending urgent CTA of head
and neck.
Exam notable as above.
Labs showed:
-CBC with normal CBC, Hgb 11, Plt 161
-serum tox negative
-LFTs wnl
-Chem10 showing K 6.1 (hemolyzed), Cl 110, BUN/Cr ___,
Glucose
168, Ca 8.0 (albumin 2.4)
-Whole blood sample Na 140, K 5.2, Cl 111, Glucose 145, lactate
1.4
-Repeat Chem10 showing K 4.8, BUN/Cr ___, glucose 51
-Trop 0.03x1
-Lipid profile notable for normal LDL and HDL 31
-A1c 5.4
-normal coags
-Urine culture pending
Imaging showed:
-CTA Head/Neck:
1. 3.8 x 3.0 cm mass, probably extra-axial, in the anterior
right
frontal lobe with surrounding edema and local mass effect
causing
effacement of the anterior horn of the right lateral ventricle
and right frontal sulci and 7.0mm leftward midline shift.
2. No intracranial hemorrhage.
3. Pending evaluation of the intracranial and cervical
vasculatures.
4. There is a large planar sphenoidal and cribriform meningioma
that measures 5.1 under x 5.2 cm with surrounding vasogenic
edema
and effacement of the anterior horn of the right ventricle with
7.0 mm leftward shift (3:288). MRI brain is recommended to
further investigate the large planar sphenoidal and cribriform
meningioma.
There is noncalcified plaque narrowing the right vertebral
artery
at the origin, (3:82). Segments V3 and V4 of the vertebral
artery
and proximal cervical portion of carotid arteries are irregular
likely due to noncalcified atherosclerotic plaques or less
likely
fibromuscular dysplasia. MRA fat-sat of the neck is recommended
to further investigate the irregularities of the vertebral
artery
and carotid arteries.
Consults:
-Neurology was consulted as above and after discovery of
intracranial mass, recommended neurosurgical consult.
-Neurosurgery was consulted and evaluated the patient, feeling
that it was possible his symptoms were consistent with his
intra-cranial lesion. However, given improvement in his
neurologic deficits, he was recommended to have brain MRI and
medical optimization prior to surgery, which they would need to
consider further before even offering. Per discussion with
neurosurgery and accepting medicine resident, operative
intervention was not felt to be urgent.
-Both neurosurgery and neurology recommended keppra 500mg BID
for
seizure ppx. Per neurosurgery, SBP goals were <160, neuro checks
were to be performed q4H, and dexamethasone was not recommended
I/s/o prior diagnosis of T2DM. They also recommended CT Torso
for
work-up of potential primary cancers, which could spread to the
CNS.
Patient received:
-Levetiracetam 500mg IV x1
-Dextrose 50% 25 gm x1
-500cc LR x1
On arrival to the floor, patient reports the above story and
denies any current complaints. He does add that he is r-handed
and no longer feels confused.
Past Medical History:
-CAD s/p LAD stent
-HTN
-Type 2 DM
-CHF
-PVD
-bilateral eye surgery
-Stage III CKD likely ___ HTN and DM
-Retinopathy with vitreous hemorrhage/legally blind
-BPH
-Anemia of chronic disease
Social History:
___
Family History:
Patient is unsure as both his parents died.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8 188 90 66 16 99 RA
Weight: 69.5kg (recent weights have been ~67 kg)
GENERAL: NAD, sitting up in bed in NAD at about 30 degrees
HEENT: AT/NC, EOMI grossly, pupils with post-surgical changes
bilaterally, anicteric sclera, MMM with midline tongue on
protrusion and symmetric smile, palatal elevation, and eyebrow
raise
NECK: supple, no LAD, no JVD appreciated on exam; no carotid
bruits bilaterally
HEART: RRR, normal S1, wide-split S2, no murmurs, gallops, or
rubs
LUNGS: CTAB with bibasilar crackles but no rhonchi or wheezing,
breathing comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, BS+
EXTREMITIES: no cyanosis, clubbing; 2+ pitting edema in
bilateral
___, which are WWP
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, strength ___ in shoulder shrug, biceps b/l; ___ in
triceps b/l; able to lift both legs up against downward pressure
and dorsiflexion ___, plantarflexion ___ bilaterally; sensation
to light touch grossly intact in all division of CN5, UE, torso,
and ___ bilaterally
SKIN: lymphedematous changes in b/l ___
DISCHARGE PHYSICAL EXAM:
VS: T 97.6, BP 173/78, HR 62, RR 18 97% RA
General: Alert, oriented x3. No acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, poor visual
acuity, no
significant nasolabial asymmetry, JVP 8-9 cm
CV: rrr, wide-split S2, no murmurs/rubs/gallops
Lungs: CTAB - no wheezes, rhonchi, or rales
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, trace edema in bilateral ankles
Neuro: strength ___ bilaterally, sensation intact to light touch
Pertinent Results:
ADMISSION LABS
==============
___ 03:18PM BLOOD WBC-5.8 RBC-3.72* Hgb-11.0* Hct-33.5*
MCV-90 MCH-29.6 MCHC-32.8 RDW-12.8 RDWSD-42.3 Plt ___
___ 03:18PM BLOOD Neuts-66.8 Lymphs-18.6* Monos-9.4 Eos-2.8
Baso-1.0 Im ___ AbsNeut-3.85 AbsLymp-1.07* AbsMono-0.54
AbsEos-0.16 AbsBaso-0.06
___ 03:18PM BLOOD Plt Smr-NORMAL Plt ___
___ 07:59PM BLOOD ___ PTT-30.1 ___
___ 03:18PM BLOOD Glucose-168* UreaN-25* Creat-2.1* Na-144
K-6.1* Cl-110* HCO3-26 AnGap-8*
___ 03:18PM BLOOD ALT-13 AST-28 AlkPhos-105 TotBili-0.2
___ 03:18PM BLOOD Albumin-2.4* Calcium-8.0* Phos-3.3 Mg-1.8
Cholest-134
___ 03:46PM BLOOD %HbA1c-5.4 eAG-108
___ 03:18PM BLOOD Triglyc-85 HDL-31* CHOL/HD-4.3 LDLcalc-86
___ 07:43AM BLOOD PEP-NO SPECIFI FreeKap-51.8*
FreeLam-50.9* Fr K/L-1.0 IgG-799 IgA-206 IgM-95 IFE-NO MONOCLO
DISCHARGE LABS
==============
___ 05:10AM BLOOD WBC-10.2* RBC-4.30* Hgb-12.5* Hct-37.8*
MCV-88 MCH-29.1 MCHC-33.1 RDW-12.9 RDWSD-40.8 Plt ___
___ 05:10AM BLOOD Plt ___
___ 05:10AM BLOOD Glucose-145* UreaN-53* Creat-2.0* Na-138
K-4.6 Cl-103 HCO3-23 AnGap-12
___ 05:10AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.1
IMAGING
=======
CTA Head ___:
1. There is no evidence of large territorial infarct,
intracranial hemorrhage or hydrocephalus. Small infarcts
identified on a more recently performed MRI are not appreciated
on this less sensitive CT noncontrast exam.
2. Large right frontal extra-axial enhancing mass centered over
the planum
sphenoidale most compatible with a meningioma is better
characterized on the more recently performed MRI head study.
3. There is associated mass effect on the frontal horn of the
right lateral ventricle and leftward shift of the anterior falx
by approximately 7 mm.
4. Atherosclerotic calcifications of the carotid siphons with
areas of at
least moderate narrowing of the left paraclinoid ICA.
5. No dissection, aneurysm or occlusion of the head neck. Mild
arteriosclerotic disease is identified in the intracranial
vessels, more
significant at the middle and posterior cerebral arteries. No
significant ICA stenosis by NASCET criteria.
6. Mild mucosal thickening is noted in the left maxillary sinus
with air-fluid level, suggesting an ongoing inflammatory
process.
MRI Head ___:
1. Multiple punctate acute to subacute infarcts involving the
left frontal, parietal occipital lobes in a watershed type
distribution.
2. Enhancing right frontal extra-axial mass arising from the
planum sphenoidal is most compatible with a meningioma. Extent
surrounding right frontal lobe edema , Can be seen with atypical
meningioma. Local mass effect.
3. A few small chronic infarcts.
4. Evidence of moderate white matter small vessel disease.
TTE ___
EF 35%
1) Moderate global LV systolic dysfunction c/w diffuse
cardiomyopathic process.
2) Grade II LV diastolic dysfunction with elevated LVEDP.
Myocardial relaxation significantly impaired in setting of
moderate left ventricular hypertrophy. Global longitudinal
strain
with apical preservation of myocardial strain suggestive but not
confirmative of cardiac amyloid.
3) There are apical hypertrebaculations not making the cut off
criteria for non-compaction cardiomyopathy.
4) Myocardial strain is reduced in the basal myocardial segment
not following coronary artery distribution in particular the mid
to apical inferior myocardial segment show above average
contractility.
Carotid series ___
Less than 40% stenosis in the bilateral internal carotid
arteries.
CT Head ___
1. Unchanged right frontal lobe mass with surrounding vasogenic
edema and
persistent 5 mm leftward shift, similar to ___ MR
brain.
2. Known left sided infarctions from the prior MRI of the brain
are not well seen on the current exam.
STRESS MIBI ___
-Severe, large reversible inferior wall defect extending from
the
apex to the base in the distribution of the right coronary
artery.
-Systolic dysfunction with transient ischemic dilatation and
regional inferior wall hypokinesis. Left ventricular ejection
fraction of 39%.
Brief Hospital Course:
Mr. ___ is a ___ with multiple CV risk factors (PVD, T2DM,
CAD s/p LAD stent), and Stage 3 CKD, admitted for mental status
changes, found to have new right frontal lobe mass and left
cerebral infarcts as well as newly depressed EF and large
inferior wall ischemia on stress MIBI, deemed to require
neurosurgery for tumor resection.
ACUTE ISSUES:
=============
#Right frontal mass:
On admission, the patient was found to have a large right
frontal extra-axial enhancing mass concerning for malignant
meningioma with associated edema and local mass effect. After
discussion between the family and all teams involved, tumor
resection with neurosurgery was planned for ___.
Despite the significant cardiac risk associated with surgery,
the duration of antiplatelet therapy required by stenting the
RCA and possible LM would dangerously delay surgical treatment
of his brain mass. Patient was started on dexamethasone 4 mg q6h
and keppra 500 mg q12h. He will need to hold aspirin, plavix and
anticoagulation until after surgery.
#Punctate infarcts:
MRI head showed multiple acute to subacute infarcts involving
the left frontal, parietal, occipital lobes in a watershed
distribution. No evidence of atrial fibrillation on telemetry or
signs of thrombus on TTE. Depressed EF on TTE and significant
findings on stress test suggest possible ischemia that could
lead to transient hypoperfusion vs amyloidosis which can also
cause ischemic and embolic strokes. During this admission, he
was usually hypertensive between 160-200s. For someone in this
range, a SBP of 140 or less at home could have causde
hypoperfusion leading to his infarcts, and his BP in urgent care
immediately prior to presentation was 146/71. As such, neurology
recommended blood pressure goal of 160-180 to allow
autoregulation. They cautioned against significant drops in
blood pressure. See below for blood pressure management.
#HTN:
Attempting to allow autoregulation of BP as his infarcts appear
watershed and would not want to lower BP significantly
artificially. Initially increased home imdur to 120 mg daily to
reduce blood pressure when SBP >200. Also had to hold lisinopril
and spironolactone in the setting ___ so PO hydralazine had
to be added. Prior to discharge, after ___ improved, hydralazine
was stopped, lisinopril and spironolactone were restarted and
imdur was reduced back to home dose of 60 mg daily. Metoprolol
succinate XL 25 mg daily was switched to carvedilol 6.25 BID. BP
goal 160-180 as above per neurology.
#HFrEF
#Reversible Inferior wall defect
#Non-ischemic cardiomyopathy:
TTE shows newly depressed ejection fraction (TTE in ___
showed EF 55-60% -> EF 35% on TTE this admission) possibly due
to ischemia given stress MIBI showed worse reversible inferior
wall defect. Reduced ejection fraction could also be due to
infiltrative disease such as amyloidosis given strain in the
basal myocardial segment with preservation of the apex. SPEP,
UPEP and light chains were unremarkable. Continued on
lisinopril, spironolactone and metop switched to carvedilol.
Home diuretic regimen of lasix 80 mg BID was changed to Lasix 80
mg daily because of recent ___ and ___ appearing Euvolemic
without diuresis (likely due to eating less while inpatient).
___ on CKD:
The patient has baseline Stage 3 CKD, likely ___ HTN and DM. He
has baseline Cr of ~2.0. Of note, Creatinine elevated
to 2.7 on ___. Leading etiology seems intrinsic renal injury
given FeUrea >35% possibly ___ to ATN caused by hypovolemia, as
his ___ improved with gentle fluid resuscitation and holding
diuresis. Due to his ___, his diuretics were adjusted as above.
#Hypoglycemia:
#IDDM:
The patient has IDDM at baseline with self-management of
insulin. Although he does have retained vision (___), he has
some visual compromise that could lead to mis-dosing. He also
does not frequently monitor home FSBG due to a change in glucose
strips. Patient was taking lantus 16U QHS at home and was
hypoglycemic on admission, which could have contributed to his
confusion. His lantus was reduced to 12U QHS and his blood
sugars were well controlled despite starting dexamethasone.
#Health care proxy
After discussion with social work, wife and cousin, HCP changed
to wife per patient. All members in agreement. Please see social
work note from ___, new HCP on file.
CHRONIC ISSUES:
===============
#Diabetic retinopathy/legal blindness:
Continued home latanoprost and timolol
#CAD s/p LAD stent with unrevascularized RCA disease
Had recent cath showing 90% RCA lesion but no stent as patient
did not want to take Plavix given episode of hemoptysis.
However, patient reports taking Plavix recently. Patient was
discharged off aspirin and plavix for surgery. Continued home
statin and imdur.
# BPH: not on any home medications
# Chronic ___ fungal rash: continue home ketoconazole
TRANSITIONAL ISSUES:
===================
[ ] Closely monitor blood pressure. Goal BP 160-180. Avoid
significant drops in blood pressure to prevent further watershed
infarcts. Blood pressure medications at discharge: carvedilol
6.25 mg BID, isosorbide mononitrate ER 60 mg daily, lisinopril
40 mg daily, spironolactone 25 mg daily.
[ ] For brain mass, per neurosurgery should continue on
dexamethasone and keppra for seizure prophylaxis at least until
surgery.
[ ] Please hold aspirin and plavix prior to neurosurgery on
___. He should not take any antiplatelet or anticoagulant
medications until after his surgery. Recommend discussing with
neurosurgery before restarting any of these medications.
[ ] Ensure close follow-up with cardiology for newly reduced EF
and reversible inferior wall defect likely caused by RCA disease
seen on stress MIBI.
[ ] Recommend continued work-up of infiltrative diseases for
non-ischemic cardiomyopathy/newly reduced ejection fraction seen
on TTE.
[ ] Please continue to monitor Cr and volume status and titrate
diuretic regimen accordingly. Discharged on Lasix 80 mg daily.
[ ] Needs close monitoring of blood sugar. Lantus qhs has been
reduced to 12U to prevent further hypoglycemic episodes. His
blood glucose remained controlled even on dexamethasone.
However, patient may have increased PO intake at home, so please
monitor and adjust accordingly.
[] Please f/u safety at home. Per OT, concern for safety given
that patient is legally blind and lives alone. Does not like to
use his walking stick. Per discussion with wife, she will stop
by to check on him twice a day. Also discharged with ___, home
OT and ___. Recommended using blister packs for medications but
patient declined.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Timolol Maleate 0.5% 1 DROP RIGHT EYE BID
2. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
3. Glargine 16 Units Bedtime
4. Spironolactone 25 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Vitamin D 1000 UNIT PO DAILY
11. Furosemide 80 mg PO QAM
12. Ketoconazole 2% 1 Appl TP BID
13. Lisinopril 40 mg PO DAILY
14. Furosemide 40 mg PO QPM
15. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice daily Disp
#*56 Tablet Refills:*0
2. Dexamethasone 4 mg PO Q6H cerebral edema from brain mass
RX *dexamethasone 4 mg 1 tablet(s) by mouth every 6 hours Disp
#*112 Tablet Refills:*0
3. LevETIRAcetam 500 mg PO Q12H
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice
daily Disp #*56 Tablet Refills:*0
4. Glargine 12 Units Bedtime
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 12 Units before BED; Disp #*1 Syringe Refills:*0
5. Atorvastatin 80 mg PO QPM
6. Furosemide 80 mg PO QAM
RX *furosemide 40 mg 2 tablet(s) by mouth every morning Disp
#*56 Tablet Refills:*0
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Ketoconazole 2% 1 Appl TP BID
9. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
10. Lisinopril 40 mg PO DAILY
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Spironolactone 25 mg PO DAILY
13. Timolol Maleate 0.5% 1 DROP RIGHT EYE BID
14. Vitamin D 1000 UNIT PO DAILY
15. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you follow up with your neurosurgeon
16. HELD- Clopidogrel 75 mg PO DAILY This medication was held.
Do not restart Clopidogrel until instructed by your doctor after
your surgery
___. HELD- Furosemide 40 mg PO QPM This medication was held. Do
not restart Furosemide until you see your doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
=======
Right frontal mass
SECONDARY
==========
Cerebrovascular accident
Diabetic retinopathy
Peripehral artery disease
Coronary artery disease
Heart failure with reduced ejection fraction
Non-ischemic cardiomyopathy
Hypertension
Acute kidney injury
Insulin dependent diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___
WHAT BROUGHT YOU INTO THE HOSPITAL?
- You were admitted for confusion.
WHAT WAS DONE FOR YOU IN THE HOSPITAL?
- You were found to have a brain tumor and a stroke.
- You were evaluated by neurosurgery who scheduled you for
surgery to remove the brain tumor.
- You were evaluated by cardiology who explained the risks of
surgery to you due to your heart disease.
WHAT SHOULD YOU DO AFTER LEAVING THE HOSPITAL?
- It is important that you continue to take your medications as
prescribed.
- You need to follow up with all your doctors' appointments
listed below.
- Please weigh yourself daily. If you gain more than 3 lbs,
please call your PCP.
- Do not take aspirin/warfarin/clopidogrel or any other blood
thinner until cleared by your neurosurgeon.
- You will need to go for surgery scheduled for ___.
Please call the neurosurgery office ___ one week in
advance to confirm the timing of surgery.
We wish you the best in your recovery!
Your ___ Care Team
Followup Instructions:
___
|
19770723-DS-20
| 19,770,723 | 27,773,646 |
DS
| 20 |
2189-09-22 00:00:00
|
2189-09-24 14:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with no significant past medical history complains of SOB
and cough. Pt. states he was diagnosed with PNA ___. He
initially went to the PCP ___ with SOB and fever. He was
given rx cipro and finished the 10-day course of antibiotics
last ___. While he initially felt better after his course of
abx, he has since worsened in terms of cough. He woke up the
morning of admission with severe SOB and cough. He has been
having some sputum that is "stringy" and yellow that is
increasing in quantity (a few tablespoons on the day). The
patient improved with an albuterol inhaler prescribed several
days ago and felt better for only 30 minutes after each
inhalation treatment.
In the ED, he was given albuterol neb x 2 with improvement.
Labs were significant for WBC 11.1 (74% PMNs). CXR indicates
left lower lobe patchy opacity remains concerning for pneumonia,
not significantly changed in the interval. Patient was started
on levofloxacin.
Sick contacts significant for daughter has cold-like symptoms,
wife has allergies. Pet turtle at home, no other animals.
Patient does not recall most recent TB test. Recent travel to
___ in ___, ___ in last year. Remote history of
travel to many places in the world. No pleuritic pain, no leg
swelling, no blood in sputum (once in late ___, no recent long
trips. No change in appetite, no rashes, no change in po intake.
No fevers, chills, or night sweats.
On general ROS, patient denies blurry vision, tinnitus, oral
lesions, chest pain, palpitations, abdominal pain, N/V, joint
pains, new skin lesions.
Past Medical History:
None. No prior history of pneuemonias (prior to ___.
Social History:
___
Family History:
Noncontributory. Maternal grandmother had HCC.
Physical Exam:
Admission Exam:
98.6 98.1 110/62 (110-128 / 62-70) 115 (111-126) 24 95on2LO2
General: Anxious but well-appearing gentleman lying in bed,
interactive, no resp distress, speaking in full sentences
HEENT: nc/at, sclera anicteric
Neck: supple, no LAD
CV: RRR, S1/S2, no m/r/g
Lungs: scattered wheezes but generally clear b/l
Abdomen: soft, nontender, nondistended, +BS
Ext: WWP, 2+ pulses, no c/c/e
Neuro: AOx3, speech fluent, linear, appropriate, moving all 4
extremities
Skin: no rashes
Discharge Exam:
VSS WNL
General: Well-appearing gentleman lying in bed, interactive, no
resp distress, speaking in full sentences
HEENT: nc/at, sclera anicteric
Neck: supple, no LAD
CV: RRR, S1/S2, no m/r/g
Lungs: CTAB
Abdomen: soft, nontender, nondistended, +BS
Ext: WWP, 2+ pulses, no c/c/e
Neuro: AOx3, appropriate, moving all 4 extremities
Pertinent Results:
Admission Labs:
___ 04:25PM WBC-11.1* RBC-5.58 HGB-16.5 HCT-46.3 MCV-83
MCH-29.5 MCHC-35.5* RDW-13.2
___ 04:25PM NEUTS-74.2* LYMPHS-15.8* MONOS-3.0 EOS-5.9*
BASOS-1.1
___ 04:25PM PLT COUNT-235
___ 04:25PM GLUCOSE-105* UREA N-9 CREAT-1.0 SODIUM-142
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-30 ANION GAP-15
___ 04:25PM CALCIUM-10.4* PHOSPHATE-2.5* MAGNESIUM-2.0
Pertinent Labs: See admission and discharge labs
Discharge Labs:
___ 06:50AM BLOOD WBC-7.2 RBC-4.96 Hgb-14.6 Hct-41.2 MCV-83
MCH-29.4 MCHC-35.4* RDW-13.7 Plt ___
___ 06:50AM BLOOD Glucose-160* UreaN-12 Creat-1.0 Na-136
K-4.6 Cl-100 HCO3-23 AnGap-18
___ 06:50AM BLOOD Calcium-9.3 Phos-2.1* Mg-1.4*
Pertinent Micro:
___ BCx x 2 - pending
Pertinent Imaging:
___ CXR IMPRESSION:
Left lower lobe patchy opacity remains concerning for pneumonia,
not
significantly changed in the interval. Followup radiographs 4
weeks after
treatment are recommended to ensure resolution of this finding.
Brief Hospital Course:
___ with no significant past medical history presents with
dyspnea and cough likely ___ PNA vs. reactive airways.
#Dyspnea: The patient presents with worsening dyspnea in the
setting of recent PNA (treated with 10-day course of cipro).
While it is unclear, this likely represents continuation of
pneumonia vs. reactive airways. Of note patient was afebrile.
While he was admitted with WBC11 and tachycardia, both had
resolved on the following morning. Patient was oxygenating well
on room air, and he symptomatically felt much improved. He was
discharged on a total 7 day course of levofloxacin, with
albuterol inhaler as needed for reactive airway component.
#Anxiety: He has a history of anxiety and is followed by a
psychiatrist. The patient noted that some of his dyspnea was
driven by anxiety. He received small dose of lorazepam on first
night with good effect. This anxiety could be contributing to
tachycardia.
TRANSITIONAL ISSUES:
Patient will follow-up with PCP in the coming week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Guaifenesin-CODEINE Phosphate 5 mL PO Q4H:PRN cough
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Levofloxacin 750 mg PO DAILY
Please continue through ___.
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth once a
day Disp #*3 Tablet Refills:*0
3. Guaifenesin-CODEINE Phosphate 5 mL PO Q4H:PRN cough
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Pneumonia
Secondary diagnosis: Reactive airways
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you at the ___
___. You were admitted because you were
short of breath, along with a worsening cough. The other issue
may be that your airways are sensitive after your recent upper
respiratory infection.
While you were here, you received oxygen therapy, some nebulized
inhalers and started on a new antibiotic. This morning, you were
very well-appearing and breathing comfortably.
You will be continued on this antibiotic for a total 7 day
course.
Followup Instructions:
___
|
19771418-DS-14
| 19,771,418 | 28,845,083 |
DS
| 14 |
2119-09-13 00:00:00
|
2119-09-14 05:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right lower quadrant abdominal pain
Major Surgical or Invasive Procedure:
___ Laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ year old male who presents for constant
right lower quadrant abdominal pain with associated nausea onset
last night. He denies vomiting, diarrhea, fevers, chills.
Patient has history of appendicitis that was medically managed,
states this pain does not feel similar.
Patient reports 2 months of cough since returning from
___. He reports green phlegm, denies hemoptysis. Denies
night sweats, reports some sweating with cough during the day.
Denies weight loss. Patient has been fasting during
the day for ___.
Past Medical History:
GERD
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Temp: 97.9 HR: 81 BP: 137/88 Resp: 16 O(2)Sat: 97 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Extraocular muscles
intact
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nondistended, upper right lower quadrant
minimally tender
Extr/Back: No peripheral edema
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
On discharge:
Pertinent Results:
___ 04:23PM BLOOD WBC-6.3 RBC-5.55 Hgb-15.2 Hct-44.4
MCV-80* MCH-27.3 MCHC-34.2 RDW-13.0 Plt ___
___ 04:23PM BLOOD Neuts-68.5 ___ Monos-3.2 Eos-1.7
Baso-1.6
___ 04:23PM BLOOD Glucose-100 UreaN-11 Creat-0.9 Na-141
K-4.3 Cl-105 HCO3-26 AnGap-14
___ 04:23PM BLOOD ALT-36 AST-21 AlkPhos-79 TotBili-0.3
___ 04:23PM BLOOD Calcium-9.9 Phos-3.7 Mg-2.1
___ 04:27PM BLOOD Lactate-2.5*
IMAGING:
___ CT abdomen and pelvis with contrast
Acute uncomplicated appendicitis
Brief Hospital Course:
Mr. ___ was admitted on ___ under the acute care surgery
service for management of his acute appendicitis. He was taken
to the operating room and underwent a laparoscopic appendectomy.
Please see operative report for details of this procedure. He
tolerated the procedure well and was extubated upon completion.
He was subsequently taken to the PACU for recovery.
The patient was transferred to the surgical floor
hemodynamically stable. His vital signs were routinely monitored
and he remained afebrile and hemodynamically stable. He was
initially given IV fluids postoperatively, which were
discontinued when he was tolerating PO's. His diet was advanced
on the morning of ___ to regular, which he tolerated without
abdominal pain, nausea, or vomiting. He was voiding adequate
amounts of urine without difficulty. He was encouraged to
mobilize out of bed and ambulate as tolerated, which he was able
to do independently. His pain level was routinely assessed and
well controlled at discharge with an oral regimen as needed.
On the evening of ___, Mr. ___ was discharged home with
scheduled follow up in ___ clinic. He was afebrile,
hemodynamically stable and in no acute distress.
Medications on Admission:
Omeprazole
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
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 ___ 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" a couple 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 could have a poor appetite for a couple days. 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 dressings 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. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
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.
o If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
19771489-DS-9
| 19,771,489 | 29,062,877 |
DS
| 9 |
2165-08-31 00:00:00
|
2165-08-31 08:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right hand table saw injury
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Irrigation and debridement of open fractures of the
index and middle fingers.
2. Primary arthrodesis of the ___ metacarpophalangeal joint
using autograft.
3. Open reduction, internal fixation of index finger
proximal phalanx.
4. Open reduction, internal fixation of index finger middle
phalanx.
5. Revision amputation of index finger at the level of
distal interphalangeal joint.
6. Excision of index finger flexor digitorum profundus from
zone 2 to zone 4.
7. Middle finger flexor digitorum profundus reconstruction
from zone 3 to zone 4 using tendon graft.
8. Open carpal tunnel release.
9. Allograft nerve reconstruction of middle finger radial
digital nerve.
10.Primary repair of superficial palmar arch under
operating microscope.
11.Skin graft reconstruction of middle finger volar radial
defect (1 x 2 cm).
12.Complex repair of volar skin and dorsal index finger
wound (combined length of 8 cm).
History of Present Illness:
___ RHD M ___ speaking, who was ___ around 11am
this morning. Patient put hand on table by accident in the area
of the saw blade while picking up a piece of wood. Patient was
transferred from ___. Patient is accompanied by
his daughter. At the OSH patient had hand x rays which revealed
fractures of the long metarcarpal head, as well as digital
fracture of index and long finger. Patient has multiple full
thickness lacerations with exposed tendons and partial
amputation
of distal index finger. Currently patient only had some moderate
pain to right hand. Overall he states he doing well. Denies
f/c/n/v
Past Medical History:
Hemochromatosis
HTN
HLD
Pancreatic Cancer (s/p whipple)
Social History:
___
Family History:
There is no family history of pancreas cancer
Physical Exam:
NAD
AOx3
R hand brisk capillary refills digits ___, revision amp of R
index finger
Pertinent Results:
___ 06:49AM BLOOD WBC-7.7 RBC-2.91*# Hgb-8.7*# Hct-26.3*#
MCV-90 MCH-29.9 MCHC-33.1 RDW-12.8 RDWSD-42.1 Plt ___
Brief Hospital Course:
Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have right hand table saw injury and was admitted to the hand
surgery service. The patient was taken to the operating room on
___ for fixation of hand fractures and revascularization,
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 OT who determined that
discharge to home with OT was appropriate. The hospital course
is notable for:
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
nonweight bearing in the right extremity, and will be discharged
on aspirin 121.5mg daily for DVT prophylaxis. The patient will
follow up with Dr. ___ per routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
RX *acetaminophen 325 mg 2 capsule(s) by mouth 5 times daily
Disp #*120 Capsule Refills:*0
2. Aspirin 121.5 mg PO DAILY
RX *aspirin 81 mg 1.5 tablet(s) by mouth daily Disp #*42 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*60 Capsule Refills:*0
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5 to 1 capsule(s) by mouth every ___ hours
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right hand tablesaw injury
Discharge Condition:
NAD
AO
Right hand and fingers WWP
Discharge Instructions:
INSTRUCTIONS AFTER HAND SURGERY:
- You were in the hospital for hand surgery. It is normal to
feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Nonweight bearing right upper extremity, OK for finger range
of motion as taught by the occupational therapist
MEDICATIONS
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Aspirin 121.5 daily for 4 weeks
WOUND CARE:
- Dressing should remain on at all times. Do not remove. Do not
get wet. You may shower. No baths or swimming for at least 4
weeks.
- Splint must be left on until follow up appointment unless
otherwise instructed
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
-Please follow up with Dr. ___ in the Hand Surgery Clinic
for post-operative evaluation. You have an appointment scheduled
for ___ at 11AM in ___.
___
___
-Please follow up with your primary care doctor regarding this
admission within ___ weeks for any new medications/refills.
Followup Instructions:
___
|
19772209-DS-8
| 19,772,209 | 26,930,197 |
DS
| 8 |
2156-06-05 00:00:00
|
2156-06-05 17:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Sulfa (Sulfonamide Antibiotics) / Prochlorperazine /
Dilaudid / Gluten
Attending: ___.
Chief Complaint:
Chest ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o pericarditis and eosinophilic esophagitis p/w chset ___
radiating to L shoulder similar in character to prior
pericarditis flares also associated with nasuea.
.
Pt reports that stabbing ___ in her chest started 4 days ago
and has worsened since then. Today it became very painful and
she called the cardiology clinic and was told to come in to the
ED. She says the ___ worst when lying flat and worsens with dep
breathing. There is some radiation to her L shoulder. She is
nasueated because of the severity of the ___. No vomiting. No
shortness of breath although breathing shallowly due to ___.
She reports this is similar to the ___ of her other
pericarditis flares which she has been intermittently having
since she was diagnosed with pericarditis ___ year ago.
.
Of note, she reports that last week she had fevers most of the
week, the highest up to 102. She had accompanying chills and
soaking night sweats. She was having diarrhea at the time that
consisted of loose stools with every bowel movement. No blood
and stools foul smelling. She also reports cramping ___ when
she would have a bowel movement. She says the fevers stopped a
few days ago and the diarrhea has lessened although is still
present. She reports she started a gluten free diet one month
ago and has been eating a lot of salads and vegetables since
that time. She always washes her vegetables.
.
ROS: She denies current fever, chills, change in vision or
hearing, adominal ___, dysuria, hematuria, numbness or tingling
in extremities, weakness of extremities. She reports
intermittent headaches of migraine nature.
.
In the ED, initial VS: 97.9 89 114/70 16 100% RA. CXR was
benign. Trop negative and ED ultra-sound showed no effusion. Pt
was given 1L NS and cardiology was consulted with ___ admission
recommended. Pt was given morphine x 2, zofran, and ativan with
some improvement in ___ and nausea. VS at transfer: 98.1 93
105/56 22 99%
.
Pericarditis/Esophagitis Hx:
Patient has seen many specialists and have had an extensive
workup for this chronic ___. Her extensive recent
history began in ___ when she was seen by ___ GI for abd
___ and found on GE junction ___ to have reactive
changes and some increased intraepithelial eosinophils. She had
periodic GI symptoms until ___ when she presented to ___
___ after a syncopal event and chest ___. She was
diagnosed with costochondritis and put on steroids with little
effect--according to patient, she only took steroids in for a
few days and stopped because of side effects. She was then seen
as outpatient by ___ GI for abd ___ and found on GE
junction ___ to have reactive changes and some increased
intraepithelial eosinophils. Originally diagnosed with
pericarditis by clinical picture and ST depressions on EKG in
___ at ___ and sent home on ibuprofen. An
outpatient cardiologist then confirmed a pericardial rub and an
outpatient echo showed no pericardial effusion. On ___,
p/w episode to ___. ___ (-), RF (-), RPR (-),
___ < 20, TTG IgA <3, ferritin, ceruloplasmin wnl. ___
admited to ___ w/ RLQ ___ and EGD showed
esophagitis. Also found to have peripheral eosinophilia.
Negative parasitic eval. +evidence of late-acute EBV. Evaled by
GI/ID/rheum here. Had mild transaminitis (EBV vs. percocet
use). ___ rheum visit at ___ in the setting
of increasing frequency of fevers/night sweats (she has had
night sweats intermittently throughout this course of illness),
showed ESR 10, lyme negative, neg hep panel, neg IBD panel, neg
CMV, neg HIV; also neg cardiolipin/phospholipid ab, ldh,
immunoelectrophoresis, CPK. On ___, Dr. ___ of
posterior cervical LNs; neg ASLO titer, quantiferon gold.
___, admitted to ___ w/ CP. EKG/TTE wnl and d/c'd w/
pericarditis outpt treatment w/ ___ team. At some point in
early ___, a PCP (Dr. ___ diagnosed her w/ lyme disease
and started her on plaquenil and clarithromycin. On review of
these records, her diagnosis was based on Lyme IFA (IgG, IgM,
IgA) borderline positive (1:80 titer), Lyme IgM negative, and
Lyme IgG negative by CDC/___ result and positive by IgenexIgg
result. In the context of other negative Lyme serologies, these
results are likely negative. She was also seen in ___ clinic
around this time and had a fentanyl patch. She was then
relatively chest ___ free for about ~ ___ months. On
___, admitted to ___ for CP and syncope in which she
subluxed her left shoulder. She then began to see BI
cardiologist Dr. ___ in ___ who d/c lyme meds and started
her on colchicine/ibuprofen w/ a plan to escalate to steroids if
that failed, another medication (perhaps immunomodulators) if
steroids fail, and pericardiectomy if imunomodulators fail. Pt
is no longer taking ibuprofen because of the gastritis seen on
recent EGD.
Past Medical History:
Recurrent symptomatic pericarditis
Anxiety disorder due to a general medical condition
Panic attacks
Fibroid
Pulmonary nodule/lesion, solitary - right middle lobe seen on
CT at ___ ___
Eosinophilic esophagitis
Anxiety
Hypercholesterolemia
Headache-migraine
Psoriasis
Appendectomy at ___
Shoulder surgery
Repair of deviated septum
Social History:
___
Family History:
Father ___
___ Aunt Cancer; Cancer - Breast
Maternal Grandfather Cancer - ___
Mother ___
Paternal Aunt AutoImmune Disease; Cancer - Breast; Cancer -
___ other spinal bifida
Paternal Grandfather CAD/PVD; Diabetes - Unknown Type
Paternal Uncle AutoImmune Disease; ___ - Type II
Two paternal uncles with ___, possibly secondary to
sarcoidosis
Physical Exam:
Admission Exam:
VS - Temp 97.6 F, BP 115/92, HR 89, R 20, O2-sat 98% RA
* Pulsus negative at <6mm Hg
GENERAL - thin female in distress from ___, hiccuping
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART - PMI non-displaced, RRR, nl S1-S2, no rub noted
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, A&Ox3, strength/sensation grossly intact
.
Discharge Exam:
VS: T 97-99.9 BP 80-108/50-70 HR ___ RR 18 O2 Sat 98% RA
GEN: Tearful young woman in distress, arousable, somewhat
histrionic
HEENT: NCAT, EOMI, MMM
Neck: Supple, JVP below the clavicle, no kussmaul's sign.
CV: RRR, normal S1/S2, no S3/S4. No rubs.
PULM: CTAB, no increased WOB. No wheezes, rales or rhonchi.
ABD: NTND, NABS. No rigidity, rebound or guarding.
EXT: WWP, no c/c/e.
NEURO: A/Ox3, CN II-XII intact. Non focal.
Pertinent Results:
Admission Labs:
___ 08:15PM BLOOD WBC-8.5 RBC-4.49 Hgb-13.0 Hct-39.7 MCV-88
MCH-29.0 MCHC-32.8 RDW-12.1 Plt ___
___ 08:15PM BLOOD Neuts-51.8 ___ Monos-5.7
Eos-10.5* Baso-0.6
___ 06:45AM BLOOD ESR-3
___ 08:15PM BLOOD Glucose-109* UreaN-13 Creat-0.9 Na-140
K-4.0 Cl-104 HCO3-28 AnGap-12
___ 08:15PM BLOOD ALT-13 AST-19 CK(CPK)-52 AlkPhos-81
TotBili-0.2
___ 08:15PM BLOOD Lipase-19
___ 08:15PM BLOOD cTropnT-<0.01
___ 06:45AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.8
___ 06:45AM BLOOD CRP-0.3
.
Discharge Labs:
___ 06:50AM BLOOD WBC-4.7 RBC-3.99* Hgb-11.7* Hct-35.2*
MCV-88 MCH-29.3 MCHC-33.2 RDW-12.1 Plt ___
___ 06:45AM BLOOD Amylase-52
___ 08:15PM BLOOD Lipase-19
___ 08:15PM BLOOD cTropnT-<0.01
___ 08:15PM BLOOD CK-MB-1
___ 06:45AM BLOOD CRP-0.3
___ 06:45AM BLOOD ESR-3
___ 06:45AM BLOOD Amylase-52
.
TTE (___):
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Normal study. No structural heart disease or
pathologic flow identified. Compared with the prior study
(images reviewed) of ___, the findings are similar. If
clinically indicated, a cardiac CT would be better able to
identify thickened/calcified pericardium while a cardiac MRI
would be better able to identify pericardial inflammation.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
RUQ Ultrasound (___):
Hepatic echotexture is within normal limits. No focal nodules or
masses are identified within the hepatic parenchyma. There is no
intra- or
extra-hepatic biliary ductal dilation. The common hepatic duct
measures 4 mm. Portal vein is patent with flow in the
appropriate direction. The pancreas appears within normal
limits. The gallbladder is contracted and contains no stones.
There is no hydronephrosis in either kidney. The spleen measures
11.5 cm. Imaged portions of abdominal aorta and IVC are normal
in caliber and there is no ascites.
IMPRESSION: Normal right upper quadrant ultrasound.
Specifically, no
evidence of cholelithiasis or cholecystitis.
Brief Hospital Course:
Primary Reason for Admission: ___ h/o pericarditis and
eosinophilic esophagitis p/w chset ___ radiating to L shoulder
similar in character to prior pericarditis flares.
.
Active Problems:
.
# Chest ___: There was no objective evidence of pericarditis on
this admission. Notably, ESR and CRP were normal, TTE showed no
evidence of effusion. EKGs had non-specific dynamic ST-T wave
changes, but no changes that are specific for pericarditis. On
admission for the same problem one month ago, she had a Cardiac
MR that showed no evidence of pericardial inflammation, though
the study was sub-optimal. At that time she was also seen by GI,
who felt her ___ was not from a GI source and felt that she
DOES NOT have eosinophillic esophagitis (does not meet
diagnostic criteria), though she does have a peripheral
eosinophillia. She has had an extensive rheumatologic workup
that has been completely normal. Rheum was again consulted on
this admission and recommended sending TNFr1a genetic mutation
test. They felt FMF genetic screening was NOT indicated. They
also recommended 5 days of Prednisone 20mg, which the patient
declined due to concerns over steroid side effects. Neuro was
also consulted on this admission to r/o neuropathic source of
her ___ or MS, and neuro felt her ___ was not neurologic in
origin and recommended no additional neurological workup. Her
___ was not responsive to Toradol, but did respond to oral and
IV morphine, which is atpyical for pericarditis. Of note, she is
seen in ___ Clinic, where she is prescribed Nucenta for
chronic ___. There is documentation in the ___ record of her
running out of this prescritpion early, at which time she was
informed that her ___ contract prevented her from receiving a
refill early. Her PCP was contacted, and did not have any
insight into the cause of her ___, but did mention that he was
concerned her ___ was a somatic manifestation of her
undertreated chronic anxiety disorder. It is unclear what is
causing her ___ at this time, but on this admission, the team
was most concerned for malingering vs somatization disorder.
However, organic causes of her ___ should continue to be
considered given her EKG changes.
.
TRANSITIONAL ISSUES: Pt was discharged with ___ of Fentanyl
patch, which have helped in the past, and order for repeat
Cardiac MR the week after admission. She will follow up with Dr.
___, her PCP and allergy/immunology.
.
Chronic Problems:
.
# Eosinophilic Esophagitis/Gastritis: Pt has no objective
evidence of this on most recent GI biopsy. Unlikely to be the
cause of her ___ per prior GI note.
- Cont home omeprazole 20mg BID
- Sucralfate 1g QID
- alum-mag hydroxide-simeth 200-200-20 mg/5 mL, ___ MLs PO QID
- No NSAIDs per above
.
# Nausea/Vomiting: Unclear cause, though we were concerned for
possible opiate withdrawl. Her nausea was worst on admission and
gradually resolved over the course of her hospital stay. It was
relieved by opiates and benzos, which is consistent with opiate
withdrawl. There was associated diaphoresis and loose stools,
which further support the case for opiate withdrawl.
- Lorazepam 0.5-1mg Q6hrs PRN anxiety and nausea
- Ondansetron ___ IV Q8hrs PRN nausea
- Promethazine 25 mg q4h prn nausea
- No compazine (allergy)
.
# Anxiety/Insomnia: Pt reports issues with both and takes
lorazepam and ambien at home for this. On a very high dose of
ambien (20mg Qhs).
- Lorazepam as above
- Ambien 20mg Qhs PRN insomnia
.
Transitional Issues: She was d/c'ed with Cardiology, PCP and
___ and order for repeat outpatient cardiac MR.
___ on Admission:
1. zolpidem 20mg Qhs
2. multivitamin 1 tab daily
3. morphine 15 mg Tablet Q4prn (pt does not report this
medication)
4. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO Q6 prn
5. alum-mag hydroxide-simeth 200-200-20 mg/5 mL ___ MLs PO QID
6. sucralfate 1 gram Tablet Sig: Two (2) Tablet PO twice a day.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) BID
Disp:*8 Capsule(s)* Refills:*0*
8. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO at
onset of headache, may repeat once in 2 hours if needed as
needed for headache.
9. Pt also reports she is taking BID colchicine although this is
not on her med list from recent hospital discharge
10. Pt reports she is taking Tapentadol (NUCYNTA) 50 mg Oral
Tablet TAKE 1 TABLET EVERY SIX HOURS AS NEEDED although it is
not on her med list from recent hospital discharge
Discharge Medications:
1. zolpidem 5 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime).
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea and anxiety.
3. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
200-200-20 MLs PO QID (4 times a day).
4. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO
ONCE MR1 (Once and may repeat 1 time) for 1 doses.
11. tapentadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for ___.
12. morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for breakthrough ___.
13. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO
ONCE (Once) for 1 doses.
15. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Transdermal
Q72H (every 72 hours) for 10 days.
Disp:*4 * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Priamry Diagnosis:
Pericarditis
Secondary Diagnosis:
Eosinophilic Esophagitis
Headache-Migraine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you at the ___
___. You were admitted for chest ___. We feel your
___ is likely due to your chronic pericarditis, though we were
unable to find evidence of inflammation on this admission. For
this, we re-started your Colchicine and performed an ultrasound
of your heart. We also consulted the Rheumatologists and
Neurologists to ensure there was no other cause for your ___.
They felt your problem is not autoimmune of neurologic in
nature. We feel you are safe to return home.
We made the following changes to your medications:
STARTED Colchicine 0.6mg by mouth twice a day
STARTED Fentanyl Patch 25mch/hr over the chest every 72 hours
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19772209-DS-9
| 19,772,209 | 23,582,554 |
DS
| 9 |
2156-07-23 00:00:00
|
2156-07-24 16:35:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Sulfa (Sulfonamide Antibiotics) / Prochlorperazine /
Dilaudid / Gluten
Attending: ___.
Chief Complaint:
Shaking and loss of consciousness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ yo F with h/o chronic pericarditis, anxiety
disorder, no prior seizure history, who presents with ___ chest
pain and witnessed seizure. On ___, patient began to develop
chest pain that she states as present but not severe. Yesterday,
___, she woke up with ___ chest pain that radiated to the
left shoulder and back, was associated w mild SOB. She
characterized the pain as sharp and improved with leaning
forward. Yesterday at 3 pm, she was lying in bed and her husband
noticed her face got red, her facial veins 'popped out', her
face appeared strained and she became unresponsive and began
shaking for ___ seconds. She remembers shaking but doesnt
remember the entire episode. Her husband reports that she she
was then unresponsive for a few minutes. She bit her tongue and
had urinary incontinence. She endorses mild nausea, new
heacache, loose stools, dysuria and urinary urgency over past
few days. No diarrhea, vomiting, abdominal pain, cough, fevers.
She has been under a lot of stress lately because she has been
staying in a hotel for the past 2 weeks as she discovered her
apartment has 'black mold'. She moved into her new apartment
today.
.
In the ED, initial VS: 97.6 96 95/59 18 100% RA. On exam, she
was oriented to person only. Tearful. PERRL, EOMI, face
symmetric, tongue protrudes symmetrically. Reports decreased
sensation left side of face. ___ strength RLE, otherwise
strength ___. EKG showed sinus tach, rate 103 bpm, no ST
elevations. Labs were significant for negative serum tox,
Troponin negative. CBC and lytes WNL. Urine tox positive for
opiates and methadone. CXR was normal. Head CT neg for bleed.
Bedside echo done and no effusion seen. She was given lorazepam
1mg PO x1 and morphine. VS prior to transfer were T 98.5, Pulse:
102, RR: 16, BP: 109/62, O2Sat: 100 RA, Pain: 5.
.
Currently, patient complaining of ___ chest pain and feeling
nervous and scared. She is also complaining of diplopia.
Past Medical History:
Recurrent symptomatic pericarditis
Anxiety disorder due to a general medical condition
Panic attacks
Fibroid
Pulmonary nodule/lesion, solitary - right middle lobe seen on
CT at ___ ___
Eosinophilic esophagitis
Anxiety
Hypercholesterolemia
Headache-migraine
Psoriasis
Appendectomy at ___
Shoulder surgery
Repair of deviated septum
Social History:
___
Family History:
Father ___
___ Aunt Cancer; Cancer - Breast
Maternal Grandfather Cancer - ___
Mother ___
Paternal Aunt AutoImmune Disease; Cancer - Breast; Cancer -
___ other spinal bifida
Paternal Grandfather CAD/PVD; Diabetes - Unknown Type
Paternal Uncle AutoImmune Disease; ___ - Type II
Two paternal uncles with ___, possibly secondary to
sarcoidosis
Physical Exam:
Admission Exam:
VS - Temp 97.9F, BP 117/79, HR 54, R 20, O2-sat 97% RA
GENERAL - anxious, thin female, frequently tearful then smiling
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, ND, TTP in umbilical area, LLQ, 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, A&Ox person, hospital, year, CNs II-XII intact w
subjective diplopia, muscle strength ___ throughout, sensation
intact throughout but reports 'pins/needles over RLE
.
Discharge Exam:
VS: T ___ BP 90-105/60-70 HR ___ RR 18 O2 Sat 99% RA
GENERAL - Less anxious appearing today, NAD
LUNGS - CTAB, no increased WOB, no wheezes, rales or rhonchi
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, ND, no rigidity, rebound or guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - A/Ox3, CN intact. Non focal
Pertinent Results:
Admission Labs:
___ 10:20PM BLOOD WBC-5.9 RBC-4.38 Hgb-12.6 Hct-37.1
MCV-85# MCH-28.7 MCHC-33.9 RDW-11.9 Plt ___
___ 10:20PM BLOOD Neuts-41.1* ___ Monos-6.4
Eos-10.1* Baso-1.4
___ 10:20PM BLOOD Glucose-98 UreaN-12 Creat-0.9 Na-137
K-3.9 Cl-105 HCO3-24 AnGap-12
___ 07:10AM BLOOD CK(CPK)-44
___ 10:20PM BLOOD cTropnT-<0.01
___ 07:10AM BLOOD CK-MB-1 cTropnT-<0.01
___ 10:20PM BLOOD Calcium-9.1 Phos-3.8 Mg-2.0
___ 09:40AM BLOOD Prolact-16
___ 10:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Discharge Labs:
___ 05:35AM BLOOD WBC-4.8 RBC-4.40 Hgb-12.7 Hct-37.9 MCV-86
MCH-28.9 MCHC-33.6 RDW-12.0 Plt ___
___ 07:10AM BLOOD Glucose-87 UreaN-9 Creat-0.7 Na-138 K-3.9
Cl-106 HCO3-25 AnGap-11
.
MRI Brain (___):
There is no evidence for cortical dysplasia, heterotopia or
hippocampal
asymmetry. Intracranial flow voids are maintained. There is a
nonspecific
left frontal periventricular hyperintensity without enhancement.
A faint
lesion is also seen in the right parietal area which could
represent partial volume averaging with the ventricle.
Mucosal thickening is also seen in the sphenoid sinus.There is
mucosal
thickening in the bilateral ethmoid and right maxillary sinuses.
Minimal
right mastoid opacification is noted.
No evidence for acute ischemia or hydrocephalus.
IMPRESSION:
No definite seizure focus identified.
Area of gliosis in the left frontal periventricular ___ matter
without
enhancement. This could be related to remote nonspecific
insult.Appearance is not classic for demyelination although this
cannot be entirely excluded.
.
Paranasal sinus opacification as detailed.
.
EEG (___):
ROUTINE SAMPLING: The background activity shows a symmetric
___ Hz
alpha rhythm which attenuates with eye opening. Frequently,
through the
course of recording, there are intermittent bursts of bilateral
central
and posterior temporal theta frequency slowing. These bursts, at
times,
only appear over the left hemisphere, e.g. at 7:55:13. Of note,
the
study is reviewed under the electrode setting "T1T2CzRI-Univ
[PTC] 40"
to normalize the placement of the electrodes, as the study was
recorded
using an amplifier without a headbox.
SPIKE DETECTION PROGRAMS: There were no automated spike
detections.
SEIZURE DETECTION PROGRAMS: There were 52 automated seizure
detections
predominantly for electrode and movement artifact. There were no
electrographic seizures.
PUSHBUTTON ACTIVATIONS: There are five pushbutton activations.
For the
entry at 08:36, the EEG shows no electrographic seizures. On
video, the
patient is being examined by the neurology team.
For the entry at 09:06, EEG shows no electrographic seizures
and is instead captures myogenic artifact. On video, the patient
is
staring while the right hand is shaking.
For the entry at 09:54, EEG shows no electrographic seizures
it captures myogenic artifact. On video, the patient has slow
trunk
flexion-extension movements while saying "no, I cannot control
it."
The entries at 13:06 and 13:07 capture the onset and offset of
the same event. For these, EEG shows rhythmic movement artifact
lasting
40 seconds with immediate return to normal background after
cessation of
the movements and no seizures are seen. On video, the patient is
lying
on her left, develops whole truncal shaking, followed by
opisthotonus
posturing with neck and back hyperextension.
For the entry at 14:04, the EEG shows rhythmic movement
artifact with superimposed myogenic artifact, but no
electrographic
seizures. On video, patient has body trembling while sitting in
bed,
saying "I cannot help it" to her visitor. She then slides down
in bed
with bilateral ___ shaking and develops back-and-forth head
movement as
she hyperventilates.
SLEEP: The patient progressed from wakefulness to stage II, then
slow
wave sleep at appropriate times with no additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 75 bpm. Note is made of heart rate increasing to 100-120 bpm
during
pushbutton events.
IMPRESSION: This is an abnormal video EEG because of
intermittent
bursts of slowing in the bilateral central and posterior
temporal
regions during wakefulness and drowsiness which, at times,
appeared only
over the left side. These findings are indicative of subcortical
dysfunction in these regions. There are five pushbutton
activations,
none of which shows any evidence of electrographic seizures. On
video,
on two occasions, the patient is able to speak to state that she
cannot
stop the symptoms. During other events, she has waxing and
waning
flexion extension of the trunk, pelvic thrusting, shaking of the
right
arm, head rocking back-and-forth, and neck and back
hyperextension.
These events are consistent with non-epileptic seizures. Note is
made
of sinus tachycardia during pushbutton events.
Brief Hospital Course:
___ Reason for Admission: ___ with h/o chronic pericarditis,
anxiety disorder, no prior seizure history, presents now with
___ chest pain and concern for new seizure.
.
Active Problems:
.
# Pseudoseizure: Initial concern was for epileptic seizure and
Neurology was consulted in the ED. MRI and EEG were performed
(see results/reports) and no evidence of epileptiform seizure
was found. MRI did show nonspecific left frontal periventricular
hyperintensity without enhancement, but the neurology service
did not feel this could represent a cause of her symptoms.
Thought was given to LP for possible demyelenating disease, but
given the absence of focal neuro deficits separated in time and
space, MRI finding was felt to be incidental and not indicative
of an underlying demyelinating disease. There was no fever,
leukocytosis or meningeal signs to suggest an infectious cause
for her symptoms. Given her known anxiety disorder, histrionic
behavior and negative workup, Psychiatry was consulted. Psych
felt the patient may have an undertreated anxiety disorder and
felt that in the absence of medical causes for her symptoms,
conversion disorder vs somatization disorder were possible
causes for her presentation. The patient's anxiety medications
were increased (added Klonopin) and she seemed somewhat less
anxious. Ultimately, Ms ___ was diagnosed with
pseudoseizure and no medical cause for her presentation was
found. She was encouraged to follow up with her PCP and to
continue her outpatient psychiatric care.
.
# Chest Pain: The patient reported ___ chest pain, which is a
chronic problem for her. She had previously been diagnosed with
pericarditis, initially at ___, and is followed by Dr. ___ at
___ for her diagnosis of chronic pericarditis. On this
admission, she stated her pain was exactly the same as the pain
she has experienced with prior flares of her chronic
"pericarditis." She has had an extensive cardiac workup
including repeated TTEs, multiple cardiac MRIs and a full
rheumatologic workup without any evidence of pericarditis or
connective tissue disorder. Troponins and CKBM were negative,
and the suspicion for ACS was very low in this otherwise low
risk young woman. On prior admissions, her chest pain has not
responded to Toradol, NSAIDs or Colchicine. She does endorse a
small amount of relief with a Fentanyl Patch and narcotic pain
mediacations. Given she has had an extensive workup for her pain
on multiple prior admissions, we did not pursue further
diagnostic testing for her chest pain. She was given Oxycodone,
a Fentanyl patch and benzodiazepines for her pain.
.
Chronic Problems:
.
# Eosinophilic Esophagitis/Gastritis: Pt has no objective
evidence of this on most recent GI biopsy. At this time, it does
not appear that she meets the diagnostic criteria for
eosinophillic esophagitis.
.
# Anxiety/Insomnia: Patient has significant anxiety, which is
likely a major contributing factor to her symptoms. She was
continued on her home Ambien and Ativan and also given Klonopin.
On the day of discharge, she was also given 5mg of Zydis, which
seemed to help with her severe anxiety.
.
Transitional Issues: Prior to discharge, I talked to her
outpatient pain physician and informed him of her
hosptialization. He asked that I given her enough Fentanyl
patches to last 2 weeks, at which time she could again be seen
in pain clinic. Otherwise, he asked that I not provide
additional narcot pain medications. She will follow up with
Allergy/Immunology and Psychiatry as well as her PCP and pain
management doctor.
Medications on Admission:
lorazepam 1 mg Tab BID prn anxiety and nausea
zolpidem 20 mg at bedtime, as needed for insomnia
sumatriptan 50 mg prn headache
fentanyl 12 mcg/hr Transderm Patch Transdermal
Nucynta (tapentadol) 50 mg ___ tabs q6h prn pain
Zofran 4 mg po q8h prn nausea
Fluticasone 50 mcg 2 sprays BID
omeprazole 20 mg po BID
Docusate 100 mg po BID
Senna 1 tab po BID
Colchicine 0.6 mg po BID
Multivitamin daily
Discharge Medications:
1. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every ___ (72) hours for 10 days.
Disp:*5 * Refills:*0*
2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for anxiety.
3. zolpidem 5 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime)
for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
4. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO
once a day as needed for headache.
5. Nucynta 50 mg Tablet Sig: ___ Tablets PO every six (6) hours
as needed for pain.
6. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal BID (2 times a day).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
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).
10. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
11. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Pseudoseizure
Secondary Diagnosis:
Anxiety Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure caring for you at the ___
___. You were admitted for shaking episodes. We
performed an MRI and EEG and are pleased to inform you that you
did not have a seizure. It is unclear what is causing your
symptoms at this time, but we are concerned that an undertreated
anxiety disorder or other psychiatric problem may be
contributing to your symptoms. We would like you to follow up
with your pain psychiatrist and to initiate care with a
psychotherapist as well. You should continue to follow up with
your primary care physician for ongoing workup of your concerns.
We have provided you with a refill for your Fentanyl patches as
prescribed by Dr. ___. Thank you for allowing us to
participate in your care.
Followup Instructions:
___
|
19772404-DS-19
| 19,772,404 | 28,710,252 |
DS
| 19 |
2192-05-11 00:00:00
|
2192-05-11 20:29:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Influenza Virus Vacc,Specific
Attending: ___.
Chief Complaint:
Falls and balance disturbance
Major Surgical or Invasive Procedure:
___ PICC line placement
___ PICC line removal
History of Present Illness:
Ms. ___ is an ___ year old female with a history of
breast cancer ER/PR positive, HER2 negative diagnosed in ___
s/p resection/XRT/hormonal treatment, prior history of ovarian
cancer (treated with chemo in ___, seizure disorder and Factor
V Leiden complicated by DVTx2 on warfarin, who presented to OSH
neurology for frequent falls with back pain.
During the evaluation she was found to have diffuse disease that
appears to be metastases to the lung and liver on CT. These
findings prompted transfer to the ___ ED.
Her history of falls began one month ago when she had her
initial fall with head strike and was thought to have had a
concussion. Since that event, she has had difficulty with
balance and multiple falls. At home she intermittently uses a
cane. Her most recent fall was 5 days prior to ED visit. It was
described by her daughter as mechanical in nature, without loss
of consciousness or headstrike.
She corroborates that she "lost her balance." She had an MRI/MRA
of the brain on ___ at ___ which reportedly did not show any
acute processes. Echo was also performed as part of evaluation.
Denies fever no urinary incontinence, retention or fecal
incontinence or retention. No back pain. Mild subjective
weakness in her lower extremtities after standing for a while.
She's noticed a slight "flap" in her hands occassionally. No
numbness, tingling, or saddle anesthesia.
In the ED:
Initial Vitals: 8 98.4 92 131/67 18 97%
Transfer Vitals: 5 97.5 91 131/68 16 93% RA
Meds: None given
Studies: OSH films being uploaded
Labs: Per OSH records below
Fluids: None
Access: ___
She currently feels well. She is comfortable. She has
"heaviness" in her breathing. Her husband noted some increased
abdominal girth. She denies CP, cough, dysuria, N/V/D.
Past Medical History:
1. History of right invasive ductal carcinoma, with ductal and
lobular features, moderately differentiated ___
___, grade 1), ER/PR positive, HER2 negative ___. Treated with
partial mastectomy, partial breast irradiation by Dr. ___
___ ___ years of hormonal therapy with Arimidex. Lung and liver
mets in ___, discharged home with hospice after declining
liver biopsy and further treatment.
2. Distant history of ovarian cancer in ___, stage I, treated
with adjuvant chemotherapy (likely carboplatin and paclitaxel).
3. History of deep vein thrombosis x 2, heterozygous for Factor
V Leiden on anticoagulation.
4. History of pernicious anemia, on chronic B12.
5. Seizure disorder
6. osteoporosis, treated with many years of intravenous
bisphosphonate
7. GERD
8. Asthma
Social History:
___
Family History:
No family history of malignancy in the immediate family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - T: 97.6 BP: 142/86 HR: 94 RR: 22 02 sat: 97% on RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, dry MM, nontender
supple neck, no LAD, no JVD
CARDIAC: Normal rate, regular rhythm, s1/S2, no murmurs
RESPIRATORY: CTAB, no wheezes, rales, rhonchi, breathing
comfortably without use of accessory muscles
GI: mildly distended, tympanitic, non-tender, firm mass to
palpation over the RUQ near her past CCY scar - scar tissue vs
palpable liver, no rebound/guarding
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, few beat nystagmus to the right, one
beat asterixis, ___ strength in the upper and lower extremities,
sensation intact throughtout upper and lower extremities. Finger
to nose normal, slightly uncoordinated on the left with heel to
shin
SKIN: warm and well perfused, no excoriations, ecchymoses over
the buttocks
DISCHARGE PHYSICAL EXAM:
VS: T98.7 BP144/65-171/58 HR90 RR20 92RA
GENERAL: No acute distress, pleasant
HEENT: anicteric sclera, moist mucous membranes
CARDIAC: RRR, normal s1/S2, no murmurs
LUNGS: diffuse crackles, no wheezes
ABD: +BS, mildly distended, nontender, large palpable mass
RUQ/epigastric area
EXT: moving all extremities well, no cyanosis, clubbing or edema
PULSES: 2+ DP and ___ pulses bilaterally
NEURO: CN II-XII grossly intact, + mild asterixis, AOx3
SKIN: warm well perfused
Pertinent Results:
ADMISSION LABS:
___ 07:05AM BLOOD WBC-10.8 RBC-3.86* Hgb-11.9* Hct-36.4
MCV-94 MCH-30.7 MCHC-32.6 RDW-14.5 Plt ___
___ 07:05AM BLOOD ___ PTT-38.6* ___
___ 07:05AM BLOOD Glucose-104* UreaN-25* Creat-1.1 Na-132*
K-4.6 Cl-99 HCO3-20* AnGap-18
___ 07:05AM BLOOD ALT-34 AST-89* TotBili-0.9
___ 07:05AM BLOOD Albumin-2.7* Calcium-8.1* Phos-3.6 Mg-1.8
PERTINENT LABS:
___ 05:42AM BLOOD Osmolal-281
___ 07:05AM BLOOD Osmolal-275
___ 07:00AM BLOOD TSH-2.7
___ 07:05AM BLOOD CEA-69* ___ ___*
URINE:
___ 01:11AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:11AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 01:11AM URINE RBC-1 WBC-5 Bacteri-MOD Yeast-NONE Epi-1
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage
regimen of 2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_______________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 12:38PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:38PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 12:38PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
___ 12:38PM URINE CastHy-56*
URINE CULTURE (Final ___: NO GROWTH.
___ CT CHEST WITH CONTRAST
1. Large 3.4 x 5.3 cm left lower lobe lesion, along with left
upper lobe and right lower lobe nodules are highly suspicious
for metastatic disease.
2. Multiple enlarged left hilar, lower paratracheal and upper
paratracheal
nodes are lymph node metastatic involvement.
3. There are no bone metastases.
4. Moderate-to-severe coronary artery calcification.
5. Mild centrilobular, paraseptal emphysema and mild diffuse
bronchial
thickening are likely smoking related.
___ CT ABD PELVIS WITH CONTRAST
1. 3.9 cm asymmetric right breast soft tissue mass seen at the
visualized
lower thorax. Correlation with mammography and clinical exam is
recommended.
2. 5.5 cm irregular soft tissue attenuation mass abutting the
posterior
pleural surface in the left lower lobe. Few epicardial lymph
nodes identified on the visualized lung bases.
3. Innumerable ill-defined hypodense masses throughout the liver
parenchyma, in keeping with diffuse metastases.
4. Pancreatic head is heterogenous in attenuation. No
pancreatic ductal
dilatation. Metastases or primary pancreatic neoplasm is not
excluded.
5. 7 mm hyperdense lesion at the pancreatic body may relate to
interdigitation of fat versus a small cystic lesion such as
IPMN.
6. 1.1 cm rounded lesion at the lateral limb of the left adrenal
gland is
suspicious for metastatic deposit.
7. No lymphadenopathy. No evidence of osseous metastases in the
abdomen and pelvis.
___ PORTABLE CXR
Single frontal view of the chest. Left PICC terminates in the
lower SVC.
Heart size and cardiomediastinal contours are stable. Lung
volumes have
slightly improved, though still hypoinflated. There is
bibasilar atelectasis without focal consolidation, pleural
effusion, or pneumothorax.
___ CXR
A left-sided PICC line terminates at the cavoatrial junction.
The
lung volumes are low with mild relative elevation of the right
hemidiaphragm that appears unchanged. The cardiac, mediastinal,
and hilar contours appear stable including mediastinal and left
hilar lymphadenopathy. There is no definite pleural effusion or
pneumothorax. There is a persistent medial left basilar opacity
with a rounded contour, suggesting a pleural-based mass
concerning for malignancy. Smaller nodules are not well
depicted on radiographs.
IMPRESSION: Stable appearance of the chest including
lymphadenopathy and a left lower lobe opacity worrisome for
malignancy.
___ RUQ ULTRASOUND (prelim)
1. Diffusely infiltrative hepatic metastases were better
delineated on recent CT
2. No visualized flow in the left portal vein. This vessel,
which was atretic on the recent CT, is likely being compressed
by adjacent metastases.
DISCHARGE LABS:
___ 02:35AM BLOOD WBC-14.0* RBC-3.35* Hgb-10.2* Hct-32.4*
MCV-97 MCH-30.6 MCHC-31.6 RDW-16.3* Plt ___
___ 02:35AM BLOOD ___ PTT-65.7* ___
___ 08:30AM BLOOD PTT-51.4*
___ 02:35AM BLOOD Glucose-143* UreaN-22* Creat-1.0 Na-136
K-3.7 Cl-100 HCO3-20* AnGap-20
___ 02:35AM BLOOD ALT-29 AST-98* AlkPhos-168* TotBili-1.2
___ 02:35AM BLOOD Albumin-2.4* Calcium-7.8* Phos-4.4 Mg-1.9
___ 11:49AM BLOOD Ammonia-88*
___ 07:05AM BLOOD CEA-69* ___ CA125-785*
___ 11:49AM BLOOD Phenyto-11.5 Phenyfr-PND
___ 11:49AM BLOOD Phenyto-11.5
___ 05:29AM BLOOD Phenoba-31.6 Phenyto-13.2
___ 09:45AM BLOOD Lactate-4.5*
___ 06:00PM BLOOD Lactate-4.1*
___ 01:24PM BLOOD Lactate-4.0*
Brief Hospital Course:
___ with history of breast cancer (___), ovarian cancer (___),
Factor V Leiden on warfarin for history of two DVTs, and seizure
disorder with two recent falls who presented for concern of
metastatic malignancy. She was discharged home with hospice.
# Mental status changes. During admission, patient became more
restless and unable to concentrate or focus. She was
intermittently alert and oriented x3, and mental status waxed
and waned throughout the day. This was likely multifactorial and
may be related to hospital delirium, liver dysfunction due to
tumor burden, decreased clearance of sedating medications
(diazepam, narcotic pain meds), seizure disorder or possible
leptomeningeal disease (MRI negative). During admission she
developed new asterixis and abnormal lfts, most c/w greater
burden of disseminated intrahepatic disease than seen on
imaging. She was treated with lactulose with mild improvement.
No obvious infection was found. Neuro Oncology was consulted and
Dr. ___ the patient. MRI brain at OSH negative.
# Metastases to the lung and liver, new. Primary is unknown.
Based on history of breast and ovarian cancers, these are most
likely. However, given pace of disease, a more aggressive tumor
is favored. T
She was at high risk for clotting given her history of clots
and metastatic malignancy. Her warfarin was held, and she was
started on a heparin drip to prepare for liver biopsy to guide
further management. However, on day of biopsy, patient stated
she did not want any further diagnostic or therapeutic tests.
After discussion with her family, the patient changed her mind
and the biopsy was scheduled for the following day. On the day
of the rescheduled biopsy, the patient again stated she did not
was the procedure and wanted to go home. After a family
discussion, the biopsy was postponed until she felt better.
During the the rest of her admission, the goals of care changed
the biopsy was no longer pursued.
# Factor V Leiden on warfarin. She had supratherapeutic INR on
admission. INR 3.8 at OSH. INR 2.9 on admission here. Warfarin
was held. Heparin gtt was started. Liver biopsy was not
ultimately pursued. Given change in goals of care,
anticoagulation was discontinued.
# UTI. Complained of urinary frequency. She did have chief
complaint on admission of falls and balance issues. UA with
moderate bacteria, small leuks. UCx >100k pansensitive Ecoli.
She was treated with ceftriaxone 1g Q24H from ___ to ___.
Recheck of UA (given ongoing mental status changes) showed no
UTI.
# Hyponatremia. Resolved after 1L IVF. Serum and urine osm low.
Urine Na 24. Consistent with hypovolemic picture. Less
consistent with SIADH.
# Falls. This appeared to be mechanical in nature. Exam shows
full strength and mildly uncoordinated heel to shin on left. She
has intact sensation and no signs of cord compression or cauda
equina on exam. She would require MRI imaging or a bone scan to
evaluate for bony disease. Physical Therapy recommended patient
be discharged to rehab. Her goals of care changed, and she was
discharged to home with hospice.
# Seizure disorder: No seizures since ___. Continue home
phenobarbital and phenytoin. Drug levels were within normal
range.
ACCESS: ___ placed ___ and removed on ___ on discharge
EMERGENCY CONTACT:
Next of Kin: ___
Relationship: DAUGHTER
Phone: ___
Other Phone: ___
### TRANSITIONAL ISSUES ###
-Home with hospice.
-Symptomatic medications - olanzapine, morphine, scopolamine,
lidocaine patch.
-Avoid hepatically-cleared medications given ongoing
encephalopathy.
-Anticoaguation discontinued given hospice goals.
-Inpatient neurologist Dr. ___ these changes to
reduce sedation, but we will defer to outpatient neurologist:
- stop Phenytoin Sodium Extended 400 mg PO HS
- start Phenytoin 150mg in the morning and 200mg at bedtime
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pamidronate 90 mg IV Q3 MONTHS
2. AtroVENT (ipratropium bromide) 0.06 % nasal TID: PRN PND
3. Docusate Sodium 50 mg PO HS
4. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral daily
5. Warfarin 2 mg PO DAILY16
6. Phenytoin Sodium Extended 400 mg PO HS
7. Furosemide 10 mg PO 3X/WEEK (___)
8. Psyllium Wafer 1 WAF PO DAILY
9. PHENObarbital 129.6 mg PO HS
10. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
11. Mag 64 (magnesium chloride) 64 mg oral daily
12. Diazepam 5 mg PO DAILY:PRN anxiety/seizure
13. Cyanocobalamin 1000 mcg IM/SC QMONTH
14. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
2. PHENObarbital 129.6 mg PO HS
3. Phenytoin Sodium Extended 400 mg PO HS
4. AtroVENT (ipratropium bromide) 0.06 % nasal TID: PRN PND
5. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO Q2H:PRN
pain
6. OLANZapine (Disintegrating Tablet) 5 mg PO Q4H:PRN
delirium/restlessness
RX *olanzapine 5 mg 1 (One) tablet,disintegrating(s) by mouth
every four (4) hours Disp #*30 Tablet Refills:*0
7. Scopolamine Patch 1 PTCH TD Q72H
RX *scopolamine base [Transderm-Scop] 1.5 mg/72 hour Apply to
dry area of skin Q 72 hours Disp #*30 Each Refills:*0
8. Lidocaine 5% Patch 1 PTCH TD QAM painful area
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) apply to painful
area once a day (12 hours on, 12 hours off) Disp #*30 Each
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Breast cancer most likely metastatic to liver and lung
-Urinary tract infection
-Hyponatremia
SECONDARY:
-Factor V ___
-History of DVTs
-Seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure to take care of you at ___
___. You were admitted to the hospital because of
falls and difficulties with your balance. You were found to have
breast cancer that was most likely metastatic to the lung and
liver. You declined a biopsy of your liver to further
characterize the mass and evaluate you for treatment. You had a
urinary tract infection which was treated with antibiotics.
After discussion with your family and oncology doctors, you
decided to return home with hospice care.
You should also talk to your primary neurologist about your
seizure medications. The neurologist you saw here recommended
the following changes in order to reduce sedation but prevent
seizures:
- stop Phenytoin Sodium Extended 400 mg PO HS
- start Phenytoin 150mg in the morning and 200mg at bedtime
Followup Instructions:
___
|
19772551-DS-24
| 19,772,551 | 29,540,204 |
DS
| 24 |
2192-01-11 00:00:00
|
2192-01-11 14:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
CVL
History of Present Illness:
Mr. ___ is a ___ man with a history of type 1
diabetes diagnosed at age ___, hypertension, hyperlipidemia, and
peripheral vascular disease status post left femoropopliteal
bypass with reversed ipsilateral greater saphenous vein
___ who presents from home with rigors.
The patient states that he has a ___ for his lower extremity
wounds that visits 3 times a week. On ___ the ___ noticed
that he had a fever to 104. Since the patient felt fine he did
not come to the emergency department. The patient continued to
feel fine until ___ evening when after eating dinner he
developed severe rigors and nausea without vomiting. He also
noticed that his blood sugar, which is normally very well
controlled, was significantly elevated. Initially he thought it
was food poisoning secondary to his meal, however, when it did
not resolve he presented to the ED.
He states that he did not notice any change in his lower
extremities over the last few days. He also denies pain in the
legs but does have a numb tingling feeling in the left lower
extremity.
In the ED, initial vitals: 103, 102, 140/48, 19, 97% RA patient
Labs notable for: Lactate 3.0, CRP 98.4, hemoglobin A1c 7.2, WBC
18.2, mild anemia
Patient received:
___ 15:50 IV Piperacillin-Tazobactam 4.5 g
___ 17:04 SC Insulin Lispro 6 UNIT
___ 17:59 IV Vancomycin 1500 mg
___ 18:24 PO Acetaminophen 1000 mg
___ 18:52 IV Clindamycin 600 mg
___ 17:05 IVF 3L NS
Consults: vascular, no surgical needs about the by the evening
Vitals on transfer: 102.4, 80, 91/42, 19, 98% RA
Past Medical History:
Type 1 Diabetes mellitus, diagnosed Age ___ (was a patient of Dr.
___
Hypertension
Hyperlipidemia
PVD
OA
Social History:
___
Family History:
Noncontributory to current presentation
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.7, 106/51, 76, 17, 99% on room air
GENERAL: Well-appearing man lying in bed in no apparent distress
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
ABD: soft, distended but nontender, bowel sounds normal
EXT: 2+ pitting edema of the left lower extremity to the thigh,
1+ pitting edema of the right ankle and foot. Bilaterally warm
and well perfused.
SKIN: Right ankle and foot with 1+ pitting edema and chronic
venous stasis changes noted no open ulcers. Left lower
extremity about ___ inches below the knee erythematous and
flaking with two shallow 1cm ulcers on the lateral aspect of the
left shin.
NEURO: Moving all extremities with purpose no focal deficit,
right pupil submillimeter larger than left pupil both equal and
reactive to light.
DISCHARGE PHYSICAL EXAM:
98.1 PO 113 / 64 L Lying 65 18 93 Ra FSBS 109
GEN: NAD
HEENT: MMM, OP clear
CV: RRR
RESP: CTA bilat
ABD: +BS, soft, ND. + distended
EXT: LLE with erythema that has decreased and is below the
purple demarcation. He has a small fluid filled blister on the
lateral aspect of his left leg that is similar in appearance to
the day prior and not increased in size.
NEURO: A+Ox3, fluent speech, no facial droop.
Psych: Normal Affect
Access: + RIJ CVL; + RUE pIV
Pertinent Results:
ADMISSION LABS:
===============
___ 03:00PM WBC-18.2* RBC-4.43* HGB-12.1* HCT-37.5*
MCV-85 MCH-27.3 MCHC-32.3 RDW-15.4 RDWSD-47.4*
___ 03:00PM NEUTS-90.1* LYMPHS-4.1* MONOS-5.1 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-16.41* AbsLymp-0.74* AbsMono-0.92*
AbsEos-0.00* AbsBaso-0.02
___ 03:00PM %HbA1c-7.2* eAG-160*
___ 03:14PM GLUCOSE-307* LACTATE-3.8* NA+-136 K+-5.1
CL--105 TCO2-18*
___ 04:10PM CRP-98.4*
___ 04:10PM GLUCOSE-285* UREA N-26* CREAT-1.6* SODIUM-137
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-18* ANION GAP-16
___ 04:59PM O2 SAT-52
___ 04:59PM GLUCOSE-261* NA+-132* K+-4.5 CL--105 TCO2-21
___ 04:59PM ___ PH-7.40
___ 05:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-1000* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:00PM URINE RBC-1 WBC-1 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 07:13PM LACTATE-3.0*
___ 07:13PM ___ PO2-23* PCO2-35 PH-7.36 TOTAL CO2-21
BASE XS--5
___ 07:00PM GLUCOSE-181* UREA N-24* CREAT-1.7* SODIUM-140
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-18* ANION GAP-15
___ 07:00PM CALCIUM-7.7* PHOSPHATE-1.4* MAGNESIUM-1.7
MICRO:
======
___ BLOOD CULTURES - NGTD
___ BLOOD CULTURES - NGTD
___ BLOOD CULTURES - NGTD
___ URINE CULTURES - NEGATIVE
IMAGING:
========
CT LLE W/O CONTRAST (___)
1. Extensive soft tissue edema and skin thickening of the left
lower leg, as described above.
2. No soft tissue gas or fluid collections identified.
CXR (___)
1. Mild pulmonary vascular congestion.
2. Left mid lung and retrocardiac opacities may represent
developing pneumonia in the appropriate clinical setting.
ART EXT (___)
On the right side, monophasic doppler waveforms are seen in the
femoral,
superficial femoral, popliteal, posterior tibial and dorsalis
pedis arteries.
On the left side, monophasic doppler waveforms are seen in the
femoral,
superficial femoral, popliteal, posterior tibial and dorsalis
pedis arteries.
The right ABI is 0.82 and the left ABI is 0.44. Pulse volume
recordings
demonstrate symmetric amplitudes at the levels studied.
ART DUPLEX (___)
1. Patent left superficial femoral artery-popliteal artery
bypass graft.
2. Elevated velocities of the native common femoral artery and
at the distal anastomosis, indicating areas of focal stenosis.
CXR (___)
There is increase of a interstitial opacity in the lower lobes
and vascular congestion concerning for elevated venous
pressures.
Cardiomediastinal and hilar silhouettes are stable. There is
there is small bilateral pleural effusions. There is no
pneumothorax.
DISCHARGE LABS:
===============
___ 05:46AM BLOOD WBC-8.7 RBC-3.40* Hgb-9.2* Hct-28.6*
MCV-84 MCH-27.1 MCHC-32.2 RDW-15.5 RDWSD-47.4* Plt ___
___ 05:46AM BLOOD Glucose-130* UreaN-9 Creat-1.5* Na-141
K-4.2 Cl-104 HCO3-23 AnGap-14
___ 06:20AM BLOOD Calcium-8.0* Phos-3.7 Mg-1.8
Brief Hospital Course:
Mr. ___ is a ___ man with a history of type 1
diabetes diagnosed at age ___, hypertension, hyperlipidemia, and
peripheral vascular disease status post left femoropopliteal
bypass with reversed ipsilateral greater saphenous vein
___ who presents from home with rigors and left lower
extremity rash concerning for cellulitis with bacteremia.
=================
ACTIVE ISSUES
=================
#Left lower extremity cellulitis
#Fever and leukocytosis
Patient presented with signs and symptoms concerning for sepsis
secondary to left lower extremity cellulitis. He initially got
Zosyn in the emergency department as well as clindamycin. He
also got 3 L of IV fluid with significant improvement in his
lactate to normal. Chest x-ray was potentially concerning for
pneumonia but patient did not have any signs or symptoms of
respiratory infection. UA neg. CRP elevated. Blood cultures were
negative. He was covered empirically with vancomycin, cefepime,
and Flagyl while in the ICU, subsequently narrowed to Unasyn and
Bactrim on the flood and ultimately Bactrim/Augmentin for a
total of 10 days of antibiotics on discharge.
#Type 1 diabetes
#Hyperglycemia
Patient with long-standing type 1 diabetes since the age of ___ontrolled blood sugar at baseline. Reports that
hemoglobin A1c is 6.6. A1c 7.2 on admission likely secondary to
recent hospitalizations. No evidence of DKA, however was
hyperglycemic as high as the 400s at times, likely in the
setting of acute infection. His SBG levels were managed with
input from the ___ team. As his infection was better
controlled, his glucose control became too tight and he had an
episode of hypoglycemia to the ___. He as restarted on his home
medications with better control.
# PVD
Seen by vascular surgery in the emergency department for his
peripheral vascular disease. ABIs on ___ revealed stenosis. He
was continued on Plavix, aspirin, atorvastatin. He was covered
on a heparin drip until vascular surgery decided no longer
indicated. He will follow up with vascular for angiogram in the
next ___ weeks per vascular surgery consult recommendations.
___ on CKD 3
Patient with known CKD baseline creatinine 1.3-1.5 likely
secondary to diabetes and hypertension. Creatinine on admission
1.6-1.7 potentially prerenal with delay in improvement after
fluids. FeNa 0.3% suggesting pre renal etiology. However,
rising creatinine with relative hypotension is concerning for
ATN vs. other intrinsic renal process. Patient has no known
cardiac history and echocardiogram in ___ of this year was
normal, although diastolic function cannot be assessed,
therefore making cardiorenal causes less likely. His Creatinine
returned to baseline at 1.3 and then to 1.5 on restarting ace
inhibitor prior to d/c.
# Anemia
Patient with chronic normocytic anemia likely secondary to CKD
and anemia of chronic disease. Previous iron studies not
consistent with iron deficiency anemia. No evidence of active
bleeding. H/H was monitored while inpatient and was stable.
# HTN
Held home ACE inhibitor on admission in the setting of
hypotension but restated prior to d/c.
==================
CORE MEASURES:
==================
# Communication:
Name of health care proxy: ___ (brother)
Phone number: ___
# Code: Full, presumed
Greater than 30 minutes spent in care coordination and
counseling on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Pantoprazole 40 mg PO Q24H
4. Ramipril 10 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Aspirin 325 mg PO DAILY
7. Toujeo SoloStar (insulin glargine) 300 unit/mL (1.5 mL)
subcutaneous QHS
8. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL
subcutaneous QACHS
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 Tablet by mouth
twice a day Disp #*12 Tablet Refills:*0
2. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*24 Tablet Refills:*0
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL
subcutaneous QACHS
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Ramipril 10 mg PO DAILY
10. Toujeo SoloStar (insulin glargine) 300 unit/mL (1.5 mL)
subcutaneous QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Sepsis
Lower extremity cellulitis
Chronic:
Type 1 diabetes
PVD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a pleasure taking care of you while you were in the
hospital. You were admitted with an infection of your leg. You
were treated with IV antibiotics and you improved. You have been
switched over to 2 oral antibiotics and will take these for the
next 6 days. Please take all of the medications as prescribed.
Please follow up as directed below.
Followup Instructions:
___
|
19772572-DS-12
| 19,772,572 | 29,598,040 |
DS
| 12 |
2133-08-02 00:00:00
|
2133-08-02 17:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Demerol
Attending: ___.
Chief Complaint:
right sided facial pain, right wrist pain, headache after a fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH significant for hypothyroidism, HTN, HLD,
pre-diabetes, s/p unwitnessed fall 5 steps ?LOC, t/f from ___
___ were CT head, c-spine and wrist x-rays revealed. She was
admitted to Trauma service at ___ and a trauma workup was
completed with CT torso, b/l wrist x-rays, elbow x-rays, chest
and pelvic xray. Injuries identified were small L SDH, R ___ fx,
R occipital condyle fx, R distal radius fracture.
Past Medical History:
Hypothyroidism, HLD, HTN, prediabetes,
Social History:
___
Family History:
non-contributory
Physical Exam:
Discharge Physical Exam:
VS ___ RA
Gen - NAD
HEENT - PERRL; R periorbital ecchymosis, tenderness to palpation
R periorbital region; skin intact; EOMI; sensation intact in
V1-3
dermatomes; no palpable deformities; CN VII gross motor intact;
dried blood b/l nares; no intraoral lesions;
Cardio: sinus rhythm
Resp: normal breath sounds
abdomen: soft, non-tender to palpation, non-peritoneal
MSK: RUE splinted, good perfusion on her digits, swollen
Pertinent Results:
___ 05:01AM ___
___ 05:01AM ___ PTT-26.4 ___
___ 05:01AM PLT COUNT-277
___ 05:01AM WBC-15.1* RBC-4.76 HGB-13.9 HCT-42.7 MCV-90
MCH-29.2 MCHC-32.6 RDW-13.4 RDWSD-44.0
___ 05:01AM LIPASE-26
___ 05:01AM estGFR-Using this
___ 05:01AM UREA N-13 CREAT-0.9
___ 05:09AM GLUCOSE-134* LACTATE-2.1* NA+-142 K+-3.9
CL--108 TCO2-24
___ 05:09AM COMMENTS-GREEN TOP
___ 12:49PM URINE MUCOUS-RARE
___ 12:49PM URINE RBC-14* WBC-2 BACTERIA-MOD YEAST-NONE
EPI-5
___ 12:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:49PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:49PM URINE UHOLD-HOLD
___ 12:49PM URINE HOURS-RANDOM
--------------
EXAMINATION: WRIST(3 + VIEWS) LEFT
INDICATION: ___ s/p fall, evaluate for fracture.
TECHNIQUE: Three views of the left wrist.
COMPARISON: None available.
FINDINGS:
No fracture or dislocation is seen. There is severe first CMC
and moderate to
severe triscaphe joint degenerative change. No bony erosion,
periostitis, or
soft tissue calcification is identified. No suspicious lytic or
sclerotic
lesion is identified. No radiopaque foreign body is detected.
IMPRESSION:
No fracture or dislocation in the left wrist. Severe first CMC
and moderate
to severe triscaphe joint degenerative change.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
___, MD
___, MD electronically signed on SAT ___ 8:27
AM
------------------
CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRAST Clip #
___
Reason: traumatic injuries? traumatic injuries?
Contrast: OMNIPAQUE Amt: 170
UNDERLYING MEDICAL CONDITION:
History: ___ with fall down stairs.
REASON FOR THIS EXAMINATION:
traumatic injuries?
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read by ___ on SAT ___ 10:06 AM
-No evidence of trauma.
-Indeterminate right adrenal lesion. Dedicated, nonemergent CT
or MRI is
recommended for further characterization.
-Cholelithiasis without evidence of cholecystitis.
-DISH of the mid thoracic spine.
-Hepatic steatosis.
Final Report
EXAMINATION: CT torso
INDICATION: History: ___ with fall down stairs. // traumatic
injuries?
TECHNIQUE: MDCT axial images were acquired through the chest,
abdomen and
pelvis following intravenous contrast administration with split
bolus
technique.
IV Contrast: 130 mL Omnipaque.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 8.3 s, 64.9
cm; CTDIvol =
11.2 mGy (Body) DLP = 727.2 mGy-cm. Total DLP (Body) = 727
mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST: HEART AND VASCULATURE: Atherosclerotic calcifications
are dense.
There is focal ectasia of the infrarenal aorta up to 21 mm.
There is no
central pulmonary embolus. There is no pericardial effusion.
Coronary
calcifications are moderate.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES:
No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is scarring atelectasis at the lung
bases, bilaterally.
There is a 3 mm pulmonary nodule in the right middle lobe
(series 2, image
69).
BASE OF NECK: Visualized portions of the base of the neck show
no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous low attenuation
throughout.
There is no evidence of focal lesion or laceration. There is no
evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder
contains
gallstones without wall thickening or surrounding inflammation.
PANCREAS: A 3 mm hypodensity in the tail of the pancreas (series
2, image 112)
likely represents a side-branch IPMN. There is mild prominence
of the main
pancreatic duct. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesion or laceration.
ADRENALS: An 8 mm nodule in the right adrenal gland is
indeterminate. The left
adrenal gland is unremarkable.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
Multiple hypodensities in the kidneys, bilaterally are either
too small to
characterize or are consistent with simple renal cysts. There
is no
concerning renal lesion. There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel
loops
demonstrate normal caliber, wall thickness, and enhancement
throughout.
Diverticulosis of the sigmoid colon is noted, without evidence
of wall
thickening and fat stranding. The appendix is not visualized.
There is no
evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is of normal size and
enhancement. There is no
evidence of adnexal abnormality bilaterally.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or
retroperitoneal hematoma.
Extensive atherosclerotic disease is noted.
BONES: There is no acute fracture. No focal suspicious osseous
abnormality.
There is DISH of the mid thoracic spine. There is no fracture
or traumatic
malalignment. No dislocation.
SOFT TISSUES: There is diastases of the anterior abdominal wall.
The
superficial soft tissues otherwise unremarkable.
IMPRESSION:
1. No evidence of trauma.
2. Indeterminate right adrenal lesion. Dedicated, nonemergent
CT or MRI is
recommended for further characterization.
3. Cholelithiasis without evidence of cholecystitis.
4. DISH of the mid-thoracic spine.
5. Hepatic steatosis.
------------------
___ ___ 8:02 AM
WRIST(3 + VIEWS) RIGHT Clip # ___
Reason: reduced?
UNDERLYING MEDICAL CONDITION:
History: ___ with fracture, s/p reduction
REASON FOR THIS EXAMINATION:
reduced?
Wet Read by ___ on SAT ___ 9:10 AM
Improved impaction and alignment of the intraarticular
comminuted fracture of
the distal radius.
Final Report
EXAMINATION: WRIST(3 + VIEWS) RIGHT
INDICATION: History: ___ with fracture, s/p reduction //
reduced?
reduced?
TECHNIQUE: Three views of the right wrist.
COMPARISON: Radiograph from the same date.
FINDINGS:
Interval placement of a cast. Mildly displaced, comminuted
impacted fracture
distal radius with extension to the wrist joint with minimal
dorsal
displacement distal fracture fragment.
IMPRESSION:
Assessment is limited by overlying cast. Improved alignment of
the
intraarticular comminuted fracture of the distal radius.
CT scans from OSH CT head and C-spine: small SDH at the falx,
and non-displaced small occipital condyle fx.
Brief Hospital Course:
The patient was admitted to the hospital after a fall on
___. We did a workup for her injuries in addition to the ___
___ workup (CT head, c-spine) with x-rays and CT
torso, ___ CT CHEST/ABD/PELVIS W/, WRIST(3 + VIEWS)
RIGHT, ELBOW (AP, LAT & OBLIQUE, WRIST(3 + VIEWS) LEFT, TRAUMA
#2 xrays (AP CXR & PELVIS)and we identified the following
injuries: a small left sided subdural hematoma, a right sided
ZMC fracture a non-displaced, right sided occipital condyle
fracture, a right sided distal radius fracture. She was assessed
by Plastics service for your facial fracture, which did not
require surgical intervention but plastics would like to
follow-up as an outpatient. Neurosurgery was consulted for her
small questionable SDH (SDH versus artifact) but it was felt
that it was tiny to necessitate any intervention of follow-up.
They also did not suggest a c-collar for the occipital condyle
fracture. She assessed by Orthopedics service for your wrist
fracture who suggested non-operative management but placed a
splint. Her tertiary trauma evaluation did not identify any
other injuries at the current time. During her hospitalization
she was hemodynamically stable. She was assessed by the physical
and occupational therapy services which suggested a rehab
facility for recovery. When she medically cleared, she was
discharged to the rehab facility.
Medications on Admission:
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 88 mcg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. PARoxetine 10 mg PO DAILY
7. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
6. Levothyroxine Sodium 88 mcg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. PARoxetine 10 mg PO DAILY
9. Polyethylene Glycol 17 g PO ONCE Duration: 1 Dose
10. Senna 8.6 mg PO BID
11. Simvastatin 20 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
small left sided subdural hematoma, Right sided zygomatic bone
fracture, right sided occipital condyle fracture, right sided
disal radius fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a fall. We did a workup
for your injuries with x-rays and ct scans and we identified the
following injuries: a small left sided subdural hematoma (brain
bleed that happens after injury to the head), a Right sided
zygomatic bone fracture (this is a fracture of a bone in your
face called zygomatic), a right sided occipital condyle fracture
(this is a fracture at the base of your skull), a right sided
distal radius fracture (this is a fracture at your wrist).
During your hospitalization we checked also your hematocrit
which was sable and you did not have sings of acute blood loss.
You were assessed by Plastics service for your facial fracture,
which did not require surgical intervention but plastics would
like to follow-up as an outpatient. Neurosurgery was consulted
for your small questionable brain bleed (subdural hematoma) but
it was felt that it was tiny to necessitate any intervention of
follow-up. You were assessed by Orthopedics service for your
wrist fracture who suggested non-operative management but placed
a splint on your arm. Your tertiary trauma evaluation did not
identify any other injuries at the current time. You were
assessed by the physical and occupational therapy services which
suggested a rehab facility for recovery. When you were medically
cleared you were discharged to the rehab facility.
Followup Instructions:
___
|
19773436-DS-7
| 19,773,436 | 23,343,418 |
DS
| 7 |
2202-09-25 00:00:00
|
2202-09-26 08:39:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Univasc / Lipitor / Crestor
Attending: ___.
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History primarily from daughter but supplemented/confirmed by pt
where indicated.
___ w nephrolithiasis and recurrent UTIs, CKD3-4, intermittent
falls, neuropathy, ? COPD p/w confusion and fall. Pt was in USOH
until about ___ PTA when she was with her daughter and had a
witnessed fall into a cabinet, without LOC. Since around that
time she has been confused (which pt describes as "dazed" and
which she mentions was manifested by reversing order of
phrases).
Daughter reports that she has also been more shaky. Sleeping a
lot, maybe more cold as has been in warm blankets more than
usual, some episodes of loose stools, (non-bloody per pt). No
HA,
aphasia, chest pain. Has been more wheezy with exertion. Has her
chronic cough (for which her PCP started her on empiric COPD
treatment) for some time now, and which is non-productive. No
rhinorrhea, sore throat, myalgias (beyond baseline aches/pains),
flu like symptoms. Has had L sided groin pain last week,
reportedly she told other people, intermittent over last week.
Has had some dysuria, hematuria, urinary frequency (baseline)
with baseline incontinence, abd pain, rashes, joint pains (other
than usual, and other than hip pain since ___).
Pt endorses the confusion, which she says is better than in the
ED, but denies f/c/n/v/CP. Endorses the wheezing with activity.
No sick contacts. Denied dysuria to me but does endorse baseline
urinary urgency. No rash, new joint pain.
Pt had another fall on day of presentation, was walking to sink
and felt her L knee go out, then subsequently went down, no head
strike, no LOC, got back up and sat on the toilet. Denied
orthostasis. Endorses decreased PO over the last week or so.
Both dtr and patient agree no med changes other than initiation
of cephalexin as started by urology in ___. Has been on
pregabalin and oxybutynin for a long time. No etoh, drugs.
Presented to ED, initially hypertensive but then subsequently
normotensive. Given CTX given previous sensitivities. Because of
L calf pain had ___ and Xray. Admitted to medicine. Given 1L
LR.
Past Medical History:
h/o 1st degree AV block, dyslipid, HTN, h/o atypical chest pain,
?OSA, chronic LBP with resulting neuropathy, DM2, hypothyroid,
obesity, reflux, recurrent UTIs, CRF (last Cr 1.8)
Social History:
___
Family History:
father with HTN
otherwise reviewed and non-contributory to current presentation
Physical Exam:
ADMISSION:
==============
Constitutional: VS reviewed, NAD, pleasant but slightly confused
HEENT: eyes anicteric, normal hearing, nose unremarkable, MMM
without exudate, neg cervical LAD, neck supple with full ROM
CV: RRR, I/VI SEM best at LUSB without radiation
Resp: CTAB
GI: sntnd, NABS, no suprapubic tenderness
GU: no foley, neg CVAT
MSK: no synovitis, B knee replacement scars, negative L log roll
or pain with flexion/extension
Ext: wwp, neg edema in BLEs
Skin: no rash grossly visible
Neuro: slightly tangential and non-linear but generally able to
tell most of a medical history, naming intact to high and low
frequency words, repetition intact, A&Ox3, DOWB slowly but well,
4+/5 BUE/BLE (possibly slightly decreased LLE per baseline),
SILT
BUE/BLE, CN II-XII intact
Psych: normal affect, pleasant
DISCHARGE:
==============
VS: ___ 0728 Temp: 98.3 PO BP: 115/71 HR: 59 RR: 18 O2 sat:
94% FSBG: 128
Constitutional: Alert, NAD
HEENT: NC/AT, face symmetric
CV: RR, somewhat faint HS but no m/r/g
Resp: CTAB; breathing appears comfortable
Abd: S/NT/ND, BS present
Skin: no rash grossly visible
Neuro: AAOx3 today, conversant with clear speech, normal
coordination of b/l arms & hands
Psych: mildly guarded, no active auditory or visual
hallucinations, cooperative with my interview and exam today
Pertinent Results:
ADMISSION LABS:
===============
___ 08:51AM BLOOD WBC-11.7* RBC-3.85* Hgb-12.2 Hct-36.3
MCV-94 MCH-31.7 MCHC-33.6 RDW-12.7 RDWSD-43.9 Plt ___
___ 08:51AM BLOOD Neuts-86.2* Lymphs-5.7* Monos-6.6
Eos-0.3* Baso-0.4 Im ___ AbsNeut-10.11* AbsLymp-0.67*
AbsMono-0.78 AbsEos-0.03* AbsBaso-0.05
___ 08:51AM BLOOD ___ PTT-26.6 ___
___ 08:51AM BLOOD Glucose-204* UreaN-30* Creat-1.6* Na-143
K-4.4 Cl-109* HCO3-22 AnGap-12
___ 08:51AM BLOOD ALT-10 AST-15 AlkPhos-103 TotBili-0.3
___ 08:51AM BLOOD proBNP-148
___ 08:51AM BLOOD cTropnT-<0.01
___ 08:51AM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.0 Mg-2.0
___ 08:51AM BLOOD TSH-1.3
___ 08:51AM BLOOD T4-6.0
.
URINE STUDIES:
___ 09:15AM URINE Color-Straw Appear-Clear Sp ___
___ 09:15AM URINE Blood-NEG Nitrite-POS* Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 09:15AM URINE RBC-1 WBC-2 Bacteri-MANY* Yeast-NONE
Epi-0
___ 12:37AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
.
.
MICRO:
===============
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
.
IMAGING:
===============
CT Head - IMPRESSION:
1. No acute intracranial abnormalities.
2. Mild paranasal sinus disease, as above.
.
HIP - IMPRESSION:
Possible mild cortical irregularity of the left femoral head on
AP view may be artifactual, however, if there is high clinical
concern, a dedicated CT can be obtained for further evaluation.
No evidence of dislocation.
.
B KNEE FILMS - IMPRESSION:
Patient is status post bilateral total knee arthroplasties
without evidence of hardware complications.
.
CXR - IMPRESSION:
Mildly hypoinflated lungs without acute cardiopulmonary process.
.
LLE U/S - IMPRESSION:
No evidence of deep venous thrombosis in the left lower
extremity
veins.
.
L FOOT FILMS - IMPRESSION:
No evidence of fracture or dislocation of the first phalanx of
the left foot.
.
RENAL U/S - IMPRESSION:
1. Renal atrophy and increased cortical echogenicity bilaterally
suggestive of medical renal disease. No hydronephrosis.
2. Nonobstructive stones in the right kidney measuring up to 1.5
cm in the interpolar region.
.
TTE - IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and global
biventricular systolic function. No valvular pathology or
pathologic flow identified. Small pericardial effusion.
.
MRI BRAIN - IMPRESSION:
1. Mild thickening and enhancement of the mid to posterior
aspect of the falx could represent an en plaque meningioma
versus leptomeningeal thickening and enhancement possibly in an
infectious or neoplastic context.
2. No evidence of acute infarction or hemorrhage.
3. Mild paranasal sinus disease.
.
DISCHARGE LABS:
===============
___ 06:22AM BLOOD WBC-5.4 RBC-3.45* Hgb-11.0* Hct-33.2*
MCV-96 MCH-31.9 MCHC-33.1 RDW-13.1 RDWSD-45.4 Plt ___
___ 06:22AM BLOOD Glucose-122* UreaN-34* Creat-1.7* Na-143
K-3.9 Cl-107 HCO3-23 AnGap-13
.
.
Brief Hospital Course:
___ y/o F w/ CKD3-4, nephrolithiasis w/ recurrent UTIs on chronic
suppressive abx, hypothyroidism, DM p/w AMS and mechanical fall.
HOSPITAL COURSE BY PROBLEM:
===========================
.
#Altered mental status:
#Presumed toxic metabolic encephalopathy:
Approximately one week of encephalopathy prior to admission.
Neuro exam non-focal. Psych was consulted. Suspect that this
represents delirium in the setting of UTI. Could also consider
untreated depression given subacute anhedonia and lack of
activity per discussion with family. Pt's level of agitation
waxed and waned throughout course, further supporting diagnosis
of delirium. MRI showed mild thickening and enhancement of the
mid to posterior aspect of the falx. Neurology evaluated her and
felt that this was likely incidental finding and did not warrant
any further inpatient workup. Per psychiatry recommendations,
she was started on ramelteon and Seroquel for sleep. Her
oxybutynin was held given concern that this could be
contributing to her mental status changes as well. She refused
Seroquel on most nights. Of note, she was continued on her
pregabalin, ranitidine, and paroxetine; however, could consider
these as possible causes of AMS if she continues to have issues.
Over the course of her hospitalization, her mental status
gradually improved. She was seen by OT who recommended rehab.
She was seen by Neurology who felt her presentation was most
consistent with delirium and advised outpatient follow-up in
___ clinic with additional brain imaging as below.
.
# MRI brain showing: "Mild thickening and enhancement of the mid
to posterior aspect of the falx"
- Neurology evaluated her and ultimately advised outpatient
Neurology follow-up with repeat MRI brain as outpatient
- Neuro appointment pending at the time of discharge, but
___ team working on setting up an appointment.
.
# Nephrolithiasis
# Recurrent UTIs:
While there were no WBCs on UA, given AMS and dtr's report that
patient had reported some dysuria, opted to treat as UTI. Urine
culture grew e. coli, sensitive to CTX. She was treated for
complicated UTI for 7 days given significant delirium. Case was
discussed with urology who felt that her remaining stone was
unlikely to be nidus of infection. After CTX was completed, she
was restarted on her ppx Keflex and this was continued on
discharge.
.
# DOE / Cough: Pt reportedly with DOE and cough at home. CXR
negative. TTE unremarkable. Pt adamantly denied any respiratory
symptoms on the floor. She was continued on her home Advair and
albuterol prn, though often refused home Advair, and had no
respiratory or exertional complaints while hospitalized. Could
consider stress testing and / or PFT's as an outpatient if she
reports DOE at rehab or when she resumes her usual activities at
home.
.
# DM: Placed on ISS and DM diet. Held home linagliptin as
non-formulary and resumed upon discharge to rehab.
.
# Urinary incontinence: Held oxybutynin as above in case
contributing to mental status decline/proclivity towards
confusion and permanently discontinued this medication upon
discharge. Notified patient's daughter (___) of this change in
medication by phone and the clinical reasoning behind it and she
was in agreement.
.
# Neuropathy: Continued home pregabalin.
.
# Depression: Continued home paroxetine.
.
# GERD: Continued home ranitidine.
.
# OSA: Diagnosed on sleep study at BI-P in ___. Did
not order CPAP while in house in order to avoid worsening
agitation (per dtr's report, pt has had paranoid thoughts
towards sleep team).
**Of note, per patient's daughter's report, patient was
instructed by her ___ physician NOT to drive based upon
the results of the OSA testing in ___, but the patient did
not adhere to this recommendation and subsequently refused to
take the ___ physician's calls.
-We have clearly instructed the patient and the patient's
daughter (___) that the patient is not to drive until she is
cleared to do so by her PCP or her ___ specialist.
.
.
.
TRANSITIONAL ISSUES:
===================+
1) Neuro outpatient follow-up for evaluation of possible early
dementia, recent AMS, and MRI brain finding of "Mild thickening
and enhancement of the mid to posterior aspect of the falx"
2) Needs CPAP for OSA treatment
3) Patient should not drive until cleared to do so by her PCP or
her ___ specialist.
4) Plain films of the hip reported abnormal appearance of the
left femoral head. While the patient had reportedly mentioned L
groin pain prior to admission, she denied any pain here and was
ambulating without issue. This was thought to most likely
represent artifact but can consider dedicated CT of the left hip
as outpatient if pt reports pain with resuming usual activities
(i.e. walking). This was discussed with the patient's daughter.
5) Could consider stress testing and / or PFTs as outpatient if
she reports exertional dyspnea at rehab or when she resumes her
usual activities at home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pregabalin 150 mg PO BID
2. Oxybutynin XL (*NF*) 10 mg Other DAILY
3. linaGLIPtin 5 mg oral DAILY
4. estradiol 0.01 % (0.1 mg/gram) vaginal 3x/wk
5. Ranitidine 150 mg PO BID
6. Saccharomyces boulardii 250 mg oral BID
7. Simvastatin 20 mg PO QPM
8. iodoquinol-HC ___ % topical DAILY
9. Ferrous Sulfate 325 mg PO BID
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
12. PARoxetine 20 mg PO DAILY
13. Levothyroxine Sodium 88 mcg PO DAILY
14. Vitamin D ___ UNIT PO 1X/WEEK (___)
15. Cephalexin Dose is Unknown PO Q24H
Discharge Medications:
1. Ramelteon 8 mg PO AT 6PM
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
2. Cephalexin 250 mg PO/NG Q24H
RX *cephalexin 250 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
3. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
4. estradiol 0.01 % (0.1 mg/gram) vaginal 3x/wk
5. Ferrous Sulfate 325 mg PO BID
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. iodoquinol-HC ___ % topical DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. linaGLIPtin 5 mg oral DAILY
10. PARoxetine 20 mg PO DAILY
11. Pregabalin 150 mg PO BID
12. Ranitidine 150 mg PO BID
13. Saccharomyces boulardii 250 mg oral BID
14. Simvastatin 20 mg PO QPM
15. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Fall
Acute Toxic Metabolic Encephalopathy
Possible early dementia with behavioral disturbance
Urinary Tract Infection (Recurrent)
Nephrolithiasis
OSA - untreated
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You presented to the hospital with worsening confusion following
a recent fall. You were found to have a urinary tract infection
and were treated with antibiotics. With this, your confusion
slowly improved. You were seen by the psychiatrists who
recommended medications to help with sleep. You were also seen
by the Neurology team, who advised that you be seen in Neurology
clinic and have repeat brain imaging performed as an outpatient.
You were also seen by the occupational therapists who
recommended that you be discharged to rehab. We expect you will
only need a short stay in rehab before returning home.
Because of your untreated obstructive sleep apnea, you may not
drive until you have been cleared to do so by your primary care
physician or pulmonary/sleep specialist.
Followup Instructions:
___
|
19773650-DS-14
| 19,773,650 | 29,878,325 |
DS
| 14 |
2143-02-15 00:00:00
|
2143-02-15 08:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PSYCHIATRY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
I have depression
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Pt is a ___ y/o male with a history of depression, who recently
moved to ___ from ___ to attend college at ___
___. Pt says that this most recent epidose of depression began
a few months ago. At that time, his former girlfriend who
attends
school in ___ was raped. He thinks that incident served as a
trigger for his current depression. At that time he sought
treatment with a therapist, Dr. ___, whom he still sees.
Pt says that he has felt chronically depressed since. He
endorses
hopelessness but denies any suicidal thoughts or HI. He had an
appt. with Dr. ___ morning. Pt says that we was so upset
with feelings of hopelessness that very few words were exchanged
during the hour long interview. Pt says that he cried vigorously
for the duration. After the session had ended, he left the
building and sat on the front steps where he continued to cry.
He
also experienced severe anxiety, felt dizzy, palpitations,
hyperventilation and numbness of both hands. He returned to his
therapist's office. Dr. ___ was very concerned for his pt and
called EMS. Pt says that his doctor strongly encouraged an
evaluation in the ED and pt agreed. Pt says that he "had a
breakdown". He says he has had multiple breakdowns in the past.
On interview, the pt endorses severe hopelessness, an
unintentional 25 pound weight loss, 5 hours of sleep per night,
poor concentration. He also endorses history of attacks of
anxiety associated with hyperventilation, palpations, trembling,
and numbness of extremitis. He denies any VAH, thought
broadcasting, ideas of reference. He also denies symptoms of
mania including decreased need for sleep, grandiosity,
distractibility, rapid fleeting thoughts.
He reports having no friends or social supports. He has very
limited contact with his parents.
Past Medical History:
Past Psych Hx
Pt reports episodes of depression for ___ years. He says that he
has taken medications, but he does not know their names and they
were not of benefit to him. He has been off medications for
about ___ year. He has never been hospitalized and has never
attempted suicide. He is seeing a therapist (Dr. ___
for app. 2 months.
No significant PMHx
No significant Substance abuse history
Social History:
___
Family History:
Denies FHx of suicide/mental illness
Physical Exam:
Per initial note by Dr. ___ ___
General: Well-nourished, in no distress.
HEENT: Normocephalic. PERRL, EOMI. Oropharynx clear.
Neck: Supple
Lungs: Clear to auscultation; no crackles or wheezes.
CV: Regular rate and rhythm; no murmurs/rubs/gallops; 2+ pedal
pulses
Abdomen: Soft, nontender, nondistended; no masses or
organomegaly.
Extremities: No clubbing, cyanosis, or edema.
Skin: Warm and dry, no rash or significant lesions.
Neurological:
*Cranial Nerves: ___ grossly intact.
*Motor- Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power
___ throughout.
*Sensation- Intact to light touch
*Coordination- Normal on finger-nose-finger
Pertinent Results:
___ 01:20PM GLUCOSE-102* UREA N-8 CREAT-0.8 SODIUM-140
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16
___ 01:20PM TSH-2.2
___ 01:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:20PM WBC-19.4* RBC-5.32 HGB-15.7 HCT-45.6 MCV-86
MCH-29.5 MCHC-34.4 RDW-12.5
___ 01:20PM NEUTS-87.0* LYMPHS-9.4* MONOS-3.3 EOS-0.1
BASOS-0.2
___ 01:20PM PLT COUNT-367
___ 01:19PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 01:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-2* PH-8.0 LEUK-NEG
Brief Hospital Course:
1.Legal: ___
2.Medical: No acute or chronic issues. Pt has no PCP. So was
provided with information on how to obtain PCP and urgent care
services through the school.
3.Psychiatric: At time of admission the patient denied suicidal
thoughts, plan or intent, but did note that he had been briefly
overwhelmed with saddness. He describes a long standing history
of depression with intermittent, brief (minutes) peirods of
passive suicidal thinking. He has a difficult time identifying
his triggers to feeling overwhelmed but appears to be related to
the experiences of an ex-girlfriend recently and adjustment to
being in a new country and school. He was started on Citalopram
to treat depression. This medication was well-tolerated.
Patients outpatient Therapist Dr. ___ was contacted at
time of admission in order to discuss circumstances of patients
hospitalization and to obtain relevant history. He expressed no
acute concerns with pt's disposition back to home and f/u appt
was scheduled. Treatment with a psychiatrist was also
estabilished. The patient was well engaged in group and milieu
therapy in his time in the hospital. At time of discharge, he
was bright, calm, clearly future oriented, and looking forward
to his return to ___. He is very dedicated to music and his
ongoing work at school.
4.Substance Abuse: No acute or chronic issues
5.Social/Milieu:
Pt was encouraged to participate in units
groups/milieu/therapy opportunities.
Usage of coping skills and mindfulness/relaxation methods were
encouraged. The school counseling center was contacted and
coordinated with during his hospitalization.
6.Risk Assessment:
Will note that while patient represents a chronic risk of
relpase into impulsive and potentially dangerous behaviors when
most overwhlemed, he is no longer at acute risk to himself. He
is in good behavioral control, sober, and future oriented (w/
plan to return to school and his music performance), and
connected with outpt treatment (he feels very connected to and
helped by his therapist, provided with referral to new
psychiatrist). He has a good understanding of his chronic risk
of relapse and can clearly articulate a safety plen if he feels
unsafet again and feels able to utilize it.
7.Disposition:
Disposition discussed with pt and with outpt therapist Dr.
___. Pt's school was contacted to discuss pt's
treatment/discharge and he will be connected with ___
Counseling upon discharge. Pt was connected w/ outpt psychiatry
intake.
Medications on Admission:
n/a
Discharge Medications:
1. Citalopram 20 mg PO DAILY x20 day supply
Discharge Disposition:
Home
Discharge Diagnosis:
Axis I: Major Depressive Disorder
Axis II: deferred
Axis III: none active
Axis IV: social isolation, mental illness
Axis V: 50
Discharge Condition:
Pt is stable
Pt is ambulatory
Appearance: young ___ man dressed in ___ appears stated
age
Behavior: intermittent eye contact, no notable PMA/PMR, no
nystagmus, no tremors
Speech: grossly normal rate/tone/prosody, no
slurring/dysarthria
Mood: 'I'm doing good today'
Affect: Largely Full, Reactive
Thought Process: largely linear
Thought Content: no prominent
delusions/paranoia
Perceptions: denies Auditory/Visual/Somatic hallucinations
Suicidality/Homicidality: patient denies SI/HI
Insight/Judgment: notably improved
Cognitive Exam: Alert/Ox3,
memory/registration/recall/attention grossly intact
Discharge Instructions:
During your admission at ___, you were diagnosed with
Depression and treated with medication called Citalopram.
Please follow up with all outpatient appointments as listed.
Please continue all medications as directed.
Please avoid abusing alcohol and any drugs--whether prescription
drugs or illegal drugs--as this can further worsen your medical
and psychiatric illnesses.
Please contact your outpatient psychiatrist or other providers
if you have any concerns.
Please call ___ or go to your nearest emergency room if you feel
unsafe in any way and are unable to immediately reach your
health care providers.
It was a pleasure to have worked with you and we wish you the
best of health.
If you need to talk to a ___ Staff Member regarding issues of
your hospitalization, please call ___
Followup Instructions:
___
|
19773700-DS-13
| 19,773,700 | 26,423,577 |
DS
| 13 |
2175-06-18 00:00:00
|
2175-06-19 09:46:00
|
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, left hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with history of HTN, hyperglycemia, chronic back pain
secondary to spinal stenosis and chronic left hip pain treated
with injections, who presented with left parasternal chest pain
for three days and chronic left hip pain worsening over last
month. The chest pain is in the setting of acute worsening of
his left hip pain. At its worst it was a ___ in intensity,
described as sharp, worse with palpation and coughing. He states
that the pain improves when he lays flat in bed. He denies any
SOB, diaphroesis associated with the chest pain. He states that
his left hip pain has been getting progressively worse over the
last month. He has been evaluated as an outpatient for this
pain, and is scheduled for an outpatient hip MRI on ___,
and subsequent steroid injection. He is not sure when his last
steroid injection was, but he has received 5 total over the last
many years, and he reports that they typically last for ___ year.
His left hip pain is worse with ambulation. He states that when
he was younger, he was hit by a police detective who was
speeding through the city, and the car drove over him. Since
then he has experienced left hip pain. He was mostly concerned
about the hip pain, which is what prompted him to come to the
hospital today.
In the ED, initial vitals were 98.2 110 118/92 18 98% on RA. Per
report: EKG noted poor R wave progression and no st changes;
bedside U/S was without effusion; and CXR noted no acute
process. AsA 325mg was given in addition to his home percocet
for hip pain. His first troponin was negative and a plan was
made for a second troponin and a stress mibi given limited
ambulation. Most recent vitals prior to transfer: 97.4 89 115/87
14 95% on RA.
On arrival to the floor, he denies any chest pain. He reports
that his hip remains painful, but less so when he lays in bed.
He denies any SOB, cough, fevers.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-HTN
-Type 2 Diabetes
-Hypertriglyceridemia
-ED
-Insomnia
-Knee pain on chronic narcotics
-LBP/spinal stenosis on chronic narcotics
-retinal tear
-hx drug abuse
Social History:
___
Family History:
- HTN in "everyone in my family"
- Daughter with ___, unknown type
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T=97.7 BP=114/88, HR=94, RR=20, O2=96%RA
Wt: 154.2lbs
GENERAL: NAD, pleasant.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with no JVD.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4. No tenderness to palpation.
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB,
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Tenderness to
palpation over the left hip, but no evidence of deformity or
scarring.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
NEURO: A+Ox3, CN ___ grossly intact. Strength ___ in proximal
and distal muscle groups on the left lower extremity and ___ in
the right lower extremity. Patellar tendon reflex 2+ on left,
unable to elicit on right. Sensation to light touch intact over
right lower extremities, but slightly diminished on the left.
DISCHARGE PHYSICAL EXAM:
VS: 97.7, 98-120/68-79, 78-88, 18, 97%RA
GENERAL: NAD, pleasant.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with no JVD.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4. No tenderness to palpation.
LUNGS: No chest wall deformities, scoliosis or kyphosis. CTAB,
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Tenderness to
palpation over the left hip, but no evidence of deformity or
scarring. No tenderness to palpation over the left foot.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
NEURO: A+Ox3, CN ___ grossly intact.
Pertinent Results:
ADMISSION LABS:
Brief Hospital Course:
___ yo male with history of HTN, hyperglycemia, chronic back pain
secondary to spinal stenosis and chronic left hip pain treated
with injections, who presented with left parasternal chest pain
for three days and chronic left hip pain worsening over last
month.
# Chest Pain: Had resolved upon arrival to the floor. On
admission he reported ___ chest pain over the last three days,
worse with cough, palpation, and movement. No associated SOB,
diaphoresis. Cardiac enzymes were negative x2. EKG did not show
any evidence of ischemia. He has no personal or family history
of CAD. Musculoskeletal pain from costocondritis seems to be the
most likely etiology given his previously reproducable pain with
palpation, and that it gets worse with coughing. However, he
does have multiple risk factors for coronary artery disease,
including male gender, age, hyperlipidemia, and would likely
benefit from an outpatient stress test. For risk factor
modification, he was started on a baby aspirin and statin.
# Left Hip Pain: Acute worsening of his chronic left hip pain.
No evidence of infection given lack of leukocytosis, fevers, or
evidence of hot or inflamed joint. Does endorse some tenderness
to palpation over the left hip, but no abnormalities are
appreciated on external exam. Strength is slightly diminished on
the left, as is sensation to light tough. He is scheduled for
outpatient MRI of the left hip on ___. We treated him
with percocet and ibuprofen and his pain improved.
# Hyponatremia: Mild hyponatremia noted on admission labs. Also
with elevated Hct, which could be suggestive of hypovolemic
hyponatremia. Resolved with IVF.
# Dyslipidemia: Lipid panel notable for total cholesterol 237,
LDL 127, Trig 317, HDL 49. Given his diabetes, his LDL goal is
<70. He was started on simvastatin.
# Type 2 DM: Most recent HgbA1C of 6.9 in ___, which
technically meets criteria for diabetes. Recheck is pending at
the time that this discharge summary was signed. His finger
sticks were monitored, and he was maintained on a diabetic diet.
He was also given diet education and handouts on appropriate
food choices.
CHRONIC ISSUES:
# GERD: On ranitidine as needed as an outpatient. Given his
standing ibuprofen and new aspirin, we started him on
omperazole, and continued ranitidine as needed.
# HTN: Well controlled on current regimen. Continued lisinopril,
HCTZ.
# History of narcotics abuse: His home dose of percocet was
non-formulary, but he was maintained on a similar dose and was
not discharged with any prescriptions for additional narcotics.
TRANSITIONAL ISSUES:
- new T2DM, pending A1C
- risk factors for coronary artery disease, likely needs a
stress given age, male sex, and concomittant risk factors even
without anginal chest pain
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Percocet *NF* (oxyCODONE-acetaminophen) 7.5-325 mg Oral TID
2 tabs
2. Ibuprofen 800 mg PO Q8H
3. Hydrochlorothiazide 12.5 mg PO DAILY
Please hold for SBP<90
4. Clonazepam 1 mg PO QHS:PRN insomnia
Please hold for RR<12 or sedation
5. Ranitidine 150 mg PO BID:PRN acid
6. Lisinopril 10 mg PO DAILY
Please hold for SBP<90
7. traZODONE 50-100 mg PO HS:PRN insomnia
8. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Clonazepam 1 mg PO QHS:PRN insomnia
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Ibuprofen 800 mg PO Q8H
4. Lisinopril 10 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Ranitidine 150 mg PO BID:PRN acid
7. traZODONE 50-100 mg PO HS:PRN insomnia
8. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
10. Simvastatin 10 mg PO DAILY
RX *simvastatin 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
11. Percocet *NF* (oxyCODONE-acetaminophen) 7.5-325 mg Oral TID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Musculoskeletal chest pain, chronic left sided hip pain
and low back pain, new type 2 diabetes mellitus
Secondary: gastroesophageal reflux disorder, insomnia,
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___
___. You presented with chest pain and left hip pain.
While you were here you had labs checked, which did not show any
evidence of a heart attack. Your pain was controlled with oral
pain medications, and it improved.
While you were here you were found to have elevated cholesterol.
As a result, you were started on a new medication called
simvastatin. The point of this medication to decrease your
cholesterol, which will help decrease your risk for coronary
artery disease. Also, we started you on a small dose of aspirin
to help decrease your risk of heart attack as well.
Also, you had a lab test which showed that you have diabetes. It
is very important to follow a diabetic diet, and you were given
handouts with instructions on which foods are better for you
with your new diagnosis of diabetes.
Also, because you were started aspirin, and because you take
ibuprofen chronically at home, we started you on a medication to
present stomach ulcers. This medication is called omeprazole.
You should take this medication daily, and continue to use
ranitidine as needed for acute episodes of acid reflux.
Please note that the following changes have been made to your
meds:
Please START simvastatin 10mg daily
Please START aspirin 81mg daily
Please START omeprazole 20mg daily
Followup Instructions:
___
|
19773753-DS-15
| 19,773,753 | 20,798,280 |
DS
| 15 |
2179-02-20 00:00:00
|
2179-02-28 10:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Ultram / Penicillins / Clindamycin / Cipro / Haldol / lithium /
Tegretol / Trilafon / Depakote
Attending: ___.
Chief Complaint:
Fever, dysuria
Major Surgical or Invasive Procedure:
___ s/p outpatient endometrial biopsy
History of Present Illness:
___ yo with hx bipolar, HTN, morbid obesity who underwent an
endometrial biopsy ___ for thickened endometrium. This was done
in the OR setting due to her habitus and difficulty with exams.
She presents with
fever, dysuria, malaise. She reports h/o UTIs.
She reports baseline feeling of inability to void completely
which worsened the past 2 days and now also has frequency and
dysuria.
Denies headache, cough, sore throat.
No vaginal bleeding, abnl vaginal discharge, hematuria,
diarrhea,
F/C, N/V, CP/SOB. no known sick contacts. has constipation. last
BM today.
Past Medical History:
Allergies:
Last Verified ___ by ___..
Cipro
Clindamycin
Depakote
Haldol
lithium
Penicillins
Tegretol
Trilafon
Ultram
PMH:
obstructive sleep apnea -on CPAP
hypertension
morbid obesity
arthritis
h/o diabetes insipidus secondary to chronic lithium
impaired glucose tolerance.
PSYCHIATRIC HISTORY: Bipolar disorder.
Multiple psych admissions in past for mania and depression, tx
ECT many years ago. Most recently at ___ ___ ___
**see ___ ___ d/c summary ___ copied in our OMR**
No suicide attempts, no violence
prior tx lithium -> diabetes insipidus
___ -> hepatotoxicity
Psychiatrist Dr ___ @___ ___
Therapist ___ ___
case worker, ___ ___.
PSH:
D&C
OB/GYN Hx:
- G0
- PMB with EMBx benign s/p endometrial biopsy ___ for thickened
endometrium
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAM
================
VS:
102.1 88 124/44 19 97% RA
98.9 84 130/52 16 94% RA
Gen: A&Ox3, NAD
CV: RRR
Pulm: decreased breath sounds at bases, otherwise CTAB
Abd: soft, mild b/l lower abd TTP and mod suprapubic TTP.
nondistended, no rebound/guarding. no peritoneal signs
Back: no costovertebral angle TTP
Ext: no TTP, no edema
Pelvic:
SVE: no CMT or adnexal tenderness, no abnl discharge
______________________________________________________
DISCHARGE EXAM
==============
VS:
T 98.3, BP 137/81, HR 89, RR 20, SpO2 95% on RA
GEN: sleeping with CPAP on
PULM: lungs clear to auscultation (though difficult to clearly
hear), no crackles or wheezes. using CPAP
CV: RRR
Abd: soft, nondistended, nontympanic, nontender to palpation.
Ext: BLE with +2 edema, nontender
Pertinent Results:
___ 09:47PM URINE Color-Straw Appear-Clear Sp ___
___ 09:47PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 09:47PM URINE RBC-7* WBC-107* Bacteri-FEW* Yeast-NONE
Epi-<1
___ 09:14PM BLOOD WBC-11.0* RBC-4.43 Hgb-12.5 Hct-37.3
MCV-84 MCH-28.2 MCHC-33.5 RDW-14.5 RDWSD-43.9 Plt ___
___ 09:14PM BLOOD Neuts-81.3* Lymphs-9.9* Monos-6.3
Eos-0.9* Baso-0.6 NRBC-0.2* Im ___ AbsNeut-8.94*#
AbsLymp-1.09* AbsMono-0.69 AbsEos-0.10 AbsBaso-0.07
___ 09:14PM BLOOD Glucose-118* UreaN-15 Creat-0.9 Na-134*
K-8.5* Cl-96 HCO3-26 AnGap-12
___ 09:26PM BLOOD Lactate-1.9 K-4.6
___ 03:05PM BLOOD WBC-9.0 RBC-4.20 Hgb-11.8 Hct-35.6 MCV-85
MCH-28.1 MCHC-33.1 RDW-14.7 RDWSD-45.1 Plt ___
___ 03:05PM BLOOD Neuts-80.4* Lymphs-9.8* Monos-8.7
Eos-0.1* Baso-0.3 Im ___ AbsNeut-7.19* AbsLymp-0.88*
AbsMono-0.78 AbsEos-0.01* AbsBaso-0.03
___ 06:22AM BLOOD WBC-6.5 RBC-4.30 Hgb-11.9 Hct-36.3 MCV-84
MCH-27.7 MCHC-32.8 RDW-14.6 RDWSD-44.8 Plt ___
___ 06:22AM BLOOD Neuts-77.8* Lymphs-12.8* Monos-7.4
Eos-0.3* Baso-0.8 Im ___ AbsNeut-5.05 AbsLymp-0.83*
AbsMono-0.48 AbsEos-0.02* AbsBaso-0.05
___ 06:22AM BLOOD Glucose-122* UreaN-12 Creat-0.9 Na-139
K-4.0 Cl-99 HCO3-26 AnGap-14
____________________________
MICRO
UCx (___)
CITROBACTER KOSERI. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER ___
|
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
======================
BCx (___) NGTD
____________________________
IMAGING
CT Abdomen/Pelvis w/contrast ___
FINDINGS:
Limited evaluation due to body habitus.
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of hydronephrosis. A 1.7 cm right upper
pole
hypoenhancing lesion corresponds to a hyperdense cyst on the
prior CT.
Heterogeneity throughout the left kidney may likely be secondary
to motion
artifact and body habitus. Several hypodensities within the
left upper pole
are also noted. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Few
diverticula
of the sigmoid colon are noted, without evidence of wall
thickening and fat
stranding. Colon and rectum are otherwise unremarkable. The
appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Uterus is anteflexed and unremarkable. No
large adnexal
mass. No collection.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. No CT evidence to explain patient's symptoms. Specifically,
no abscess or overt signs of pyelonephritis.
2. Hypodensities within the left kidney can be further
evaluated with
ultrasound or MRI.
======================
CXR ___
FINDINGS:
Lung volumes are low. Mild atelectasis in lung bases. No focal
consolidation. Cardiomediastinal contour is stable. No pleural
effusion or
pneumothorax.
IMPRESSION:
No focal consolidation to suggest pneumonia.
====================================
Transvaginal Pelvic US ___
FINDINGS:
Limited exam due to overlying soft tissue. The uterus is
anteverted and
measures 8.8 x 4.2 x 6.4 cm. The endometrium is homogenous and
measures 1.0
cm, previously 1.1 cm in ___. There is no free fluid or
drainable fluid
collection is seen. The ovaries are not visualized.
IMPRESSION:
1. No drainable fluid collection or free fluid.
2. Limited exam due to overlying soft tissue. Ovaries not
visualized.
3. Thickened endometrium measuring up to 1 cm, similar to prior.
The patient
has already undergone endometrial biopsy which was benign
confirmed in OMR
from pathology report from ___.
==================
Brief Hospital Course:
On ___, Ms. ___ presented to the ED with Tmax 102.1F
associated with dysuria and suprapubic tenderness. Nine days
earlier she had an EMB done in the OR for thickened endometrium.
Her pathology was negative for abnormality. She was admitted to
the Gyn service on ___ for presumed post-operative
endometritis versus cystitis.
==============
ACTIVE ISSUES
===============
*) Dysuria, fever- Urinalysis and urine culture and blood
culture were collected in the ED with UA suggestive of UTI; no
evidence of pyelonephritis on exam. Though patient's fever was
determined to be likely due to UTI, empiric treatment for
presumed post-operative endometritis after her endometrial
biopsy was done. Given patient's multiple antibiotic allergies,
she was initiated on PO Bactrim for UTI + IV gent/flagyl
(clindamycin allergy) x24h. She had recieved vancomycin x1 dose
in ED(PCN allergy). She defervesced shortly after administration
of Tylenol but again spiked a fever to 101.2F at 0330 on HD2.
Due to concern for pyelonephritis or abscess as the source of
her recurrent fevers, a CT abdomen/pelvis with contrast was
performed on HD2, which was unremarkable. She remained afebrile
for the remainder of her admission and was transitioned to PO
doxycycline/flagyl (___). Her final BCx were negative, and
her UCx grew 10,000-100,000 CFUs pansensitive Citrobacter. By
HD3, her condition was markedly improved and she was discharged
on PO Bactrim to complete 10 day course (___).
==================
CHRONIC ISSUES
==================
*) OSA- CPAP
*) Bipolar- cont home meds
*) cHTN cont home meds
*) VTE ppx: ___ TID
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
aerosol inhaler. 2 puffs inhaled every ___ hours Please dispense
with spacer
ATENOLOL - atenolol 100 mg tablet. 1 tablet(s) by mouth daily
CYCLOBENZAPRINE - cyclobenzaprine 10 mg tablet. ___ tablet(s) by
mouth at bedtime as needed for back spasm
DIAZEPAM - diazepam 5 mg tablet. 1 tablet(s) by mouth twice a
day
- (Prescribed by Other Provider)
DISPOSABLE UNDERPADS - disposable underpads . as directed 2 per
day Dx: Diabetes, Osteoarthritis, incontinence
FUROSEMIDE - furosemide 80 mg tablet. 1 tablet(s) by mouth once
a
day
IBUPROFEN - ibuprofen 400 mg tablet. 1 tablet(s) by mouth qid
with food as needed for severe joint pain
IBUPROFEN - ibuprofen 800 mg tablet. 1 tablet(s) by mouth three
times a day with food; prn back pain
LEVOTHYROXINE - levothyroxine 75 mcg tablet. 0.5 (One half)
tablet(s) by mouth once a day
LINERS - Liners . as directed 4 per day Dx: Diabetes,
osteoarthritis, incontinence
LISINOPRIL - lisinopril 30 mg tablet. 1 tablet(s) by mouth once
a
day
MEDROXYPROGESTERONE - medroxyprogesterone 10 mg tablet. 1
tablet(s) by mouth daily
POTASSIUM CHLORIDE [KLOR-CON 10] - Klor-Con 10 mEq
tablet,extended release. 2 (Two) tablet(s) by mouth once a day
ZIPRASIDONE HCL [GEODON] - Geodon 60 mg capsule. 1 capsule(s) by
mouth qday - (Prescribed by Other Provider)
Medications - OTC
ACETAMINOPHEN - acetaminophen 325 mg tablet. 3 tablet(s) by
mouth
as needed for pain - (Prescribed by Other Provider; ___)
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 Tablet(s) by
mouth daily
DIPHENHYDRAMINE HCL [BENADRYL] - Benadryl 25 mg capsule. 1
capsule(s) by mouth at bedtime
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO TID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth three times a day Disp #*16 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
3. Atenolol 100 mg PO DAILY
4. Cyclobenzaprine 10 mg PO HS:PRN back spasm
5. Diazepam 5 mg PO BID PRN anxiety
6. Furosemide 80 mg PO DAILY
7. Levothyroxine Sodium 37.5 mcg PO DAILY
8. Lisinopril 30 mg PO DAILY
9. MedroxyPROGESTERone Acetate 10 mg PO DAILY
10. Potassium Chloride 20 mEq PO DAILY
Hold for K >
11. ZIPRASidone Hydrochloride 60 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Post-operative endometritis
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear 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.
* Abstain from alcohol while taking your prescribed antibiotics.
* You may eat a regular diet.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19773753-DS-16
| 19,773,753 | 28,837,478 |
DS
| 16 |
2180-07-26 00:00:00
|
2180-07-28 06:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ultram / Penicillins / Clindamycin / Cipro / Haldol / lithium /
Tegretol / Trilafon / Depakote
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
As per HPI by admitting MD:
___ yo F with hx of HFpEF, HTN, depression, mania (followed by
Mass Mental), sleep apnea and obesity recently d/c from ___
___ (___) now presenting for an episode of chest pressure
(like "elephant sitting" on her chest) lasting ~30min at 1:30 am
while sitting in her wheelchair and cleaning with no radiation
to jaw, back, but does endorse left arm pain (present at
baseline
due to bursitis) and ___ weakness. She called her PCP with these
complaints who called EMS on the pt's behalf. The chest pressure
resolved during the ambulance ride. She denies chest pain,
HA/D/N/V/D/C, and SOB, but does endorse discomfort with
urination and not being able to sleep well due to her C-pap
machine being
lost while in rehab. Pt endorses feeling "relaxed" now that she
is in ED.
Recently hospitalized at ___ for sepsis which was
complicated by ___, tachycardia. Discharged to rehab, and
recently was discharged from rehab on ___. After discharge from
rehab, she went to an urgent care on ___ with UTI symptoms and
was started on Macrobid for this on ___, currently on day ___
of Macrobid. She states she has recently been out of rehab and
is unclear why she was there, but that her medications were
changed and she has been confused about her medications and has
not taken them since she ran out.
In the ED initial vitals were: T 97.4 BP 142/102 HR 113 RR 18
O2
96% on RA
Labs/studies notable for:
- Trop negative x1
- Cr 1.2 (baseline 0.7-1.0)
- Hgb 10.9 (baseline ___
- Alk phos 154
- UA: protein 30, few bacteria, 20 epithelial cells, 5 WBC,
negative nitrite, negative leuk esterase
EKG: Afib, old anterior infarct and Nonspecific
intraventricular
conduction delay
CXR: no PNA, edema, or acute cardiopulmonary process
CTA Chest: No evidence of pulmonary embolism or aortic
abnormality. Within limitations of the respiratory motion no
large pulmonary parenchymal abnormalities. Stable moderate
cardiomegaly.
Patient was given:
- Aspirin 324 mg x 1
- Diltiazem 60 mg x 1
- Metoprolol tartrate 50 mg x 1
- Furosemide 80 mg x 1
- Levothyroxine 37.5 mcg x 1
- Diazepam 2 mg x 1
- Heparin gtt
- IVF
Vitals on transfer: T 98.0 HR 80 BP 124/84 RR 18 98% RA
Upon transfer to cardiology service, patient states that she is
hypomanic and very tangential at baseline. It was difficult to
obtain a history from her, but from what I could gather, her
chest pain episode occurred sometime very early this morning. It
was a squeezing, pressure-like pain that was located beneath her
left breast and moved down her left arm. It occurred while she
was sitting in her wheelchair with no exertion. She called her
PCP who called an ambulance for her. She says she had associated
dyspnea with the chest pressure. The pressure lasted until the
ambulance arrived, which was about 15 minutes. She currently
does
not have any chest pain or SOB. She denies nausea, vomiting,
abdominal pain. She endorses leg swelling, but it's not any
worse
than her usual.
___ called for collateral. The ___ was not present during
this episode of chest pain, but she says it occurred suddenly
early this morning, around 5 or 6 am. The ___ believes that the
patient's chest pain may be related to anxiety. She also states
that the patient has a tendency for manic episodes, and this
could also be contributing to her chest pain.
REVIEW OF SYSTEMS: 10 point ROS obtained and is otherwise
negative except as mentioned in HPI.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
2. CARDIAC HISTORY
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
HFpEF
Depression
Mania
Asthma
Social History:
___
Family History:
Father - CAD, deceased at ___
Mother - COPD, deceased
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: ___ 1802 Temp: 97.5 Axillary BP: 141/85 L Lying HR: 90
RR: 18 O2 sat: 97% O2 delivery: RA
GENERAL: Obese female, lying in bed. NAD. Speaks rapidly with
tangential thoughts.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Unable to assess JVP due to body habitus.
CHEST: Soreness upon palpation of sternum and left anterior
chest, but the pain feels different than her chest pressure.
CARDIAC: Irregularly irregular rhythm, regular rate, normal S1,
S2. No murmurs/rubs/gallops.
LUNGS: Resp were unlabored, no accessory muscle use. No
crackles,
wheezes or rhonchi anteriorly.
ABDOMEN: +BS. Distended but soft with no tenderness to
palpation.
DISCHARGE PHYSICAL EXAM:
========================
VS:
24 HR Data (last updated ___ @ 555)
Temp: 97.4 (Tm 97.8), BP: 144/93 (105-144/64-93), HR: 73
(58-81), RR: 18 (___), O2 sat: 96% (95-98), O2 delivery: Ra
GENERAL: Obese female, sitting in bed. Speaks tangentially, but
initially answers questions appropriately.
HEENT: moist oral mucosa, PERRL
CARDIAC: RRR, normal S1, S2. No m/g/r.
LUNGS: Unlabored respirations, no accessory muscle use.
GI: obese, soft, non tender, non distended
EXTREMITIES: Warm. +2 non-pitting edema b/l.
MSK: Pain to palpation of L shoulder; +ve painful arc test
Skin: warm, dry, no rashes
Pertinent Results:
ADMISSION LABS:
___ 02:35PM BLOOD WBC-9.6 RBC-4.40 Hgb-10.9* Hct-35.1
MCV-80* MCH-24.8* MCHC-31.1* RDW-15.2 RDWSD-43.6 Plt ___
___ 02:35PM BLOOD Neuts-66.8 ___ Monos-8.5 Eos-2.3
Baso-0.3 Im ___ AbsNeut-6.44* AbsLymp-2.07 AbsMono-0.82*
AbsEos-0.22 AbsBaso-0.03
___ 02:35PM BLOOD Plt ___
___ 08:35AM BLOOD ___ PTT-29.2 ___
___ 02:35PM BLOOD UreaN-21* Creat-1.2* Na-141 K-4.0 Cl-100
HCO3-26 AnGap-15
___ 02:35PM BLOOD ALT-22 AST-21 AlkPhos-158* TotBili-0.3
___ 02:35PM BLOOD Calcium-10.1 Phos-4.5 Mg-1.9
DISCHARGE LABS:
___ 12:45PM BLOOD WBC-9.3 RBC-4.22 Hgb-10.4* Hct-34.7
MCV-82 MCH-24.6* MCHC-30.0* RDW-16.0* RDWSD-47.3* Plt ___
___ 12:45PM BLOOD Neuts-65.7 ___ Monos-7.7 Eos-3.7
Baso-0.4 Im ___ AbsNeut-6.12* AbsLymp-2.04 AbsMono-0.72
AbsEos-0.35 AbsBaso-0.04
___ 12:45PM BLOOD Glucose-121* UreaN-29* Creat-1.2* Na-142
K-4.0 Cl-101 HCO3-29 AnGap-12
___ 12:45PM BLOOD Calcium-9.5 Phos-4.6* Mg-1.8
IMAGING:
CTA ___:
No evidence of pulmonary embolism or acute aortic abnormality.
Areas of
relative ground glass most likely relate to expiratory phase of
scan versus air trapping.
EKG ___:
Atrial fibrillation
Nonspecific intraventricular conduction delay
Anterior infarct, old
Compared with the previous tracing of ___, atrial
fibrillation has replaced sinus rhythm
TTE ___:
Poor image quality. Very limited views of biventricular systolic
function suggested mildly reduced ejection fraction. Diastolic
function unable to be asessed.
Stress ___:
Non-anginal symptoms with no ischemic ST segment changes.
Nuclear report sent separately.
Nuclear stress ___:
1. Study limited due to body habitus and arm mobility 2.
Moderately
sized fixed inferior wall defect. 3. Likely normal left
ventricular size and ejection fraction based on visual
observation.
PERTINENT MICROBIOLOGY:
UCx (___): Final, no growth
UCx (___):
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
This is a ___ with PMHx HFpEF, HTN, depression and mania
(followed by Mass Mental) who presented with an episode of chest
pressure, thought to be in the setting of atrial fibrillation
with RVR.
#CORONARIES: stress test with signs of CAD
#PUMP: Poor imaging, but perhaps less than 55%
#RHYTHM: Atrial fibrillation
ACTIVE ISSUES:
===============
#Coronary artery disease
Stress test during this admission with moderately sized fixed
inferior wall defect demonstrating evidence of CAD. She had
atypical chest pain with negative troponins and non-ischemic EKG
during this admission, so it was thought that she did not have
acute coronary syndrome during this admission. She was continued
on aspirin and atorvastatin and discharged on those medications.
#Atrial fibrillation
She has a history of atrial fibrillation and was previously
treated with metoprolol and diltiazem for rate control, as well
as apixaban for anticoagulation. She had not been taking these
medications in the outpatient setting due to insurance issues.
She was re-started on metoprolol and diltiazem during this
admission, and transitioned to long-acting doses on ___. She
was re-started on apixaban, with confirmed insurance coverage.
#HFpEF
Last echocardiogram in ___ with EF of >55%. Her heart failure
regimen on discharge:
DIURESIS: Furosemide PO 80mg daily
AFTERLOAD: Diltiazem ER 120mg
NHBK: Metoprolol XL 150mg
-Discharge weight 155.8 kg 343.47lb
-Discharge creatinine 1.2
___
Cr on presentation 1.2, 1.2 on discharge. Last baseline 1.0 in
___.
#Normocytic Hypochromic Anemia
Hgb on presentation 10.9, last baseline 14.6 in ___. Patient
recently in prolonged hospital stay at ___ and
recently discharged from rehab. Anemia of inflammation seems
most likely. This was stable during this admission.
# URINARY TRACT INFECTION S/P TREATMENT:
UCx from ___ Urgent Care collected ___ was
positive for E. coli, susceptible to nitrofurantoin. Pt had
completed a 5d course of nitrofurantoin prior to her arrival to
our service. She had no further urinary symptoms.
#Psychosis
#Depression
#Mania
Followed at ___ by Dr. ___ (___). Most
recently on Depakote 1000 mg bid; lithium 450 mg bid; olanzapine
7.5 mg qd. Pt has lithium induced DI. ___ admitted to ___
___ for increasing mania. ___ increasing akasthesia
secondary to initiation of neuroleptic -- rx with indera and
benadryl. ___ admitted to ___ inpatient
psych unit secondary to increasing mania, medication
non-compliance. D/c'd to ___ (___,
___. ___ (CNS social worker) ___.
- Changed benztropine 0.5 mg BID to Benadryl 25mg TID per
patient request
- Continued diazepam 5 mg BID
- Continued risperidone 8 mg QPM at 10 ___
- Continued ziprasidone 60 mg QPM and 40qAM
- ___ guardianship pursued during this hospitalization prior
to discharge
#Hypothyroidism
- Continued levothyroxine 37.5 mcg QD
#Sleep apnea
- Diagnosed while on inpatient psych unit with sleep study
- Uses CPAP at night
- Continued CPAP
#Asthma
- Treated with albuterol neb q4-6h
#GERD
- Continued pantoprazole 20 mg QD
#Insomnia
- Continued ramelteon QHS PRN
- Held home Benadryl 25 mg QHS
#Back pain
#L Shoulder Pain
- Continued APAP 650 mg q6h prn pain
- Gave patient lidocaine gel, per request
- follow up with outpatient Ortho follow-up for steroid
injection
TRANSITIONAL ISSUES:
====================
[ ] ___ was complaining of L shoulder/joint pain. Will need ortho
follow-up as outpatient for steroid injection as clinically
indicated.
[ ] REHABILITATION STAY: Patient's anticipated length of stay in
rehabilitation will be less than 60 days.
[ ] ___ guardianship obtained prior to discharge
#CODE STATUS: Full (confirmed)
#CONTACT:
Name of health care proxy: ___
Phone number: ___
Cell phone: ___
Proxy form in chart: Other
Other location: filed at Mass Mental
Time spent: 50 minutes
PCP notified of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benztropine Mesylate 0.5 mg PO BID
2. Diazepam 2 mg PO BID
3. Diltiazem 60 mg PO QID
4. Furosemide 80 mg PO DAILY
5. Levothyroxine Sodium 37.5 mcg PO DAILY
6. Metoprolol Tartrate 50 mg PO BID
7. Pantoprazole 40 mg PO Q24H
8. Ramelteon 8 mg PO QHS:PRN insomnia
9. RisperiDONE Oral Solution 8 mg PO QHS
10. ZIPRASidone Hydrochloride 60 mg PO QPM
11. Aspirin 81 mg PO DAILY
12. lidocaine 4 % topical DAILY
13. Bisacodyl 10 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
16. ZIPRASidone Hydrochloride 40 mg PO DAILY
17. Apixaban 5 mg PO BID
18. Docusate Sodium 100 mg PO BID
19. Lidocaine 5% Patch 1 PTCH TD QAM
20. Sodium Chloride Nasal ___ SPRY NU BID
21. Lactulose 30 mL PO DAILY:PRN constipation
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Diltiazem Extended-Release 120 mg PO DAILY
3. DiphenhydrAMINE 25 mg PO TID
4. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN Shoulder pain
5. Metoprolol Succinate XL 150 mg PO DAILY
6. Nystatin Ointment 1 Appl TP QID:PRN pannus
7. Apixaban 5 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Bisacodyl 10 mg PO DAILY
10. Diazepam 2 mg PO BID
11. Docusate Sodium 100 mg PO BID
12. Furosemide 80 mg PO DAILY
13. Lactulose 30 mL PO DAILY:PRN constipation
14. Levothyroxine Sodium 37.5 mcg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Pantoprazole 40 mg PO Q24H
17. Polyethylene Glycol 17 g PO DAILY
18. Ramelteon 8 mg PO QHS:PRN insomnia
19. RisperiDONE Oral Solution 8 mg PO QHS
20. Sodium Chloride Nasal ___ SPRY NU BID
21. ZIPRASidone Hydrochloride 60 mg PO QPM
22. ZIPRASidone Hydrochloride 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
========
Atrial fibrillation
Coronary artery disease
SECONDARY:
==========
Heart failure with preserved ejection fraction
Psychiatric comorbidities: psychosis, mania, depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___!
WHY DID YOU COME TO THE HOSPTIAL?
- You had chest pain that worried you.
WHAT HAPPENED WHILE YOU WERE HERE?
- We saw that you had atrial fibrillation, which is something
you have been diagnosed with in the past.
- We gave you medicines to make your heart rate slower, called
metoprolol and diltiazem.
- You had a stress test, that showed us an abnormality in your
heart that is probably what was causing some of your symptoms.
WHAT TO DO WHEN YOU LEAVE?
- Take all your medicines as they are prescribed to you.
- Go to all your follow-up appointments.
Best wishes,
Your ___ Team
Followup Instructions:
___
|
19773768-DS-21
| 19,773,768 | 24,282,385 |
DS
| 21 |
2150-12-10 00:00:00
|
2150-12-10 15:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
facial swelling
Major Surgical or Invasive Procedure:
-Incision and Drainage of Right Pterygomandibular space via
transcervical and transoral approaches,
-Debridement of right mandibular bone and sequestrectomy,
-Removal of facial foreign Body ( piercing )
-Removal of chronic decayed teeth #27, 28, 29, 32
History of Present Illness:
Ms. ___ is a ___ yo F with HCV and IVDU, last use 1.5
weeks ago, presenting with R sided facial swelling and pain x 2
weeks.
She reports having recently been on antibiotics (possibly
Bactrim, though she is not entirely certain of medication).
Denies fevers. Denies discharge from her mouth. Reports pain
with
movement of her neck but can move neck throughout. Seen at an
outside facility earlier today where she had a CT done showing
odontogenic R mandibular abscess (3.8x3.5x4.1 cm) with cortical
destruction of adjacent ramus of the mandible with 5 mm medial
extension.
**Of note, patient has h/o of hepatitis C and IV drug abuse,
which patient claimed that she is free of disease and sober
since
___. However, she recently restarted heroin due to severe
pain
and her last use was yesterday (___).
In the ED:
Initial vital signs were notable for: T 98.0, HR 73, BP 106/60,
RR 16, 98% RA
Exam notable for: R-sided facial swelling, no overlying
erythema, limited opening of mouth, tender and induration to R
side of face, limited extension and lateral movement of neck
Labs were notable for:
- CBC: WBC 8.5, hgb 10.4, plt 294
- Lytes:
135 / 103 / 9 AGap=10
------------- 73
4.4 \ 22 \ 0.7
- lactate 0.6
- Coags: ___: 12.0 PTT: 29.3 INR: 1.1
- UCG negative
Patient was given:
___ 03:35 IV Morphine Sulfate 2 mg
___ 03:38 IVF NS 1000 mL
___ 04:00 IV Ampicillin-Sulbactam 3 g
Consults: ___ was consulted, recommending:
- Consult medicine for admission
- Dental panoramic radiograph
- IV Unasyn while in-house
- Remain NPO
- Maintain good oral hygiene with Peridex ___ BID
- Patient will be added to OR today (___)
- Patient should be on full liquid diet if she is NOT NPO but
please keep her NPO for now.
Vitals on transfer: T 98.2, HR 81, BP 110/73, RR 14, 95% RA
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- hep C
- history of opioid use disorder with IVDU
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
Admission exam
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Discharge exam
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GEN: disheveled woman in mild discomfort
HEENT/Neck: R facial swelling diffusely TTP. Pain with jaw
movement. Bandage in place over chin/neck where prior drain was
in place. Poor dentition overall, anicteric sclera
CV: RRR no m/r/g, no carotid bruits appreciated
PULM: CTAB no wheezes, rales, or crackles. Symmetric expansion
GI: soft NT/ND +BS no rebound or guarding
SKIN: no rashes or lesions noted, no ecchymoses or petechiae
PSYCH: tearful, depressed affect
Pertinent Results:
Admission labs
___ 01:19AM BLOOD WBC-8.5 RBC-4.07 Hgb-10.4* Hct-33.6*
MCV-83 MCH-25.6* MCHC-31.0* RDW-18.9* RDWSD-55.8* Plt ___
___ 04:03AM BLOOD ___ PTT-29.3 ___
___ 01:19AM BLOOD Glucose-73 UreaN-9 Creat-0.7 Na-135 K-4.4
Cl-103 HCO3-22 AnGap-10
___ 08:00AM BLOOD ALT-15 AST-14 AlkPhos-185* TotBili-0.7
___ 07:30AM BLOOD CRP-113.1*
___ 1:26 am BLOOD CULTURE Site: ARM
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPHYLOCOCCUS HOMINIS
| STAPHYLOCOCCUS
EPIDERMIDIS
| |
STAPHYLOCOCCUS EPIDERMIDIS
| | |
CLINDAMYCIN----------- =>8 R =>8 R =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S <=0.5 S
LEVOFLOXACIN----------<=0.12 S <=0.12 S <=0.12 S
OXACILLIN-------------<=0.25 S =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
VANCOMYCIN------------ 1 S 1 S 1 S
___ 10:52 am SWAB RIGHT SUBMASSETERIC SPACE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
STREPTOCOCCUS ANGINOSUS (___) GROUP. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- 4 R
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ 0.25 S
HIV negative
MRI ___
1. Limited exam due to incomplete study and severe motion
artifact.
2. Edema secondary to the patient's known right mandibular
abscess involves the subcutaneous tissues, right buccal space
and right parotid space with obliteration of the right
parapharyngeal fat space. Question infiltration of the right
sublingual space.
3. Question right mandibular cortical breaks involving the body
and ramus.
4. Bilateral mastoid effusions.
5. Paranasal sinus disease and nonspecific mastoid fluid, as
described.
Discharge labs
___ 07:45AM BLOOD WBC-6.9 RBC-3.71* Hgb-9.5* Hct-31.3*
MCV-84 MCH-25.6* MCHC-30.4* RDW-18.9* RDWSD-57.6* Plt ___
___ 07:45AM BLOOD Glucose-73 UreaN-7 Creat-0.7 Na-146 K-4.3
Cl-108 HCO3-25 AnGap-13
___ 07:45AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7
Brief Hospital Course:
Ms. ___ is a ___ yo woman with opioid use disorder,
injection drug use, who presented with R facial pain and
swelling, found to have mandibular/dental abscess and deep space
infection of the neck.
# R mandibular/dental abscess:
# Presumed Mandibular osteomyelitis:
# Associated GPC BSI:
Patient presented with acute infection as noted above, source
likely her poor dentition. She was s/p Incision and Drainage of
Right Pterygomandibular space via transcervical and transoral
approaches, Debridement of right mandibular bone and
sequestrectomy, Removal of facial foreign Body ( piercing )
Removal of chronic decayed teeth #27, 28, 29, 32 with drain
placement by OMFS on ___. BCx from ___ also with GPCs which
ultimately speciated to staph epi and staph hominis, subsequent
cultures NGTD. ID service was consulted and patient maintained
on vanc and unasyn. Due to chronic bone changes on CT in
mandible and depth of infection per operative report, ID was
concerned for osteomyelitis. MRI was attempted on ___ however
limited due to patient's pain and inability to stay still. ID
recommended extended course of IV abx however patient left AMA.
She was discharged with prescription for augmentin and levaquin
in hopes she would have some coverage of her infection while out
of the hospital. Please refer to event note from ___ for details
on discussion with patient.
# Opioid use disorder with IVDU
# History of HCV
Had been sober since ___ and per report, free of HCV, but
began to use again in setting of pain from mandibular abscess,
with last use ___. HIV was negative. Consideration was made
for Methadone maintenance but patient declined starting
medication.
CHRONIC/STABLE PROBLEMS:
# Hep C - LFTs overall stable over admission
Transitional issues
[ ] patient to return to the hospital for IV abx treatment for
suspected osteo
[ ] f/u pathology from OR from bone fragments
[ ] patient needs to establish care with a PCP
___ than 30 minutes were spent providing and coordinating
care for this patient on day of discharge.
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
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth every 12 hours Disp #*20 Tablet Refills:*0
3. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL TID
RX *chlorhexidine gluconate 0.12 % use capful of solution to
rinse mouth three times a day Refills:*0
4. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
5. Levofloxacin 750 mg PO Q24H Duration: 10 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
R submandibular abscess
dental abscess
opioid use disorder
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 a severe infection in your right jaw with
tooth abscess. You underwent surgical washout and were placed
on IV antibiotics for soft tissue and bone infection. Your
medical teams recommended several weeks of IV antibiotics to
treat the bone infection however you did not opt to stay for
treatment. While you are being discharged against medical advice
on antibiotics by mouth, this may not adequately treat the
infection and you are at risk for worsening infection and death.
Please return to the hospital for treatment as soon as you are
able.
Please continue a soft diet and advance to regular food as you
area able. Please follow up with the oral surgeons in clinic.
Keep incisions clean and dry, change dressing once a day, do not
let incisions soak in water for extended period of time.
Thank you for allowing us to participate in your care,
Your ___ team
Followup Instructions:
___
|
19773902-DS-21
| 19,773,902 | 28,753,227 |
DS
| 21 |
2135-02-17 00:00:00
|
2135-02-18 07:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Prochlorperazine / Lidocaine / Toradol / Lipitor / Iodinated
Contrast Media - IV Dye
Attending: ___
Chief Complaint:
Left hand and leg numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ year old woman with history of
cervical spondylosis, HTN, prior MI on aspirin, prior right
carotid disease (she reports known 60% R ICA stenosis s/p CEA),
who presents following an episode of acute onset left hand and
leg weakness.
Patient reports she was in her usual state of health until
approximately 7 ___ on the day of admission, ___. She was
walking to the kitchen holding 2 plates of food. As she was
walking, she felt acute onset of left leg weakness and numbness.
The numbness is present throughout the entire left leg,
circumferentially. She also had left hand "strange" sensation
at
the same time, which she describes as both a weakness and
numbness. She was unable to continue walking and sat down. She
notes the left leg felt too weak to stand up. The numbness in
both the left hand and left leg lasted for approximately 40
minutes before resolving. She then presented to our emergency
department, as her left leg and left hand was gradually
improving. By 9 ___, 2 hours after the initial onset of
symptoms,
her weakness fully resolved and she returned back to her
baseline. She has since felt back at her baseline. throughout
this time, she denies any difficulties understanding or
expressing speech, denies slurred speech, denies visual changes
or loss of vision.
Of note, patient recently presented to urgent care on ___
after developing a thunderclap headache. Three days prior to
that
presentation, she had a holocephalic thunderclap headache
associated with neck pain while shopping. At the time she felt
that this neck pain was different from her usual pain. The
symptoms lasted ___ days and gradually went away. No double
vision. No vomiting. In addition she has had some bilateral
shoulder pain and some jaw pain which reminded her of symptoms
she had around the time that she had her heart attack. By the
time of presentation, symptoms had largely resolved. She was
recommended for lumbar puncture but declined and left AMA. She
reports that since then the headache has been gradually getting
better and now is resolved.
Otherwise patient reports more severe right neck pain than
baseline for last 3 days. Finally she does report she had upper
respiratory symptoms for the last 10 days which is also
improving. She has ongoing neck pain at her baseline.
Past Medical History:
cervical spondylosis, f/b Dr. ___
HTN
prior MI on aspirin
prior right carotid disease (she reports known 60% R ICA
stenosis)
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION EXAMINATION
=====================
Vitals: T 98.4F, HR 84, BP 137/76, RR 20, O2 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Somewhat tangential. Able
to
relate history without difficulty. Attentive, able to name ___
backward without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 5 to 4mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, 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
R 5* ___ ___ 5 5 5 ___ bilateral infraspinatus weakness
*give way component
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS. Romberg absent.
-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. Mild difficulty walking in tandem.
DISCHARGE EXAMINATION
=====================
Vitals: Temp: 97.6 (Tm 97.8), BP: 151/75 (151-160/75-85), HR: 63
(63-69), RR: 24 (___), O2 sat: 99%, O2 delivery: Ra
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Somewhat tangential.
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 5 to 4mm and brisk. EOMI without
nystagmus.
V: Facial sensation intact to light touch.
VII: L NLFF with symmetric activation.
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 4+ ___ ___ 5 5
R 5* ___ ___ 5 5
*With give-way.
-Sensory: No deficits to light touch.
-DTRs: ___.
-Coordination: No dysmetria on FNF bilaterally.
Pertinent Results:
HEMATOLOGY AND CHEMISTRIES
==========================
___ 10:12PM BLOOD WBC-5.6 RBC-3.03* Hgb-10.2* Hct-30.6*
MCV-101* MCH-33.7* MCHC-33.3 RDW-12.9 RDWSD-47.0* Plt ___
___ 10:12PM BLOOD ___ PTT-25.6 ___
___ 10:12PM BLOOD Glucose-100 UreaN-17 Creat-1.2* Na-144
K-4.1 Cl-107 HCO3-25 AnGap-12
___ 10:12PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 06:20PM BLOOD %HbA1c-PND
___ 03:44AM BLOOD cTropnT-<0.01
___ 12:00AM URINE Color-Straw Appear-Clear Sp ___
___ 12:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
MICROBIOLOGY
============
___ 12:00 am URINE Site: CLEAN CATCH
URINE CULTURE (Pending)
IMAGING
=======
___ 12:02 AM CHEST (PA & LAT)
No acute cardiopulmonary process.
___ 12:43 AM CT HEAD W/O CONTRAST
There is no evidence of acute intracranial process or
hemorrhage.
___ 12:___-SPINE W/O CONTRAST
1. No acute fracture or traumatic malalignment.
2. Multilevel degenerative changes of the cervical spine, most
severe at C5-6 and C6-7 levels.
___ 2:49 ___ MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST;
MRA NECK W&W/O CONTRAST
1. There is no evidence of acute or subacute intracranial
process, no
diffusion abnormalities are detected to indicate acute or
subacute ischemic changes.
2. Few scattered foci of high signal intensity detected on FLAIR
and T2
weighted images, which are nonspecific and may reflect changes
due to small vessel disease.
3. Normal MRA of the head with no evidence of flow stenotic
lesions or
aneurysms larger than 3 mm size.
4. Axial fat saturation images throughout the neck are normal
with no evidence of dissection.
Brief Hospital Course:
Ms. ___ is a ___ woman with history notable for
cervical spondylosis, HTN, prior MI on aspirin, and prior right
carotid disease (reportedly 59% R ICA stenosis on bedside
ultrasound) presenting following an episode of acute onset left
hand and leg weakness. Symptoms resolved by time of evaluation
in the ED, with CT and MR imaging of the brain revealing no new
ischemia, hemorrhage, or mass, consistent with a transient
ischemic attack; CT imaging of the cervical spine notable for
multilevel degenerative changes of the cervical spine, most
severe at C5-6 and C6-7 levels. Of note, vessel imaging with MR
angiogram of the neck did not reveal significant carotid
stenosis, though follow up of Ms. ___ previously noted
___ carotid stenosis on ultrasound would be reasonable
in light of her left-sided symptoms. Recent LDL (___)
was noted to be 65, with HbA1c pending at time of discharge;
current aspirin and statin regimen was continued at discharge
accordingly. In light of her suspected TIA, premarin was held at
time of discharge. Outpatient cardiac monitoring was recommended
to assess for paroxysmal atrial fibrillation.
TRANSITIONAL ISSUES
1. Follow up hemoglobin A1c and consider treatment of diabetes
for secondary prevention of stroke.
2. ___ of Hearts monitoring as outpatient to assess for
paroxysmal atrial fibrillation.
3. Outpatient echocardiogram.
4. Consider follow up carotid ultrasound to clarify presence of
___ carotid stenosis not noted on current MRA or CTA
from ___.
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 = 65 as above) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
1. Diazepam 2 mg PO Q8H:PRN neck spasm
2. Pantoprazole 40 mg PO Q12H
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Rosuvastatin Calcium 5 mg PO QPM
6. Aspirin EC 81 mg PO DAILY
7. Estrogens Conjugated 0.3 mg PO 2X/WEEK (___)
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Diazepam 2 mg PO Q8H:PRN neck spasm
3. Lisinopril 5 mg PO DAILY
4. Metoprolol Succinate XL 12.5 mg PO DAILY
5. Pantoprazole 40 mg PO Q12H
6. Rosuvastatin Calcium 5 mg PO QPM
7. HELD- Estrogens Conjugated 0.3 mg PO 2X/WEEK (___) This
medication was held. Do not restart Estrogens Conjugated until
advised otherwise by your providers
___:
Home
Discharge Diagnosis:
Transient ischemic attack
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for
evaluation of a brief episode of left hand and leg numbness.
Imaging of your brain with CT and MRI did not show signs of a
new stroke, bleed, or mass. It is likely that your symptoms were
due to a transient ischemic attack (TIA), a condition where
blood flow to a part of your brain is temporarily interrupted.
Although you had previously been noted to have a narrowing of
your neck blood vessels on the right side, this was not noted on
blood vessel imaging with MRA; you should follow up with your
outpatient providers to determine if you will need follow-up
ultrasound studies to look for blood vessel narrowing that would
benefit from surgery.
On recent blood testing, your cholesterol levels appear to be
well-controlled on your rosuvastatin. Your average blood sugar
levels were also checked, and this result was pending at time of
discharge; please have your primary care provider follow up on
this test (hemoglobin A1c). Please also continue to take aspirin
and hold your premarin to prevent future strokes; you should
follow up with your gynecologist to discuss the risks and
benefits of hormonal therapy in light of your suspected TIA.
You will also need to undergo heart rhythm monitoring after
leaving the hospital to look for atrial fibrillation, an
abnormal heart rhythm that can increase your risk of stroke. You
will also need an echocardiogram to assess for blood clots in
your heart. Please also call ___ to schedule an
appointment to receive your heart monitor and perform your
echocardiogram.
Please follow up with your primary care provider and neurologist
at the appointments listed below. Please also follow up with
your cardiologist and gynecologist to discuss the above issues.
It was a pleasure taking care of you at ___.
Sincerely,
Neurology at ___
Followup Instructions:
___
|
19774071-DS-11
| 19,774,071 | 25,564,992 |
DS
| 11 |
2166-04-27 00:00:00
|
2166-04-27 16:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Codeine / omeprazole / Cefadroxil
Attending: ___.
Chief Complaint:
Brain Mass
Major Surgical or Invasive Procedure:
___: Midline suboccipital craniotomy, excision brain
tumor
___: Craniotomy for pfossa decompression and clot
evacuation
___: IVC filter placement
___: Right VP shunt placement (nonprogrammable)
History of Present Illness:
PAtient is a ___ year old female with history of breast and
lung cancer who presents to ___ for evalaution of 2 days of
chills, headache, nasuea, vomiting, and dizziness. She was
imaged
and found to have at least two distinct cerebellar lesions as
well as 1 supratentorial lesion on the left side consistent with
metastatic disease. Neurosurgery was consulted for assistance
with her continued management and care.
Past Medical History:
Grade 3 invasive ductal breast cancer s/p R mastectomy and
chemo, adenocarcinoma Left lung, pancreatic serous cystadenoma,
migraines
radiculopathy
reflux
nephrolithiasis
pyelonephritis
Social History:
___
Family History:
noncontributory
Physical Exam:
On admission:
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
2mm bilaterally. Visual fields are grossly full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Coordination: mild dysmetria bilaterally
On Discharge:
stable
Pertinent Results:
CT Head ___:
IMPRESSION:
1. At least 3 hyperdense neoplastic lesions, one in each
inferior cerebellum and one in the left parietooccipital region
are compatible with metastases.
2. Mass effect from the cerebellar masses results in low lying
cerebellar tonsils with crowding of the foramen magnum as well
as effacement of the ___ ventricle. No hydrocephalus
identified.
___ CT Torso:
CHEST
IMPRESSION:
1. New lower right paratracheal mediastinal lymphadenopathy,
highly
suspicious for metastatic involvement.
2. Stable appearance of prior treated malignancy in the left
lower lobe.
3. No evidence of new pulmonary metastases.
ABD/Pelvis
IMPRESSION:
1. No findings to explain the patient's back pain.
2. No evidence of intra-abdominal metastatic disease.
___ MRI Brain:
IMPRESSION:
1. Multiple intracranial mass lesions, as described above,
consistent with metastatic disease.
2. Mass effect from the bilateral cerebellar mass lesions
results in low
lying cerebellar tonsils, crowding of the foramen magnum,
effacement of the cisterna magna/prepontine cistern, fourth
ventricle, and narrowing of the cerebellar pontine angle. No
evidence of hydrocephalus.
3. A T1, T2, and FLAIR hyperintense lesion in the inner table of
the right parietal bone may represent a focus of fat, however an
osseous metastatic lesion could also be considered, close
attention in the followup examinations in this area is advised.
MRI OF SPINE W CONTRAST: ___
IMPRESSION:
1. Multiple bilateral supratentorial, cerebellar and pontine
enhancing lesions are stable from prior exam.
2. Previously noted left cerebellar hemispheric lesion again
exerts mass
effect on the brainstem and inferior aspect of the fourth
ventricle.
3. New subtle rounded apparent left post central gyral 3 mm
enhancing focus, which may represent artifact, although subtle
new lesion is not entirely excluded. Close attention to this
region on followup examination is recommended.
MRI WAND-HEAD: ___
IMPRESSION:
1. Multiple bilateral supratentorial, cerebellar and pontine
enhancing lesions are stable from prior exam.
2. Previously noted left cerebellar hemispheric lesion again
exerts mass
effect on the brainstem and inferior aspect of the fourth
ventricle.
3. New subtle rounded apparent left post central gyral 3 mm
enhancing focus, which may represent artifact, although subtle
new lesion is not entirely excluded. Close attention to this
region on followup examination is recommended.
___
1. Postsurgical changes related to the patient's interval
posterior craniotomy and multiple cerebellar tumor resection.
2. Stable bilateral cerebellar edema.
___ MRI head with and without contrast
Postoperative changes are identified with resection of
cerebellar metastatic lesions. No definite residual parenchymal
enhancement seen with some mild meningeal enhancement noted.
Persistent mass effect on the fourth ventricle and quadrigeminal
cistern. No hydrocephalus. No change in previously seen
enhancing supratentorial and brainstem lesions.
CT Head without Contrast: ___
Status post interval placement of a right frontal approach
extraventricular
drain, which terminates in the third ventricle, with minimally
decreased size
of the ventricles. The quadrigeminal plate cistern, although
still diminutive,
appears slightly more patent than on prior exam.
LENIs: ___
No evidence of deep venous thrombosis in the bilateral common
femoral veins.
CT Head without Contrast: ___
Expected postoperative changes status post occipital craniectomy
without
evidence of new hemorrhage.
___ CXR
As compared to the previous radiograph, no relevant change is
seen. The right hilar and mediastinal enlargement is consistent
with the known history of lung cancer. An area of retrocardiac
atelectasis is unchanged. Mild cardiomegaly. The monitoring and
support devices are in constant position.
___ ___
1. Status post suboccipital craniectomy. Known intracranial
metastases are not adequately reassessed on this noncontrast CT.
2. No new hemorrhage or mass effect.
3. Stable position of the right frontal approach EVD catheter.
Stable
ventricular size without hydrocephalus.
___ 04:41AM HEAD CT W/O CONTRAST
1. Interval development of focal hyperdensity adjacent catheter
tip, near the interventricular foramen of ___, concerning for
a new focus of hemorrhage.
No interval change in ventricular size since ___.
2. Stable appearance of the suboccipital craniectomy with no new
posterior fossa hemorrhage.
3. Please note that CT is suboptimal for evaluation of
intracranial
metastases.
___ 16:56PM HEAD CT W/O CONTRAST
Focus of extra-axial hemorrhage along the right frontal
convexity and adjacent to the catheter tip are stable from the
prior examination.
6 mm hyperdense focus in the left parietal lobe corresponds with
a focal
metastatic lesion on prior MRI, however is more conspicuous on
the current examination. Given the lesion appears increased in
density from the prior examination, this may represent a small,
focal area of hemorrhage into the metastatic lesion. Attention
on followup exam.
___: Bilateral Lower extremity dopplers: No evidence of deep
venous thrombosis in the bilateral lower extremity veins.
Slow flow is noted in the left popliteal vein.
___: CTA chest:
1. Bilateral segmental and subsegmental pulmonary emboli with
decreased
embolic distribution and burden compared to recent CT chest ___.
2. No acute aortic pathology.
3. Improved bibasilar aeration. Residual bibasilar peripheral
opacities likely secondary to infarct with superimposed
atelectasis.
4. Unchanged right paratracheal lymph node.
Brief Hospital Course:
Patient was admitted to Neurosurgery for further workup of her
brain lesions. She was given Dexamethasone and admitted to the
Step Down Unit. A MRI brain was ordered. A consult for neuro and
rad onc was obtained. She remained stable overnight and on ___
she remained stable. Pt c/o back pain and left hip/pelvic pain.
A CT torso was ordered and showed a new lower right paratracheal
mediastinal lymphadenopathy concerning for metastatic disease.
Dr. ___ hem/onc has been following closely.
On ___, the patient remained neurologically stable. She was
consented for tumor resection and possible VPS placement on
___. Neuro oncology recommended an MRI of the spine with
contrast due to + hyperreflexia on exam. Rad onc recommended
WBRT and resection of tumor vs VPS. The patient stated she has a
daughter that is ___ ___ old and a son that is ___ ___ old and she
feels her son is having a difficult time the mom's condition and
poor prognosis. A social work consult was obtained for family
support. Also, due to her poor prognosis a palliative care
consult was obtained to aid in additional family support in end
of life discussion.
Over the weekend of ___ the patient remained
neurologically and hemodynamically stable waiting for surgery on
___.
On ___, the patient remained stable. The MRI wand of the head
was done this morning. The patient was brought to the OR for
resection of her cerebellar lesions and for placement of a VPS.
Her intraoperative course was uneventful, please refer to the
operative note for further informant ion. She was extubated in
the OR and brought to the ICU for close monitoring. A ___
demonstrated expected post operative changes. ___ showed
expected post operative changes and stable edema.
___, Ms. ___ continued to be neurologically stable. Her
steroids were continued. The post operative MRI was completed
which demonstrated persistent mass effect with no evidence of
hydrocephalus.
___, in the early morning, the patient acutely decompensated
becoming hypoxic and bradycardic. She was re-intubated with
first attempt in the right brainstem and was subsequently
extubated and re-intubated. She was started on pressors and
taken for a stat ___ which showed an acute bleed in resection
bed with increased posterior fossa swelling and enlargement of
temp horns. A 23% bolus of saline was given and her steroids
were increased. Family was contacted to come in and they
consented for an EVD placement as well as a suboccipital
craniotomy for clot evacuation and decompression. A CTA of the
chest was obtained which demonstrated bilateral pulmonary
embolisms. An echocardiogram was performed which was within
___ limits. The patient was taken to the operating room for
her decompressive posterior fossa. Surgery then placed an IVC
filter. Strict blood pressure parameters were maintained.
On ___, the patient's serum Na was 144. She was extubated later
in the day. A repeat serum Na was obtained and was 139.
On ___, the patient remained neurologically stable on
examination. The EVD was raised to 20. Her SBP was liberalized
to <160. A CSF sample was obtained and was sent for cytology.
___, Ms. ___ had a ___ which demonstrated stable
ventricles. Her EVD was clamped and two hours later unclamped
for elevated intracranial pressures. The EVD was lowered to 10.
Her head was wrapped over top of incision.
___, the patient remained neurologically stable and her drain
remained at 10. She was restarted on SC heparin.
On ___, patient was neurologically intact. Her EVD was clamped
at 1pm without any ICP issues. She was pre-oped for the OR for
possible VP shunt.
On ___, patient remained clamped overnight without any changes
in ICP or neurologic exam. Head CT performed showed stable
ventricular size, but new IVH. On exam, her posterior incision
was more larger and boggy. She was taken to the OR for a
placement of a R VP shunt. Post operatively, she remained
intact. Head CT showed that the catheter was in a good location
and no acute hemorrhage. She was transferred to the floor in
stable condition.
On ___, the patient remained neurologically intact on the
floor. She had complaints of gas pain, so she was started on
simethicone. ___ re-evaluated the patient and recommended that
she be discharged to a rehab facility. She was screened for an
available bed. Her discharge was pending insurance
authorization.
On ___ Ms. ___ developed midsternal chest discomfort that
worsened with deep breathing and was found to have an elevated
WBC 28.4. Blood cultures were sent and are negative at
discharge. UA showed moderate Leuks but negative nitrites. CXR
performed was stable. With a history of PE, bilateral ___
dopplers were performed and were negative. CTA chest showed
improving clot burden compared to ___.
On ___ WBC was 10.9. At the time of discharge on ___ she was
tolerating a regular diet, ambulating without difficulty,
afebrile with stable vital signs.
Medications on Admission:
Xalkori 250mg BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Bisacodyl 10 mg PO/PR DAILY
3. Cepastat (Phenol) Lozenge 1 LOZ PO Q2H:PRN sore throat
4. Cyclobenzaprine 10 mg PO TID:PRN neck pain
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth every 8 hours
Disp #*90 Tablet Refills:*0
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Famotidine 20 mg PO Q12H
RX *famotidine 20 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*3
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*90
Tablet Refills:*0
8. Senna 8.6 mg PO BID
9. Simethicone 40-80 mg PO QID:PRN gas pain
10. Sodium Chloride Nasal ___ SPRY NU TID:PRN stuffy nose
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Brain lesions
Cerebral vasogenic edema
Hydrocephalus
Pulmonary Emboli
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Tumor
Surgery
You underwent surgery to remove a brain lesion from your
brain.
You had a VP shunt placed for hydrocephalus. Your incision
should be kept dry until sutures or staples are removed.
Your shunt is a ___ Delta Valve which is NOT
programmable. It is MRI safe and needs no adjustment after a
MRI.
Please keep your incision dry until your staples are removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
19774071-DS-12
| 19,774,071 | 21,273,373 |
DS
| 12 |
2166-05-25 00:00:00
|
2166-05-27 12:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / omeprazole / Cefadroxil / Augmentin
Attending: ___.
Chief Complaint:
Right breast swelling secondary to malpositioned VP shunt
Major Surgical or Invasive Procedure:
VP shunt revision, drainage of right anterior chest wall
seroma/CSFoma
History of Present Illness:
___ w/ stage 1A breast cancer and stage 4 NSCLC w/ brain mets
presenting to ___ with gradual onset shortness of breath. The
patient stated that she was also having pain in the righ lower
leg for 1 week. Already has an IVC filter and has known DVTs but
no prior PE. The patient stated that she feels like she can't
get a deep breath and reports chest tightness.
In addition, the patient also reported breast pain for 1 week,
saying it was tender on lateral side. She said that it had
gradually swollen since last week. She is s/p mastecomty and a
silicon implant which was done at ___. ROS also revelaed
chills and fever last week to 100. No drainage reported.
She was recently admitted to ___ on ___ with severe
headache, nausea and vomiting. She was found to have new brain
lesions. On ___ she underwent suboccipital craniotomy with
excision of cerebellar lesions and placement of VPS. On ___
she underwent another craniotomy for posterior fossa
decompression and clot evacuation. She was discharged home on
___ and has been getting brain radiation since finished on
___. She met Dr ___ who consented her for a clinical
trial evaluating the drug Alectinib in patients with ALK+ NSCLC
with disease progression or intolerance to prior ALK inhibitor.
- In the ED, initial VS were 4 98.1 108 122/72 18 100% ra.
- Labs showed lactate 1.3, hct 34, normal chem panel, UA, ucg.
- Imaging was notable for CTA chest which was read as "1. Acute
bilateral subsegmental pulmonary embolism. 2. VP shunt catheter
is seen coiled around the right breast implant with tip in
anterior chest wall. There is a new large CSF fluid collection
surrounding the breast implant. 3. Worsening mediastinal and
left perihilar adenopathy. 4. 1.1 cm left base nodule, not
assessed previously. Follow-up chest CT is recommended in 3
months. 5. Incompletely assessed right liver lobe hyperdensity.
Non-emergent liver ultrasound is recommended." CXR read as
"Patchy right upper lung opacity could be due to pneumonia.
Discoid left mid lung atelectasis/scarring." Breast U/s read as
"4 cm fluid collection superficial to the breast implant,likey
seroma however superimposed infection cannot be excluded.(
Preliminary Report)"
- Consulted services included plastic surgery and neurosurgery.
- Patient was given 1L NS and started on IV heparin gtt.
- Patient was admitted to ___ for further mx.
- VS prior to ED 0 98.3 101 ___ 98% RA.
On arrival to the floor, the patient was stable on RA.
Complaining of chest tightness, pleuritic chest pain, left flank
pain.
REVIEW OF SYSTEMS: +nausea. Vomiting once last week. She just
finihsed abx for UTI yesterday. ROS -ve for abdominal pain,
vomiting, or diarrhea.
Past Medical History:
1. T2 N3 M0 (stage IIIB) lung adenocarcinoma with contralateral
mediastinal nodal involvement and left supraclavicular
metastasis, ALK positive.
2. Right breast adenocarcinoma pathologic T1mic, multifocal N0
(stage IA) grade 3, ER weak positive, PR negative, HER-2
positive
(3+) status post mastectomy in ___ with biopsy proven regional
nodal recurrence in the subpectoral lymph nodes on the right.
3. Pancreatic serous cystadenoma status post partial
pancreatectomy and cholecystectomy in ___.
4. Migraine headaches.
5. Sciatic and chronic back pain.
PAST SURGICAL HISTORY:
1. Partial pancreatectomy and cholecystectomy for a benign
pancreatic serous cystadenoma in ___.
2. Right total mastectomy with sentinel lymph node biopsy and
immediate reconstruction in ___.
3. Silicone breast implant, ___.
4. Excision of mass at right mastectomy site (___)
benign.
5. Fine needle aspiration of left lung mass, positive for
adenocarcinoma in ___.
6. Fine needle aspiration of left supraclavicular cervical lymph
node positive for lung adenocarcinoma on ___.
7. Fine needle aspiration of the right axillary/subpectoral mass
revealing metastatic breast cancer on ___.
8. ___: Midline suboccipital craniotomy, excision brain
tumor
9. ___: Craniotomy for pfossa decompression and clot
evacuation
10. ___: IVC filter placement
11. ___: Right VP shunt placement (nonprogrammable)
Social History:
___
Family History:
FAMILY HISTORY: The patient has had BRCA testing and was
negative for mutation. She has no family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: NAD
VITAL SIGNS: 99.2 ___ 20 98 ra
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
BREAST: rt breast w/ implant s/p mastectomy swollen, >left, no
erythema, pain, tenderness
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities
DISCHARGE PHYSICAL EXAM:
VS: 98.5 ___ 16 96% RA
General: NAD, WDWN female lying comfortably in bed
HEENT: MMM, no OP lesions, NC, AT, midline scar in occiput
CV: RR, NL S1S2 no S3S4 MRG, patchy hair loss ___ radiation
BREAST: rt breast w/ implant s/p mastectomy, no erythema, pain,
tenderness, swelling now resolved post procedure
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly, mild pain
with palp LLQ/RLQ, laparoscopic port site in RUQ well-healed
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: moves all extremities spontaneously, EOMI, normal speech
Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD WBC-7.8 RBC-4.21 Hgb-10.9* Hct-34.1*
MCV-81* MCH-25.8*# MCHC-31.9 RDW-14.4 Plt ___
___ 04:00PM BLOOD Neuts-71.2* ___ Monos-5.9 Eos-0.8
Baso-0.5
___ 04:00PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
Pencil-OCCASIONAL Tear Dr-1+
___ 04:00PM BLOOD ___ PTT-28.1 ___
___ 04:00PM BLOOD Plt ___
___ 04:00PM BLOOD Glucose-101* UreaN-8 Creat-0.6 Na-138
K-4.0 Cl-100 HCO3-29 AnGap-13
___ 04:23PM BLOOD Lactate-1.3
PERTINENT RESULTS:
___ 06:40AM BLOOD WBC-6.0 RBC-3.73* Hgb-9.7* Hct-29.5*
MCV-79* MCH-26.0* MCHC-32.8 RDW-14.5 Plt ___
___ 04:10AM BLOOD WBC-8.6 RBC-3.92* Hgb-9.9* Hct-31.4*
MCV-80* MCH-25.3* MCHC-31.6 RDW-14.6 Plt ___
___ 09:15PM BLOOD WBC-9.7 RBC-3.87* Hgb-10.2* Hct-29.9*
MCV-77* MCH-26.2* MCHC-34.0 RDW-14.5 Plt ___
___ 06:30AM BLOOD WBC-7.8 RBC-4.01* Hgb-10.3* Hct-31.1*
MCV-78* MCH-25.6* MCHC-33.1 RDW-14.4 Plt ___
___ 07:10AM BLOOD WBC-12.7* RBC-4.05* Hgb-10.3* Hct-31.8*
MCV-78* MCH-25.5* MCHC-32.5 RDW-14.5 Plt ___
___ 06:25AM BLOOD WBC-13.6* RBC-4.08* Hgb-10.3* Hct-31.7*
MCV-78* MCH-25.3* MCHC-32.5 RDW-14.8 Plt ___
___ 06:40AM BLOOD Glucose-94 UreaN-6 Creat-0.5 Na-140 K-4.0
Cl-102 HCO3-30 AnGap-12
___ 04:10AM BLOOD Glucose-112* UreaN-7 Creat-0.6 Na-136
K-4.0 Cl-100 HCO3-26 AnGap-14
___ 06:15AM BLOOD Glucose-92 UreaN-6 Creat-0.6 Na-137 K-4.3
Cl-99 HCO3-29 AnGap-13
___ 07:35AM BLOOD Glucose-125* UreaN-8 Creat-0.6 Na-138
K-4.3 Cl-100 HCO3-29 AnGap-13
___ 06:25AM BLOOD Glucose-108* UreaN-9 Creat-0.6 Na-139
K-4.5 Cl-99 HCO3-28 AnGap-17
___ 06:25AM BLOOD ALT-83* AST-56* CK(CPK)-25* AlkPhos-100
TotBili-0.3 DirBili-0.1 IndBili-0.2
PERTINENT STUDIES:
MRI HEAD ___ IMPRESSION:
1. Motion degrades image quality and limits evaluation for new
lesions.
2. Compared with ___ prior brain MRI, multiple known
enhancing
metastatic lesions have slightly increased in size, as described
above.
3. Within limits of study, no definite new lesions identified.
4. No acute intracranial abnormality.
5. Post suboccipital craniotomy with expected, evolving
postsurgical changes in the cerebellum.
CT PELVIS w/ CONTRAST IMPRESSION:
1. Slightly different position of the ventriculoperitoneal
shunt termination, in the midline of the lower abdomen, with no
associated fluid collection or CSFoma.
2. Unchanged appearance of soft tissue stranding abutting the
right rectus muscle, in keeping with recent laparoscopic port
positioning and postsurgical
change.
3. Thrombus in the cone of the IVC filter, which has not been
previously
imaged with contrast and so a comparison is not possible.
SHUNT SERIES: IMPRESSION
Ventriculoperitoneal shunt seen coursing from the skull with the
distal tip projecting over the right pelvis.
Apparent widening of the mediastinum on the limited portable
projection of the chest. Further evaluation with dedicated chest
radiographs can be obtained if clinically indicated.
Small left pleural effusion with associated atelectasis at the
left lung base.
Brief Hospital Course:
___ w/ stage 1A breast cancer and stage 4 NSCLC w/ brain mets
presenting with bilateral PEs and misplaced VP shunt s/p VP
shunt revision on ___.
# Malpositioned VP Shunt: patient presented with right breast
swelling due to VP shunt terminating around the right breast
implant with associated pocket of CSF surrounding the implant.
Neurosurgery was consulted, patient was taken back to the OR on
___ ___. Plastic surgery was also present and
drained the CSF collection in her right breast. Patient
tolerated the procedure well and her non-reprogrammable VP shunt
was successfully repositioned into the peritoneal cavity.
Post-op course was complicated by nausea and vomiting which was
refractory to zofran and compazine. The compazine was eventually
DC'd and patient was started on phenergan and 2mg decadron
initially BID but titrated down to QD. Her nausea was resolved
at time of discharge and she was discharged on PO phenergan and
decadron.
# Bladder spasm: post-op, patient also had suprapubic pain along
with urinary urgency likely due to bladder spasms secondary to
foley catheter placement and removal while intra-op. Patient was
given Pyridium for 3 days without complete resolution of the
bladder spasms. She was next transitioned to 5mg of oxybutinin
PO daily at time of discharge. Overall, her symptoms of dysuria
resolved with the oxybutinin therapy. UA and urinary cultures
were negative thorughout admission.
# Bilateral pulmonary emboli: patient presented with shortness
of breath and chest pain and found to have bilateral
sub-segmental pulmonary emboli. Due to her operative procedure,
she did not receive anticoagulation at time of admission. She
was started on a heparin drip without initial bolus 24 hours
after the VP shunt revision per neurosurgery recommendations.
Patient was kept on the heparin gtt for 24 hours and
transitioned over to therapeutic dose lovenox. Patient received
lovenox teaching and Rx prior to discharge.
CHRONIC ISSUES:
# Metastatic Lung Cancer: patient has known brain mets s/p
craniectomy and recently completed radiation treatment on
___. Consented to start clinical trial evaluating the drug
Alectinib in patients with ALK+ NSCLC with disease progression
or intolerance to prior ALK inhibitor. Patient received the
necessary lab tests and a head MRI per trial protocol while in
house prior to discharge. She will follow up with Dr. ___
___ ___ oncology as well as Dr. ___ further management of
her lung cancer.
# Transitions in care:
-- Follow up appointment with Dr. ___ ___ oncology
-- Follow-up with Dr. ___ clinical trial evaluation
-- Continue lovenox injections
-- Discharged on dexamethasone 2mg daily for management of
nausea. Please consider discontinuing in the future
-- Discharged on oxybutynin daily. Please consider discontinuing
at follow-up pending symptoms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclobenzaprine 10 mg PO TID:PRN neck pain
2. Famotidine 20 mg PO Q12H
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
4. Simethicone 40-80 mg PO QID:PRN gas pain
Discharge Medications:
1. Enoxaparin Sodium 90 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL 90 mg subcutaneous every twelve (12)
hours Disp #*14 Syringe Refills:*0
2. Famotidine 20 mg PO Q12H
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
4. Simethicone 40-80 mg PO QID:PRN gas pain
5. Docusate Sodium 100 mg PO BID
Please take this as needed while taking Oxycodone.
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
6. Cyclobenzaprine 10 mg PO TID:PRN neck pain
7. Dexamethasone 2 mg PO DAILY
RX *dexamethasone 2 mg 1 tablet(s) by mouth daily in the morning
Disp #*14 Tablet Refills:*0
8. Lidocaine-Prilocaine 1 Appl TP BID
9. Oxybutynin 5 mg PO DAILY
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. Promethazine 25 mg PO Q6H:PRN Nausea
RX *promethazine 12.5 mg ___ tabs by mouth every 6 hours Disp
#*30 Tablet Refills:*0
11. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: malpositioned ventriculo-peritoneal shunt,
bilateral pulmonary emboli
Secondary diagnosis: metastatic adenocarcinoma of the lung,
stage IA right-sided breast cancer s/p resection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were seen at the ___ due to your
ventriculo-peritoneal (VP) shunt malfunctioning and draining
into your right chest. The neurosurgery team did a procedure to
fix the shunt and the plastic surgeons drained the fluid that
was collecting in your right chest.
___ also had small blood clots in your lungs which we treated
___ with blood thinners. We started ___ on a new blood thinner
called Lovenox injections to help treat the blood clots. ___
will follow up with Dr. ___ Dr. ___ discharge.
We wish ___ the best.
Your ___ Team.
Followup Instructions:
___
|
19774071-DS-14
| 19,774,071 | 25,035,229 |
DS
| 14 |
2166-07-27 00:00:00
|
2166-07-28 09:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / omeprazole / Cefadroxil / Augmentin
Attending: ___.
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a pleasant ___ w/ stage IA breast cancer and
stage IIIB lung adenocarcinoma diagnosed in ___,
with CNS metastasis confirmed by biopsy, s/p WBRT now on
protocol
___ ___ w/ alectinib 600 mg BID, who p/w nausea, abdominal
pain, and increased weakness and dizziness on standing. Several
days ago while in the shower she felt faint and fell onto her
right shoulder but no head trauma nor LOC.
In ED: received 2L IV NS, 4 mg IV Zofran, 5 mg Morphine. She was
found to be orthostatic with SBP dropping to 88/37 and HR bumped
from 83 to 132. CT Abd/Pelv, CXR were neg for any acute process.
On arrival to OMED, pt was in significant abdominal pain. She
received 4 mg IV Morphine and nearly immediately started to have
vomiting and noted that was common for her. History was limited
due to her vomiting persistently.
REVIEW OF SYSTEMS:
10 point ROS reviewed in detail and negative except for what is
mentioned above in HPI
Past Medical History:
PAST ONCOLOGIC HISTORY:
1. Stage IA right breast cancer ___, with right axillary
recurrence ___
a) S/p R mastectomy/implant ___,
b) Tamoxifen ___
c) Herceptin x ___ year, ___
2. Stage IIIB left lung adenocarcinoma, ALK + ___, no with
disease recurrence in the brain ___.
a) Crizotinib ___ - ___
b) Alectinib 600mg twice a day started on ___
PAST MEDICAL HISTORY:
1. Metastatic adenocarcinoma of the lung, ALK+
2. Stage IA right breast cancer ___, with right axillary
recurrence ___
3. Pulmonary embolism status post IVC filter placement.
4. Migraines
5. Radiculopathy
6. GERD
7. Nephrolithiasis
PAST SURGICAL HISTORY:
1. ___: Midline suboccipital craniotomy, excision brain
tumor
2. ___: Craniotomy for pfossa decompression and clot
evacuation
3. ___: IVC filter placement
4. ___: Right VP shunt placement (nonprogrammable)
5. Pancreatic cyst excision in ___
6. Right mastectomy ___
7. Left supraclavicular LN biopsy in ___
Social History:
___
Family History:
The patient has had BRCA testing and was negative for mutation.
She has no family history of cancer.
Physical Exam:
ADMISSION PHYSICAL
General: NAD, Resting in bed vomiting frequently
VITAL SIGNS: Tc 97.7, Tm 97.8, BP 92-94/62, HR 58-72, 98% RA
HEENT: PERRL, EOMI, no nystagmus, sclera anicteric, orpharynx
with dry mucus membranes
CV: normal S1 and S2, RRR, no murmurs
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, SNT/ND, + abdominal scar from prior pancreatic
surgery
LIMBS: WWP, no ___, + tremors
SKIN: No rashes on the extremities
NEURO: CNII-XII grossly intact, no pronator drift, ___ ___
strength, sensation intact to soft touch, normal coordination,
normal FNF, toes down b/l
DISCHARGE PHYSICAL
PHYSICAL EXAM:
VITAL SIGNS: Tm 98.2, BP 96-118/50s-70s, HR 75-103, 96-98% RA
HEENT: PERRL, EOMI, no nystagmus, sclera anicteric, orpharynx
wnl
CV: normal S1 and S2, RRR, no murmurs
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, ND, minimal LUQ ttp, + abdominal scar from prior
pancreatic surgery
LIMBS: WWP, no ___
SKIN: No rashes on the extremities
NEURO: CNII-XII grossly intact, no pronator drift, ___ ___
strength, sensation intact to soft touch
Pertinent Results:
ADMISSION LABS
___ 02:25PM BLOOD WBC-9.1 RBC-4.29 Hgb-10.4* Hct-33.1*
MCV-77* MCH-24.2* MCHC-31.4* RDW-19.2* RDWSD-53.3* Plt ___
___ 02:25PM BLOOD ___ PTT-23.6* ___
___ 02:25PM BLOOD Glucose-95 UreaN-8 Creat-0.7 Na-137 K-4.1
Cl-100 HCO3-22 AnGap-19
___ 02:25PM BLOOD ALT-24 AST-21 AlkPhos-127* TotBili-1.1
___ 02:25PM BLOOD ALT-24 AST-21 AlkPhos-127* TotBili-1.1
___ 02:25PM BLOOD Albumin-4.2
___ 09:13AM BLOOD Albumin-3.7 Calcium-9.3 Phos-4.9* Mg-2.0
___ 09:13AM BLOOD Cortsol-38.4*
___ 07:00AM BLOOD HCG-<5
___ 02:28PM BLOOD Lactate-1.___BDOMEN
1. Ventriculoperitoneal shunt terminating in the midline of the
pelvis, with a
small amount of associated free fluid.
2. No evidence of bowel obstruction.
3. Mild stranding of the right anterior abdominal wall in the
region of prior
postsurgical changes from ventriculoperitoneal shunt revision in
___.
4. Infrarenal IVC filter.
Brief Hospital Course:
Ms. ___ is a pleasant ___ w/ stage IA breast cancer and
stage IIIB lung adenocarcinoma diagnosed in ___,
with CNS metastasis s/p resection and VP shunt placement, s/p
WBRT and crizotinib, now on protocol ___ ___ w/ alectinib
600 mg BID who presented with nausea, vomiting, and orthostasis.
# Orthostasis: likely ___ dehydration in the setting of
significant nausea and poor PO intake. TSH checked in ___ was
wnl and B12 was wnl. Adrenal insufficiency was on the
differential however cortisol/cosyntropin stimulation test was
wnl. Patient received IV hydration and her symptoms improved.
# Nausea/vomiting: etiology was unclear but was initially
attributed to her study drug. During her last admission she had
an extensive workup which consisted of an MRI brain and EGD.
Patient was recently on a steroid taper (which she completed at
home) however states that steroids made her symptoms worse and
therefore steroids were not continued during this
hospitalization. A CT abdomen/pelvis was performed and did not
show an acute process that would explain her symptoms. Her neuro
exam was non-focal and she did not complain of symptoms
suggestive of elevated ICP. Neurosurgery was contacted to
discuss her case and they felt a VP shunt series was not
necessary at this time. Neuro-Oncology was consulted and they
felt that patient may benefit from a LP as an out patient to
evaluate for leptomeningeal carcinomatosis as well as
paraneoplastic syndromes. Patient did not want LP in house as
she was feeling better upon day of discharge. Patient may follow
up with Neurology as an out patient to obtain LP if desired.
# Dysuria/increased frequency: UA negative for infection, Urine
culture ___ negative, chronic. ? interstitial cystitis vs.
autonomic dysregulation. Patient will follow up with uro-gyn as
an out patient.
# Vaginal pain, likely ___ pain as patient does not
have abnormal vaginal discharge or other symptoms/signs
suggestive of infection
-ibuprofen PRN
-phenazopyridine 100mg tid
-pelvic exam as out patient
# h/o PE: continued home lovenox ___ mg daily
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Cyclobenzaprine 10 mg PO TID:PRN neck pain
2. Docusate Sodium 100 mg PO BID constipation
3. Enoxaparin Sodium 130 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
4. Simethicone 40-80 mg PO QID:PRN gas pain
5. Pantoprazole 40 mg PO Q24H
6. Ferrous Sulfate 325 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Hydrocortisone 20 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
2. Simethicone 40-80 mg PO QID:PRN gas pain
3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
stomach discomfort
RX *alum-mag hydroxide-simeth [Antacid] 200 mg-200 mg-20 mg/5 mL
___ mL by mouth four times a day Refills:*3
4. Ibuprofen 800 mg PO Q8H:PRN pain
5. Ascorbic Acid ___ mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Cyclobenzaprine 10 mg PO TID:PRN neck pain
8. Ferrous Sulfate 325 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Phenazopyridine 100 mg PO TID Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*24 Tablet Refills:*3
11. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*60 Capsule Refills:*3
12. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet(s) by
mouth daily Disp #*30 Packet Refills:*6
13. Docusate Sodium 100 mg PO BID constipation
14. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*3
15. Ondansetron 8 mg PO Q8H:PRN nausea
oral dissolving tablet
RX *ondansetron [___] 8 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*60 Tablet Refills:*3
16. Enoxaparin Sodium 130 mg SC Q24H
Start: Today - ___, First Dose: First Routine
Administration Time
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: orthostasis
Secondary diagnosis: nausea, vomiting, lung cancer,
constipation, dysuria/increased urinary frequency, vaginal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for workup of your nausea, vomiting, and drop
in blood pressure. While you were here you received IV fluids
and medications to help with your symptoms. The palliative care
service was consulted and they helped us manage your symptoms.
You will follow up with Dr. ___ as an outpatient to discuss
further treatment for your lung cancer. We had considered doing
a lumbar puncture to look for causes of your dizziness, however,
as you were doing better, we decided not to do this in the
hospital.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19774071-DS-16
| 19,774,071 | 26,471,867 |
DS
| 16 |
2170-02-14 00:00:00
|
2170-02-14 13:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / omeprazole / Cefadroxil / Augmentin / morphine
Attending: ___.
Chief Complaint:
Headache, paresthesias
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o women with metastatic ALK+ NSCLC
(cerebellar and mesenteric LN mets) s/p VP shunt on lorlatinib,
and migraine who presented to the ED with several hours of
severe
bifrontal nonpulsatile headache paresthesias. She reports
feeling
fine in the preceding days and her symptoms started abruptly
after being at the mall yesterday morning with blurry and double
vision, followed by severe bifrontal headache, and then
tingling/numbness in her left hand, tongue, and both legs. She
reports no fevers/chills, neck pain, difficulty speaking or
swallowing, vertigo, arm or leg weakness, sore throat, chest
pain, dyspnea, palpitations, abdominal pain, n/v/d.
ED Course notable for:
-Her symptoms spontaneously resolved
-CT head demonstrating no acute changes or hydrocephalus
-Shunt series showed normal appearing VP shunt
-CXR normal
-Evaluated by neurology and neurosurgery. Noted to have normal
neuro exam. Neurology recommended MRI to r/o ___ thrombosis
or
worsening CNS disease.
Past Medical History:
PAST ONCOLOGIC HISTORY:
1. Stage IA right breast cancer ___, with right axillary
recurrence ___
a) S/p R mastectomy/implant ___,
b) Tamoxifen ___
c) Herceptin x ___ year, ___
2. Stage IIIB left lung adenocarcinoma, ALK + ___, no with
disease recurrence in the brain ___.
a) Crizotinib ___ - ___
b) Alectinib 600mg twice a day started on ___
PAST MEDICAL HISTORY:
1. Metastatic adenocarcinoma of the lung, ALK+
2. Stage IA right breast cancer ___, with right axillary
recurrence ___
3. Pulmonary embolism status post IVC filter placement.
4. Migraines
5. Radiculopathy
6. GERD
7. Nephrolithiasis
PAST SURGICAL HISTORY:
1. ___: Midline suboccipital craniotomy, excision brain
tumor
2. ___: Craniotomy for pfossa decompression and clot
evacuation
3. ___: IVC filter placement
4. ___: Right VP shunt placement (nonprogrammable)
5. Pancreatic cyst excision in ___
6. Right mastectomy ___
7. Left supraclavicular LN biopsy in ___
Social History:
___
Family History:
The patient has had BRCA testing and was negative for mutation.
She has no family history of cancer.
Physical Exam:
ADMISSION EXAM:
VITALS: ___ 2254 Temp: 97.8 PO BP: 98/62 R Lying HR: 92 RR:
20 O2 sat: 94% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score:
___
GENERAL: Well appearing woman resting in bed wearing pink fuzzy
hat. Somnolent
HEENT: MMM
EYES: Sclerae anicteric, PERRL
NECK: Supple
RESP: Lungs CTAB
___: RRR, nl S1/2, no murmurs
GI: Soft, nt, nd
EXT: Warm, no edema
SKIN: Warm and dry
NEURO: Somnolent frequently dozing off during interview, but
arousable and oriented x3.
ACCESS: PIV
DISCHARGE EXAM:
T 97.7 BP 146/81 HR 77 R 18 SpO2 97 Ra
GENERAL: NAD
EYES: PERRL, anicteric
HEENT: moist membranes without lesions
NECK: supple
___: RRR no MRG
RESP: CTAB, no wheezing, rhonchi or crackles
GI: Soft, NTND
EXT: warm, no edema
SKIN: dry, no rashes
NEURO: CN II-XII intact
Pertinent Results:
ADMISSION
___ 04:00PM BLOOD WBC-11.5* RBC-3.59* Hgb-10.5* Hct-34.1
MCV-95 MCH-29.2 MCHC-30.8* RDW-14.7 RDWSD-50.9* Plt ___
___ 04:00PM BLOOD Glucose-85 UreaN-13 Creat-0.8 Na-143
K-3.7 Cl-103 HCO3-26 AnGap-14
___ 04:00PM BLOOD ALT-21 AST-24 AlkPhos-86 TotBili-0.4
___ 04:00PM BLOOD Albumin-4.2 Calcium-9.7 Phos-3.6 Mg-2.1
___ 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE
___ 06:18AM BLOOD WBC-9.2 RBC-3.60* Hgb-10.6* Hct-33.4*
MCV-93 MCH-29.4 MCHC-31.7* RDW-14.6 RDWSD-50.4* Plt ___
___ 06:18AM BLOOD Glucose-76 UreaN-13 Creat-0.7 Na-144
K-4.1 Cl-104 HCO3-26 AnGap-14
___ 06:18AM BLOOD Calcium-9.3 Phos-4.6* Mg-2.2
IMAGING
___ Imaging CT HEAD W/O CONTRAST
IMPRESSION:
1. No acute intracranial abnormality.
2. Right frontal approach ventriculostomy catheter in unchanged
position in the foramen ___ with similar ventricular size
compared to prior exams. No hydrocephalus.
3. Status post suboccipital craniectomy with similar appearance
of
postsurgical changes and encephalomalacia in the cerebellum.
___ Imaging SHUNT SERIES AP & LAT S
IMPRESSION:
VP shunt catheter appears intact throughout and terminates in
the left lower quadrant of the abdomen. There is looping of the
catheter in the left lateral abdomen, unchanged from prior,
without kinking or catheter discontinuity.
___ Imaging MR HEAD W & W/O CONTRAS
IMPRESSION:
1. Stable postsurgical changes after suboccipital craniotomy and
right frontal approach ventriculostomy catheter with stable
position of its tip and unchanged configuration of the
ventricular system.
2. No evidence of acute infarction, sinus venous thrombosis,
hemorrhage or
progression of intracranial metastatic disease.
3. Stable nonenhancing white matter lesions in the cerebral
hemispheres
bilaterally as well as unchanged dural thickening and
enhancement. No new
lesions or abnormal contrast enhancement identified.
Brief Hospital Course:
___ with metastatic NSCLC s/p VP shunt on lorlatinib who
presents with headache and paresthesias.
#HEADACHE
#PARESTHESIA:
Patient presented with sudden onset of severe bifrontal
nonpulsatile headache/paresthesias, in addition to blurry vision
and paresthesias of her left hand, tongue and bilateral legs. CT
imaging, including Shunt series was unrevealing and symptoms
spontaneously resolved while in the ED. Her neurological exam
was normal. Symptoms were possibly due to side effect of
lorlatinib, but other etiologies include sinus thrombosis or
worsening CNS disease. Patient underwent MRI which was
unrevealing, demonstrating no acute process. Given the complete
resolution of her symptoms and negative work up, these symptoms
could also be related to anxiety rather than a side effect of
her chemotherapy.
#METASTATIC NSCLC: CNS mets dx ___, mesenteric LN met
___. ALK mutation G1202R, on lorlatinib 100mg daily.
Developed HLD from lorlatinib.
Will f/u with Dr. ___ on ___.
#HISTORY OF PE: Diagnosed ___. Treated with 6 months lovenox
then rivaroxaban with plan for indefinite anticoagulation.
Recently switched to dabigatran ___ due to interaction with
lorlatinib
-Continue dabigatran 150mg BID
#HYPERLIPIDEMIA: Due to initiation of lorlatinib. Started on
pravastatin outpatient
-Continue home pravastatin 20mg daily
#BILLING: >30 MINUTES were spent coordinating care with
outpatient providers and preparing paperwork
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. clindamycin-benzoyl peroxide ___ % topical BID
2. Ranitidine 150 mg PO BID
3. lorlatinib 100 mg oral DAILY
4. Dabigatran Etexilate 150 mg PO BID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. calcium carbonate-vitamin D3 1200-800 mg-units oral DAILY
7. Senna with Docusate Sodium (sennosides-docusate sodium)
8.6-50 mg oral DAILY
8. Pravastatin 20 mg PO QPM
Discharge Medications:
1. calcium carbonate-vitamin D3 1200-800 mg-units oral DAILY
2. clindamycin-benzoyl peroxide ___ % topical BID
3. Dabigatran Etexilate 150 mg PO BID
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Pravastatin 20 mg PO QPM
6. Ranitidine 150 mg PO BID
7. Senna with Docusate Sodium (sennosides-docusate sodium)
8.6-50 mg oral DAILY
8. HELD- lorlatinib 100 mg oral DAILY This medication was held.
Do not restart lorlatinib until told to restart by Dr. ___
___ Disposition:
Home
Discharge Diagnosis:
Metastatic Lung Cancer
Headache
Paresthesia
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. You came to the hospital because of headaches
and numbness/tingling. We did some lab and imaging tests,
including an MRI which were reassuring. We think this may be
from a side effect of your chemotherapy, Lorlatinib. I discussed
your case with your oncologist, Dr. ___. She would like
you to stop taking your Lorlatinib and to follow up with her as
scheduled on ___.
We wish you the best!
Your ___ Care team
Followup Instructions:
___
|
19774163-DS-21
| 19,774,163 | 27,004,602 |
DS
| 21 |
2119-06-25 00:00:00
|
2119-06-29 19:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Acetaminophen / Nitroglycerin
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with Hep C/alcoholic cirrhosis complicated by bleeding
varices recently banded ___ at OSH, severe LVH, IDDM and IVDU
who p/w worsening abdominal pain, dyspnea and leg swelling x1
month.
Per patient he saw his primary provider on ___ at ___
___ for worsening confusion and was seen at ___ ___
but left AMA. Since then, the patient reports that his leg
swelling has gotten much worse and he continued to have RLQ
pain, which he has had for at least a month. The patient and his
sister feel his legs have doubled in size over the last 2 days.
The patient's sister is also ___ that he has become more
confused over the last few days. He understands he is sick and
wants help but keeps refusing care, which is concerning to her.
Per patient and ___ records, he was admitted to ___
___ ___ with hematemesis. He was found to have a
Hct of around 21 and was given FFP and 2U PRBC with no bump in
H/H. He subsequently underwent EGD ___ with band ligation x7
of varices that likely had recently bled. The patient was stable
the day after the procedure but left AMA ___. Hematocrit that
day was 21. During that hospitalization, he also had a CT scan
for abdominal pain that did not show ascites but did show
possible enteritis/colitis. Ultimately, the cause of his
abdominal pain was thought to tbe from heroin withdrawal.
In the ___ initial vitals were: 97.3 95 145/75 19 100%
- Labs were significant for creatinine 0.9, AST/ALT 64/32, T
bili 1.6, albumin 2.9, H/H 8.2/27.5, platelet count 32, INR 1.4
- Patient has a chest x-ray that showed poor effort with likely
atelectasis. and abdominal ultrasound showed no portal vein
thrombus and no ascites. He received cefepime out of concern for
occult infection.
Vitals prior to transfer were: 90 139/76 17 100% RA
On the floor, patient is sleepy but is complaining of pain in
his abdomen and both legs. He threatens to leave AMA when the
team requests to place a second peripheral IV.
Past Medical History:
-cirrhosis from Hepatitis C and alcohol
-severe LVH with ___ noted on recent ECHO ___
-DM on insulin
-gout,
-HTN,
-schizophrenia,
-gallstones
Social History:
___
Family History:
Diabetes
Physical Exam:
>> Admission Physical Exam:
Vitals - T:98.1 BP:129/73 HR:90 RR:24 02 sat: 98RA
GENERAL: Sleepy, but easily arousable, no distress, oriented to
name and ___, not to date
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, III/VI systolic murmur at RSB worse with
Valsalva
LUNG: poor effot, scattered wheezes, no crackles appreciated
ABDOMEN: mildly distended, small umbilical hernia easily
reducible, +BS, soft with tenderness in RLQ, no
rebound/guarding, no hepatosplenomegaly appreciated
EXTREMITIES: 2+ tender pitting edema in ___ bilaterally, chronic
venous stasis changes on both legs.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
.
>> Discharge Physical Exam:
Vitals: T 98.2 (max 98.6), BP 120/73 (SBP 100-120s), HR 70
(50-70s), RR 20, O2 99% RA
I/O's: 1520/1050 but BRP
General: Alert and oriented x 3. Conversing with goal directed
speech. No acute distress. Sitting in bed and walking around the
floor.
HEENT: Missing multiple teeth (bottom R). Neck supple.
Cardiac: RRR, normal S1 and S2, no m/r/g.
Lungs: CTA bilaterally. Non-labored breathing
Abdomen: Obese. Mild guarding to deep palpation in RUQ, but no
rebound pain. Soft, nondistended.
Extremities: 1+ ___ edema bilaterally. Non-tender to touch.
Overlying skin changes consistent with chronic venous stasis
changes. BLE warm to touch.
Skin: Multiple tattoos and ecchymoses in the upper extremities
bilaterally. Weathered skin.
Pertinent Results:
>> Admission Labs :
___ 07:10PM BLOOD WBC-4.0 RBC-3.36*# Hgb-8.2*# Hct-27.5*#
MCV-82 MCH-24.4*# MCHC-29.9*# RDW-18.8* Plt Ct-32*
___ 07:10PM BLOOD ___ PTT-36.7* ___
___ 07:10PM BLOOD Glucose-253* UreaN-10 Creat-0.9 Na-138
K-3.3 Cl-100 HCO3-26 AnGap-15
___ 07:10PM BLOOD Albumin-2.9* Calcium-8.1* Phos-2.5*
Mg-1.5*
___ 07:30AM BLOOD ___ pO2-168* pCO2-40 pH-7.52*
calTCO2-34* Base XS-9 Comment-COLLECTION
___ 10:32PM BLOOD Lactate-2.8*
.
>> Discharge Labs:
___ 06:00PM BLOOD WBC-5.1 RBC-3.75* Hgb-9.3* Hct-31.5*
MCV-84 MCH-24.7* MCHC-29.4* RDW-17.7* Plt Ct-46*
___ 06:00PM BLOOD ___
___ 06:00PM BLOOD Glucose-206* UreaN-13 Creat-1.1 Na-134
K-3.3 Cl-97 HCO3-29 AnGap-11
___ 06:00PM BLOOD ALT-28 AST-39 AlkPhos-133* TotBili-1.1
___ 06:00PM BLOOD Calcium-8.2* Phos-2.7 Mg-1.7
.
>> Imaging:
___ Imaging ABDOMEN US (COMPLETE ST: 1. Nodular and
coarsened liver is suggestive of cirrhosis. No ascites.
Preliminary Report2. Normal Dopplers. No portal venous
thromboses. 3. . Splenomegaly.
.
___ Imaging CHEST (PA & LAT) : 1. New left lower lobe and
retrocardiac opacities most consistent with atelectasis however
superinfection cannot be excluded. Clinical correlation is
recommended. 2. Hypoinflated lungs.
.
___ ECHOCARDIOGRAM
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. There is severe symmetric left ventricular
hypertrophy with normal cavity size and regional systolic
function. Global left ventricular systolic function is
hyperdynamic (EF>75%). The estimated cardiac index is high
(>4.0L/min/m2). There is valvular ___ with a moderate resting
left ventricular outflow tract obstruction. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. There
is systolic anterior motion of the mitral valve leaflets. The
estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.
IMPRESSION: Marked symmetric left ventricular hypertrophy with
normal cavity size and resting moderate LVOT gradient. Dilated
ascending aorta
These findings are c/w hypertrophic obstructive cardiomyopathy
(HOCM).
Brief Hospital Course:
Patient is a ___ with EtOH/HCV cirrhosis complicated by
esophageal varices with recent banding, severe LVH and LVOT,
polysubstance abuse, who presents with chronic abdominal pain
and subacute worsening ___ edema. He did not have any ascites
on U/S so SBP was thought to be unlikely. We believe he had a
component of gut edema which may have been contributing to his
stomach pain as his symptoms resolved with diuresis.
He was initially treated with his home dose of torsemide 40 mg
PO x 1 with nearly 9L of urine output. His dose was decreased to
10 mg and was volume even. His ___ edema improved but was still
present on discharge. His abdominal pain had resolved. We
believe this is most likely ___ cirrhosis and volume overload as
he did not have clinical signs of left heart failure. He also
had a repeat ECHO here (report above) that did not suggest any
interval change from prior studies.
We will discharge him with torsemide 20 mg PO daily. We also
started him on potassium 40 mEq PO daily for low potassium. He
was instructed to weigh himself daily and call his PCP if his
weight started to increase.
Otherwise his home medications were continued. The patient
refused lactulose and reports that he is not taking it at home.
His mental status seemed at baseline. His hydroxychloroquine and
sulfasalzine were initially held but restarted at discharge.
Transitional Issues:
[ ] follow up chem 7 (potassium) for ___ (rx provided to
patient)
[ ] monitor fluid status/daily weight and adjust home torsemide
as needed
[ ] follow up with cardiology per general care team at ___
(patient has had multiple attempts at cardiology f/u in the past
per PCP and leaves before appointment)
[ ] patient also requested switching from suboxone to methadone
for his substance abuse issues, which we discussed with patient
and encouraged him to speak with his outpatient psychiatrist who
prescribes the suboxone (Dr. ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Thiamine 100 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Spironolactone 50 mg PO DAILY
6. Lactulose 15 mL PO TID
7. 70/30 42 Units Breakfast
70/30 42 Units Dinner
8. Magnesium Oxide 400 mg PO BID
9. Nicotine Patch 14 mg TD DAILY
10. Buprenorphine-Naloxone (8mg-2mg) 4 TAB SL DAILY
11. Ferrous Sulfate 325 mg PO DAILY
12. Gabapentin 600 mg PO TID
13. Hydroxychloroquine Sulfate 200 mg PO BID
14. Metoprolol Succinate XL 150 mg PO DAILY
15. SulfaSALAzine_ 1000 mg PO BID
16. Torsemide 40 mg PO DAILY
17. TraZODone 100 mg PO HS:PRN insomnia
18. Vitamin B Complex 1 CAP PO DAILY
19. Cyanocobalamin 50 mcg PO DAILY
Discharge Medications:
1. Cyanocobalamin 50 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. 70/30 42 Units Breakfast
70/30 42 Units Dinner
4. Lactulose 15 mL PO TID
5. Magnesium Oxide 400 mg PO BID
6. Metoprolol Succinate XL 150 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Nicotine Patch 14 mg TD DAILY
9. Omeprazole 20 mg PO DAILY
10. Spironolactone 50 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. TraZODone 100 mg PO HS:PRN insomnia
13. Vitamin B Complex 1 CAP PO DAILY
14. Potassium Chloride 40 mEq PO DAILY
RX *potassium chloride 20 mEq 2 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
15. Buprenorphine-Naloxone (8mg-2mg) 4 TAB SL DAILY
16. Ferrous Sulfate 325 mg PO DAILY
17. Gabapentin 600 mg PO TID
18. Hydroxychloroquine Sulfate 200 mg PO BID
19. SulfaSALAzine_ 1000 mg PO BID
20. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
21. Hydrocerin 1 Appl TP TID
RX *white petrolatum-mineral oil [Hydrocerin] Apply to affected
leg ___ times per day Refills:*0
22. Outpatient Lab Work
Chem-7
ICD-9 571
Draw on ___ and please send results to:
Dr. ___
___ ___
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain
volume overload
cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for abdominal pain and leg swelling. You were
found to be volume overloaded, and had fluid in your legs. We
think this was also contributing to your abdominal pain. We gave
you a diuretic or water pill that helped remove some of the
fluid and made changes to your home medications as described
below. You should also weigh yourself every day and call your
PCP if your weight starts to increase because your fluid may be
buiding up again. You should follow up with your PCP and have an
appointment made through her office with a cardiologist. You
should also have labs drawn on ___.
It was a pleasure taking care of you,
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19774163-DS-24
| 19,774,163 | 22,440,485 |
DS
| 24 |
2121-04-26 00:00:00
|
2121-04-25 11:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Acetaminophen / Nitroglycerin / adhesive tape / latex /
olanzapine / Seroquel
Attending: ___.
Chief Complaint:
Abdominal distension, dyspnea
Major Surgical or Invasive Procedure:
___ Paracentesis
History of Present Illness:
___ y.o M with year old male with EtOH/HepC cirrhosis and a
history of varices banded in late ___ at ___, ___, IDDM and
h/o IVDU who is presenting for worsening ascites and abdominal
pain.
He was seen in clinic yesterday and was thought to have
decompensated cirrhosis with large volume fluid overload. He was
recommended to be admitted to the hospital at that time,
however, he declined admission against medical advice.
He states that he is coming to the hospital because his doctor
told him too. He reports having therapeutic taps done at ___,
most recently on ___, with drainage of 8L. He states he
feels that they are doing the taps wrong because his ascites
continues to get worse. He states that he has taps approximately
twice per week. He reports that his abdominal distention has
become so severe that he is having difficulty breathing. He
reports a dull aching sensation in his chest associated with his
difficultly taking a deep breath. He also endorses bright red
blood in his bowel movements over the past few days. He does not
know if he has had this before. He states he had > 5 bloody
bowel movements, but denies diarrhea. He reports this resolved
on his own. He denies dark or tarry stools. He otherwise
endorses decreased appetite.
In the ED, initial vital signs were 98.4 102 134/86 20.
Diagnostic paracentesis was performed.
Labs significant for WBC 10.8, H/H of 8.5/26.3, Plt 62. BMP with
Na 129, K 3.0, Cl 89, HCO3 32, BUN 27, Cr 1.2. Lactate 2.8. UA
negative. Peritoneal fluidw ith 95 WBC, 36% polys.
CT A/P showed large volume ascites and cirrhotic morphology with
splenomegaly.
He received 4 mg IV morphine sulfate, 40 mg IV pantoprazole and
40 meq K/1000 mL
Vital signs prior to transfer 97.6 98 140/87 15 92% RA 96% Nasal
Cannula
Past Medical History:
1. Hypertrophic obstructive cardiomyopathy previously followed
at ___, now at ___.
2. Diabetes.
3. Diastolic dysfunction.
4. History of prolonged QT interval.
5. History of heroin dependence.
6. History of alcohol dependence.
7. Hepatitis C.
8. Cirrhosis.
9. Esophageal varices with GI bleeding with multiple esophageal
banding procedures.
10. History of falls.
11. Anemia.
12. Asthma.
13. RA
Social History:
___
Family History:
His mother had diabetes, but there is no family history of
premature coronary artery disease.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vital Signs: 97.7 ___ 20 95 ra 130.68 kg
General: Alert, oriented, no acute distress
HEENT: Scleral icterus, MMM, oropharynx clear, EOMI, PERRL,
neck supple, + tongue fasciculations
CV: Regular rate and rhythm, normal S1 + S2, holosystolic
murmur best heard at the LSB
Lungs: decreased breath sounds anteriorly
Abdomen: distended, dull to percussion, mild tenderness to
palpation in all quadrants without rebound or guarding, +
umbilical hernia that is reducible
GU: No foley
Ext: Warm, well perfused, 1+ DP pulses, chronic venous stasis
discoloration of bilateral lower extremities with 1+ pitting
edema up to the shins
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
alert and oriented x 3, + mild asterixis
DISCHARGE PHYSICAL EXAMINATION:
VITALS - 97.5 | 118/66 | 89 | 18 | 93%/RA | 120.75 kg
GENERAL - comfortable, at rest, rouses easily to voice, no acute
distress
HEENT - mild scleral icterus, PERRL
NECK - supple, large
CARDIAC - regular, normal S1/S2, grade III holosystolic murmur
loudest at apex
LUNGS - absent breath sounds in right lung field to at least ___
way up, basilar left crackles but otherwise clear
ABDOMEN - massively distended, tense, protruding umbilicus
(difficult to reduce), notable abdominal wall veins, normal
bowel sounds
EXTREMITIES - dry, erythematous, wrinkled skin over the
bilateral lower extremities consistent with chronic venous
insufficiency, trace to 1+ pitting edema to the mid calves
SKIN - multiple tattoos, ecchymoses
NEUROLOGIC - A&Ox3, no asterxis, attentive to days of the week
backwards, no appreciable myoclonus vs. reported admission exam
PSYCH - low mood, not consistently agreeable but appropriate
with this examiner
Pertinent Results:
ADMISSION LABS:
===============
___ 05:40PM BLOOD WBC-10.8*# RBC-2.74*# Hgb-8.5* Hct-26.3*
MCV-96# MCH-31.0# MCHC-32.3# RDW-20.4* RDWSD-66.9* Plt Ct-62*
___ 05:40PM BLOOD ___ PTT-29.0 ___
___ 05:40PM BLOOD Glucose-112* UreaN-27* Creat-1.2 Na-129*
K-3.0* Cl-89* HCO3-32 AnGap-11
___ 05:40PM BLOOD ALT-57* AST-132* AlkPhos-126 TotBili-5.7*
DirBili-4.0* IndBili-1.7
___ 05:40PM BLOOD Albumin-2.7* Calcium-7.6* Phos-2.9 Mg-2.1
___ 06:58PM ASCITES WBC-95* ___ Polys-36* Lymphs-5*
Monos-0 Eos-1* Mesothe-2* Macroph-56*
___ 06:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-8* pH-6.0 Leuks-NEG
___ 06:30PM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:30PM URINE CastHy-7*
IMAGING STUDIES:
================
___ CXR (PA/LAT)
Large right pleural effusion with consolidation in the right
lower lung
concerning for atelectasis and/or pneumonia.
___ CT ABD/PELVIS
1. Interval increase in ascites, now a large volume.
2. Cirrhotic morphology with sequela of portal hypertension
including
splenomegaly.
3. Interval enlargement of fluid containing umbilical hernia,
now measuring up to 10.1 cm.
4. Anasarca.
5. Cholelithiasis.
___ CXR (PA/LAT)
Large right pleural effusion, worsened.
MICROBIOLOGY:
=============
___ 6:30 pm URINE
URINE CULTURE (Preliminary):
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
DISCHARGE LABS:
===============
___ 06:07AM BLOOD WBC-4.7 RBC-2.32* Hgb-7.2* Hct-22.4*
MCV-97 MCH-31.0 MCHC-32.1 RDW-19.9* RDWSD-68.8* Plt Ct-38*
___ 06:07AM BLOOD ___ PTT-34.1 ___
___ 06:07AM BLOOD Glucose-109* UreaN-19 Creat-1.1 Na-133
K-3.1* Cl-92* HCO3-33* AnGap-11
___ 06:07AM BLOOD ALT-22 AST-34 AlkPhos-97 TotBili-4.6*
___ 06:07AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.5*
Brief Hospital Course:
Mr. ___ is a ___ year old man with etOH and HCV cirrhosis,
among multiple other medical conditions (HCM, dCHF, prolonged
QTc), poorly compliant with care and poor historian, who
presented with abdominal distension & dyspnea, found to have
significant ascites, increased right pleural effusion, and
downtrending hemoglobin. Patient underwent therapeutic
paracentesis, transfusion of blood & platelets, and then decided
to leave against medical advice.
At the time the patient decided to leave against medical advice,
no signs of encephalopathy on exam. Patient able to repeat back
to MD team that risk of leaving against medical advice included
worsening ascites, mental status, bleeding, further
decompensation of cirrhosis and death. Asked to follow up in
clinic this week.
ACTIVE ISSUES
# ASCITES: patient poor historian & gets fragmented care at ___
and ___ (though record not accessible). Reports having twice
weekly paracentesis, last 4 days prior to admission, when 8 L
removed. Patient does not know his medications, though notes
indicate the patient is on an oral diuretic regimen. Unable to
reach patient's ___ for further collateral (and patient refused
to allow team to contact family for collateral). Infectious work
up showed ascites negative for SBP. UA unremarkable, with
culture growing 10k-100k Gram-positive bacteria (not further
speciated at time of patient leaving AMA). Blood cultures with
no growth to date. Abdominal imaging with out portal venous
clot. CXR with large right sided hepatohydrothorax, though
possible obscuration of pneumonia, so given ceftriaxone 1 g x1
overnight ___. S/p 9L paracentisis ___ with transfusion of 1u
platelets and 1u pRBC. Patient unaware of home medications, so
given 80 mg furosemide & 150 mg spironolactone. Told to follow
up with Liver Clinic.
# HEPATIC ENCEPHALOPATHY: Improved with lactulose PO and PR.
Patient with history of hepatic encephalopathy, presenting with
asterixis, tongue fasiculations. Mental status with confusion
and waxing/waning levels of consciousness. Infectious
evaluation, as above. Discharged with PO lactulose & rifaximin.
# ANEMIA, and
# BRIGHT RED BLOOD, PER RECTUM: Hb 8.5 on admission, down to 6.7
on ___. Received 1u pRBC on ___ with appropriate bump. Had
endorsed bright red blood, per rectum, in ED, though has had
none since being in house. Vital signs stable during
hospitalization. Patient has known varices, unclear when last
banded (if done elsewhere), though last on file at ___ ___.
Stools guaiac positive. Hgb 7.0 on ___ am. Patient insisted on
leaving against medical advice. Given Rx omeprazole 20 mg BID
and nadolol 20 mg QD; told to follow up in Liver Clinic this
week.
# MILD MALNUTRIITON: patient reports poor appetite and decreased
oral intake recently. Suspect secondary to large ascites. Given
multivitamin, thiamine & folate on leaving against medical
advice.
RESOLVED HOSPITAL ISSUES
=======================
# LEUKOCYTOSIS: resolved. Perhaps related to stress reaction on
arrival; mildly elevated to 10.4. Received 1 dose ceftriaxone
for leukocytosis and possible pneumonia on CXR, though
clinically very low suspicion for pneumonia, so ceftriaxone
stopped.
# ACUTE KIDNEY INJURY: admission Cr up to 1.2, from baseline
0.8-1.1. Likely secondary to hypovolemia, perhaps given
bleeding? 100 g albumin given overnight HD#1, with improved Cr
to baseline.
CHRONIC ISSUES
==============
# CIRRHOSIS: Secondary to hepatitis C/EtOH. MELD score of 24 up
on admission. No labs in our system since ___, however,
LFTs uptrending since that time. Complicated by ascites, HE and
bleeding. Poorly compliant with medical therapies.
# HISTORY OF IV NARCOTIC ABUSE: on 80 mg methadone daily, from
Habit Management ___ clinic in ___ [___].
Continued while in house.
# TYPE II DIABETES MELLITUS: denies taking insulin, and does not
know medications. Covered with ISS while in house - all FSG
<150, so no insulin required. Stopped on discharge.
# COAGULOPATHY, and
# THROMBOCYTOPENIA: Reported BRBPR on admission, though none
while in house. Admission Hb (8.5) at baseline, though drop, as
above. INR 1.4. Coagulopathy secondary to cirrhosis.
=======================================
TRANSITIONAL ISSUES
=======================================
# ASCITES:
- Discharged on furosemide 80 mg & spironolactone 150 mg QD
- Discharge weight: 120.75 kg
- Will likely need continued outpatient paracentesis on a weekly
to biweekly basis
# ANEMIA: reported BRBPR, but none in house. Hb downtrended,
requiring 1 u PRBC transfusion. At AMA, given omeprazole 20 mg
BID and nadolol 20 mg QD.
# R PLEURAL EFFUSION: patient refused to remain in house for
diagnostic thoracentesis. Given massive ascites,
poorly-controlled, suspect hepatic hydrothorax.
# POSITIVE URINE CULTURE: UA unremarkable, with culture growing
10k-100k Gram-positive bacteria (not further speciated at time
of patient leaving AMA). Follow up culture data, consider
treatment if necessary.
# CONTACT: patient, refusing to allow team to speak with family
at this time ("my mom has made bad health decisions for me").
___ has patient's sister listed as his emergency contact
___.
-- ___, ___
Medications on Admission:
Patient unaware of home medications, other than methadone 80 mg
QD
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Furosemide 80 mg PO DAILY
RX *furosemide 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 30 mL by mouth three times daily
Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
7. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
8. Spironolactone 150 mg PO DAILY
RX *spironolactone 50 mg 3 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
10. Methadone 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: hepatic encephalopathy, diuretic-resistant
ascites, anemia, alcoholic and HCV cirrhosis
Secondary diagnoses: type II diabetes mellitus
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with increasing size of your belly
from build up of fluid and trouble breathing. Your trouble
breathing got better with drainage of the fluid from your belly,
but there's also fluid in your right lung.
You were also quite confused and sleepy, which is from build up
of toxins from your liver. We treated this with lactulose.
We believe you should remain in the hospital for further
treatment however, against medical advice, you decided to leave.
Please take NADOLOL + OMEPRAZOLE, a new medication, to help
decrease your risk of bleeding.
We wish you the very best,
Your care team at ___
Followup Instructions:
___
|
19774163-DS-25
| 19,774,163 | 24,598,558 |
DS
| 25 |
2121-07-24 00:00:00
|
2121-07-26 19:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Acetaminophen / Nitroglycerin / adhesive tape / latex /
olanzapine / Seroquel
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
Diagnostic paracentesis (___)
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ y.o M with year old male with EtOH/HepC cirrhosis and a
history of varices banded in late ___ at ___, ___, ?DM and
h/o IVDU who is presenting for medication noncompliance and
confusion.
As per relative, the patient has been complaining of abdominal
and back pain for the past 3 days. Patient was last in the
hospital for therapeutic tap on ___ and has been getting
bi-weekly paracentesis at ___. Also states the patient has been
confused. She does believe that the patient has been taking his
medicine when the visiting nurse comes. Denies fevers but
endorses chills. Denies diarrhea or vomiting. Denies blood in
stool.
In the ED initial vitals: T:98.7 | HR:86 | 144/80 | RR:18 | 98%
RA
- Exam notable for: Somnolent but arousable, confused, diffuse
abdominal tenderness and distention, ventral hernia
- Imaging notable for:
___ CXR IMPRESSION:
Mild pulmonary vascular congestion with small right pleural
effusion,
decreased in size compared to the prior exam, and associated
right basilar atelectasis. Please note that infection in the
right lung base cannot be excluded in the correct clinical
setting.
___ Complete Abdominal Ultrasound
IMPRESSION:
1. Patent main portal vein with hepatopetal flow.
2. Cirrhotic liver and moderate to large ascites.
___ CT Abd Pelvis
IMPRESSION:
1. No acute process identified.
2. Cirrhotic liver, splenomegaly, and moderate ascites.
3. Moderate right pleural effusion, decreased in size, with
focal rounded right lower lobe opacity, likely rounded
atelectasis.
4. Cholelithiasis without acute cholecystitis.
5. Large umbilical hernia containing fluid, unchanged.
- Labs notable for:
Ascites: 256 WBC wit 9% poly's
Electrolytes: Na 135 corrected for glucose of 144 is Na 136
And ___ with Cr of 1.4 from baseline 0.9-1.1 with BUN 24
Bili 2.9
Alb 2.4
CBC notable for Thrombocytopenia (___) and Anemia (Hgb of 8.3)
INR 1.5
- Patient was given: 1L NS
- Vitals prior to transfer: 98.0 | HR:81 | 144/92 | RR:21 | 100%
RA
On the floor patient was altered and unable to provide
additional history. Wanted water, and says that he may have
missed some medications
Past Medical History:
1. Hypertrophic obstructive cardiomyopathy previously followed
at ___, now at ___.
2. Diabetes.
3. Diastolic dysfunction.
4. History of prolonged QT interval.
5. History of heroin dependence.
6. History of alcohol dependence.
7. Hepatitis C.
8. Cirrhosis.
9. Esophageal varices with GI bleeding with multiple esophageal
banding procedures.
10. History of falls.
11. Anemia.
12. Asthma.
13. RA
Social History:
___
Family History:
His mother had diabetes, but there is no family history of
premature coronary artery disease.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VITAL SIGNS - 98.2 | 150/88 | 85 | 18 | 98 RA
GENERAL - Altered, obese man, NAD, lying in bed
HEENT - PERRLA, minimal scleral icterus
NECK - JVD assessment limited by habitus
CARDIAC - ___ holosystolic murmur best heard a LUSB
PULMONARY - CTAB
ABDOMEN - Distended, firm, significant reducible umbilical
hernia, +fluid wave, diffusely mildly tender to palpation; no
audible bowel sounds
GENITOURINARY - Deferred
EXTREMITIES - Warm well profused, radila 2+ bilaterally, 1+
edema bilaterally to shins
SKIN - Mildly jaundiced, venous stasis changes in bilateral
lower extremities, abrasions on toes bilaterally
NEUROLOGIC - A&Ox1, confused, significant asterixis, able to sit
up
DISCHARGE PHYSICAL EXAMINATION:
VITAL SIGNS - 97.8 120/73 89 22 98 RA
GENERAL - AOx3, obese man, NAD, sitting comfortably at bedside
HEENT - PERRLA, minimal scleral icterus
NECK - JVD assessment limited by habitus
CARDIAC - ___ systolic ejection murmur best heard a LUSB
PULMONARY - CTAB
ABDOMEN - Distended, firm, significant reducible umbilical
hernia, +fluid wave, no tenderness to palpation
EXTREMITIES - Warm well profused, radial pulses 2+ bilaterally,
2+ edema bilaterally to shins
SKIN - Mildly jaundiced, venous stasis changes in bilateral
lower extremities, abrasions on toes bilaterally
NEUROLOGIC - A&Ox3, confused, +asterixis
Pertinent Results:
===============
Admission Labs
===============
___ 12:45PM BLOOD WBC-6.2 RBC-3.41* Hgb-8.3* Hct-27.8*
MCV-82# MCH-24.3* MCHC-29.9* RDW-20.1* RDWSD-58.8* Plt Ct-71*
___ 12:45PM BLOOD Neuts-79.5* Lymphs-8.7* Monos-9.5 Eos-1.4
Baso-0.3 Im ___ AbsNeut-4.93 AbsLymp-0.54* AbsMono-0.59
AbsEos-0.09 AbsBaso-0.02
___ 12:45PM BLOOD ___ PTT-30.8 ___
___ 12:45PM BLOOD Glucose-144* UreaN-24* Creat-1.4* Na-135
K-3.7 Cl-98 HCO3-28 AnGap-13
___ 12:45PM BLOOD ALT-25 AST-58* AlkPhos-187* TotBili-2.9*
DirBili-1.8* IndBili-1.1
___ 12:45PM BLOOD Albumin-2.4* Calcium-8.0* Mg-1.6
___ 12:57PM BLOOD Lactate-1.7
___ 02:52PM ASCITES WBC-256* ___ Polys-9* Lymphs-11*
Monos-21* Eos-2* NRBC-1* Mesothe-2* Macroph-55*
___ 02:52PM ASCITES TotPro-0.8 Glucose-158
================
Notable Labs
================
___ 06:30AM BLOOD calTIBC-248* Ferritn-47 TRF-191*
___ 10:43PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:43PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-6.0 Leuks-NEG
___ 10:43PM URINE Hours-RANDOM UreaN-1092 Creat-164 Na-<20
================
Discharge Labs
================
___ 05:14AM BLOOD WBC-3.8* RBC-3.05* Hgb-7.5* Hct-25.5*
MCV-84 MCH-24.6* MCHC-29.4* RDW-20.0* RDWSD-59.0* Plt Ct-45*
___ 05:14AM BLOOD ___ PTT-35.2 ___
___ 05:14AM BLOOD Glucose-186* UreaN-22* Creat-1.2 Na-132*
K-4.3 Cl-96 HCO3-25 AnGap-15
___ 05:14AM BLOOD ALT-17 AST-42* AlkPhos-139* TotBili-4.4*
===============
Microbiology
===============
___ 12:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending): (as of ___ 3:11 pm BLOOD CULTURE
Blood Culture, Routine (Pending): (as of ___ 6:30 am BLOOD CULTURE
Blood Culture, Routine (Pending): (as of ___ 2:52 pm PERITONEAL FLUID
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
================
Imaging
================
___ CHEST (AP AND LAT)
IMPRESSION:
Mild pulmonary vascular congestion with small right pleural
effusion,
decreased in size compared to the prior exam, and associated
right basilar atelectasis. Please note that infection in the
right lung base cannot be excluded in the correct clinical
setting.
___ LIVER US
IMPRESSION:
1. Patent main portal vein with hepatopetal flow.
2. Cirrhotic liver and moderate to large ascites.
___ CT Abd/Pelvis
IMPRESSION:
1. No acute process identified.
2. Cirrhotic liver, splenomegaly, and moderate ascites.
3. Moderate right pleural effusion, decreased in size, with
focal rounded right lower lobe opacity, likely rounded
atelectasis.
4. Cholelithiasis without acute cholecystitis.
5. Large umbilical hernia containing fluid, unchanged.
Brief Hospital Course:
Mr. ___ is a ___ y/o man with history of EtOH/HCV cirrhosis
complicated by hepatic encephalopathy, varices s/p banding,
diuretic-resistant ascites; hypertrophic obstructive
cardiomyopathy; history of IVDU on methadone who presented for
altered mental status in the setting of medication
noncompliance. The patient's lactulose as restarted with
improvement in his mental status. He was also given albumen for
concern of hepato-renal syndrome and creatinine improved from
1.4 to 1.2 on discharge. He was also given 2 units PRBC for
chronic anemia.
## AMS/ hepatic encephalopathy: H/o hep C cirrhosis with many
recent paracentesis, presenting with AMS and moderate ascites.
Gets paracentesis 2xs weekly. Has significant abdominal
distention. Exam initially notable for asterixis on exam. Tox
screen neg. CXR with small pleural effusion, similar compared to
recent imaging. Not SBP based on peritoneal fluid analysis. No
positive cultures from blood or ascites. No portal vein
thrombosis seen on RUQ US. No fevers or other signs of
infection. Patient given rifamixin and aggressive lactulose
until passing clear and his mental improved over his stay and he
was cleared for discharge.
## Cirrhosis: EtOH/HepC cirrhosis. H/o SBP and esophageal
varices s/p banding. MELD score on admission is 21 (___) and
22 on discharge ___ Childs score ___ (Class C). H/o
esophageal varices with GI bleeding. Has had multiple esophageal
banding procedures in ___. Last EGD in ___ and on nadolol.
Prior to admission, most recent liver US in ___. INR 1.5.
Platelets 45 at time of discharge (at baseline from prior
discharge). Per OMR note, not a candidate for a TIPS given his
diastolic dysfunction. Nadolol and diuretics held until
followup appointment onf ___.
## ___: Cr. to ~1.5 on presentation from baseline 0.9-1.1.
Likely HRS, have given albumin. Urine lytes consistent with
renal hypo-perfusion, FeUrea <35%. Held home diuretics and
nadolol until f/u appointment ___.
## ASCITES: Presented with moderate ascites. Has been getting
paracentesis twice weekly at ___. No SBP based on
peritoneal fluid analysis. Patient received only a diagnostic
tap while in the hospital.
#Anemia: H&H 8.3/27.8 on admission and at baseline from recent
discharge in ___. Iron labs consistent with ACD (ferritin low
in setting of chronic liver disease). Hb 6.7 ___ that was
likely in part due to dilutional effect, improved to 8.4/7.5
after 1UPRBCs ___, and a second unit was given prior to
discharge.
## NUTRITION: Diet was advanced as patient cleared. Continued on
thiamine, multivitamin and folate
#Diabetes: h/o diabetes; not on medication, on insulin sliding
scale in hospital and discontinued at discahrged
#h/o IVDU: on methadone continued in hospital
TRANSITIONAL ISSUES:
- Medication changes:
-- Furosemide, spironolactone, and nadolol held during this
admission and at discharge. Patient will discuss with his
hepatologist when to restart these medications.
- Discharge weight: 133.7 kg
- Will likely need continued outpatient paracentesis on a weekly
to biweekly basis
- Patient has ___ appointment at the ___
- Communication: Mother/HCP, ___, ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 20 mg PO DAILY
3. Methadone 80 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Lactulose 30 mL PO QID
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO BID
8. Rifaximin 550 mg PO BID
9. Thiamine 100 mg PO DAILY
10. Nadolol 20 mg PO DAILY
11. Spironolactone 75 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate [Iron (ferrous sulfate)] 325 mg (65 mg iron)
1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. Lactulose 30 mL PO QID
RX *lactulose 10 gram/15 mL (15 mL) 30 mL by mouth four times a
day Disp #*900 Milliliter Milliliter Refills:*0
4. Methadone 80 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Multiple Vitamins] 1 tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*0
6. Omeprazole 20 mg PO BID
RX *omeprazole 20 mg 1 capsule(s) by mouth Twice a day Disp #*60
Capsule Refills:*0
7. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth Twice a day
Disp #*60 Tablet Refills:*0
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth Daily
Disp #*30 Tablet Refills:*0
9. HELD- Furosemide 20 mg PO DAILY This medication was held. Do
not restart Furosemide until you talk to your liver doctor
10. HELD- Nadolol 20 mg PO DAILY This medication was held. Do
not restart Nadolol until you talk to your liver doctor
11. HELD- Spironolactone 75 mg PO DAILY This medication was
held. Do not restart Spironolactone until you talk to your liver
doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Hepatic encephalopathy, acute kidney injury, acute on
chronic anemia
SECONDARY: Cirrhosis secondary to Hepatitis C virus and alcohol,
diuretic-resistant ascites
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 a taking care of you. You came to the hospital
because you were slightly more confused, likely because of
missing a few doses of your medications including your
lactulose. We restarted this medication and you felt better.
Please take this every day to ensure you have ___ bowel
movements per day so that your thinking can remain clear.
We also found that your kidney function was temporarily worse
that your baseline. We gave you albumin, and your kidney
function improved. Your blood counts were also low and we gave
you blood transfusions to help with this.
Please take all of your medications as directed and follow up
with your liver doctor.
We wish you the best of health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19774163-DS-26
| 19,774,163 | 20,527,495 |
DS
| 26 |
2121-08-07 00:00:00
|
2121-08-07 22:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Acetaminophen / Nitroglycerin / adhesive tape / latex /
olanzapine / Seroquel
Attending: ___
Chief Complaint:
Referred from clinic for paracentesis, PICC line, and palliative
care consult
Major Surgical or Invasive Procedure:
___
Large volume paracentesis
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
Mr. ___ is a ___ h/o EtOH/HCV cirrhosis (Childs C, MELD 24 c/b
___ ascites, multiple variceal bleeds, ___, DM,
HTN, HOCM, asthma, RA, h/o IVDU w/ difficult IV access who
presented to liver clinic with worsening ascites now referred by
Dr. ___ therapeutic paracentesis, PICC placement and
palliative care consult.
Patient was recently admitted from ___ for hepatic
encephalopathy. Infectious ___ including diagnostic
paracentesis negative and RUQ showed patent vasculature. Mental
status improved with lactulose and rifaxamin. His course was
complicated by ___ (HRS likely HRS s/p albumin) and his home
diuretics were held upon discharge . Since then ___ has required
therapeutic paracentesis (obtained at ___ in ___ every
___ days where 8 to 10.5 L (last 10.5 on ___, no albumin given
due to poor iv access) removed. Unfortunately, ___ has had
significant difficulty with IV access because of history of IVDU
and therefore was referred to ___ for ___ line placement,
therapeutic para, and palliative care consult.
Otherwise, the patient endorses persistent acid reflux and
nausea but no vomiting, intermittent diarrhea/constipation (on
lactulose). Mentation at baseline. ROS otherwise negative. Last
ETOH drink about 1.5 weeks ago. Has been in ___ clinic,
gets 80 mg daily with last dose this AM.
IN THE ED:
Initial vitals were T: 97.4 HR: 87 BP: 148/79 Resp: 20 O(2)Sat:
100RA
Labs of note were
CBC: ___ ___ ___
BMP: ___ ___ ___ ___ ___ ___ ___
LFTs: ___ ___ ___ ___ Albumin 2.8
INR: 1.5
Lactate: 1.5
Studies done were
CXR ___:
Right PICC tip at the ___/ right atrial junction. Slight
increased size of small right pleural effusion with right
basilar atelectasis.
Patient was given
-Albumin 25% (12.5g / 50mL) 50 g IV ONCE Duration: 1 Dose ]
-Potassium Chloride 60 mEq PO ONCE Duration: 1 Dose
-Magnesium Sulfate 4 gm IV ONCE
A PICC line was placed.
Past Medical History:
1. Hypertrophic obstructive cardiomyopathy previously followed
at ___, now at ___.
2. Diabetes.
3. Diastolic dysfunction.
4. History of prolonged QT interval.
5. History of heroin dependence.
6. History of alcohol dependence.
7. Hepatitis C.
8. Cirrhosis.
9. Esophageal varices with GI bleeding with multiple esophageal
banding procedures.
10. History of falls.
11. Anemia.
12. Asthma.
13. RA
Social History:
___
Family History:
His mother had diabetes, but there is no family history of
premature coronary artery disease.
Physical Exam:
ADMISSION EXAM
==============
VS: Tmax 97.3 BP ___ HR ___ RR 18 ___ on RA
Weight: (admit wt 136.9 kg)
GENERAL: ___, in no apparent distress, but
occasionally shifts uncomfortably
HEENT: Normocephalic, atraumatic, slight conjunctival icterus
HEART: RRR, normal S1/S2, no murmurs rubs or gallops.
LUNGS: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Abdomen extremely distended and tense. Normal bowel
sounds, tender to palpation especially in RUQ but no rebound or
guarding.
EXTREMITIES: Warm, ___, no cyanosis, clubbing or
edema. Spoon nails.
SKIN: Without rash. Many tattoos and small punctate lesions on
skin.
NEUROLOGIC: A&Ox3, CN ___ grossly normal + asterixis
ACCESS: R PICC
DISCHARGE EXAM
==============
VS: 98.3 PO 112 / 69 81 18 95 RA
Weight: 133.31 (admit wt 136.9 kg)
GENERAL: ___, in no apparent distress
HEENT: Normocephalic, atraumatic, slight conjunctival icterus
HEART: RRR, normal S1/S2, no murmurs rubs or gallops.
LUNGS: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Abdomen extremely distended but less tense after LVP on
___. Normal bowel sounds, not tender to palpation.
EXTREMITIES: Warm, ___, no cyanosis, + edema
bilaterally, Spoon nails.
SKIN: Without rash. Many tattoos and small punctate lesions on
skin.
NEUROLOGIC: A&Ox3, CN ___ grossly normal, no asterixis
ACCESS: R ___
Pertinent Results:
ADMISSION LABS
==============
___ 01:17PM BLOOD ___
___ Plt ___
___ 01:17PM BLOOD ___
___ Im ___
___
___ 01:17PM BLOOD Plt ___
___ 01:17PM BLOOD ___ ___
___ 01:17PM BLOOD ___
___
___ 01:17PM BLOOD ___
___ 01:17PM BLOOD ___
___ 01:17PM BLOOD ___
___ 01:17PM BLOOD ___
___
OTHER LABS
==========
___ 06:40PM URINE ___ Sp ___
___ 06:40PM URINE ___
___ ___
___ 06:40PM URINE ___
___ 06:40PM URINE ___
___ 12:56PM URINE ___ Na-<20
___ Cl-<20 HCO3-<2
___ 06:40PM URINE ___
___
MICRO
=====
___ 6:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
PROTEUS MIRABILIS. ___ CFU/mL.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ FLUIDGRAM ___ FLUID
___ ANAEROBIC ___
___ CULTUREBlood Culture,
___ WARD
IMAGING
=======
___ CXR
IMPRESSION:
Right PICC tip at the SVC/ right atrial junction. Slight
increased size of
small right pleural effusion with right basilar atelectasis.
DISCHARGE LABS
==============
___ 05:39AM BLOOD ___
___ Plt ___
___ 05:39AM BLOOD ___ ___
___ 05:39AM BLOOD Plt ___
___ 05:39AM BLOOD ___
___
___ 05:39AM BLOOD ___ LD(LDH)-189 ___
___
___ 05:39AM BLOOD ___
Brief Hospital Course:
HOSPITAL COURSE
===============
Mr. ___ is a ___ h/o EtOH/HCV cirrhosis (Childs C, MELD 24 c/b
___ ascites, multiple variceal bleeds, ___, DM,
HTN, HOCM, asthma, RA, h/o IVDU w/ difficult IV access who
presented to liver clinic with worsening ascites referred by Dr.
___ therapeutic paracentesis, PICC placement and
palliative care consult. ___ had a PICC line placed. ___ underwent
large volume paracentesis in ___ with 8.75 liters drained. ___
received 100g albumin x 2. Labs were notable for a persistently
elevated Cr to 1.5, from a baseline of 1.0, which did not
respond to albumin as above. His H/H was noted to be slightly
downtrending, with a Hb of 6.7 on the day of discharge, however,
the patient refused transfusion.
The patient was counseled multiple times during this admission
that ___ had a ___ condition likely measured in months,
not years. ___ was counseled that ___ had two options: ___ could
attempt to maintain sobriety, follow all medical and and dietary
advice, and continue to receive large volume paracenteses.
Alternatively, the patient could opt for palliatative care and
have a PleurX catheter placed. The patient understood these
choices, asked appropriate questions, and initially chose
medical management. However, as the patient developed ___ and
anemia, ___ chose to suddenly leave against medical advice.
ACTIVE ISSUES
=============
# Cirrhosis: EtOH/HCV cirrhosis (Childs C, MELD 24) c/b
___ ascites, multiple variceal bleeds, and ___.
Last EGD in ___ with ligation of esophageal varices
previously on nadolol, however, held on last admission. Per OMR
note, not a candidate for a TIPS given his diastolic
dysfunction. Admitted for refractory ascites and need for IV
access. ___ placed ___, LVP with 9L on ___. Continuedd home
lactulose and rifaxamin (titrated to ___ per day). Continued
home nadolod. STOPPED diuretics on discharge due to concern with
___.
# ASCITES: Patient with known refractory ascites requiring
therapeutic paracentesis twice weekly at ___
___ removed each time). No SBP based on peritoneal fluid
analysis during last admission and patient at baseline mental
status. ___ placed ___, LVP with 9L on ___. Patient left
AMA, and PICC removed on discharge.
# Acute on Chronic Renal Failure: Patient with Cr uptrending to
1.5, from a prior baseline of 1.0. ___ received albumin 100g x 2
without appropriate response. Plan for ocreotide/midodrine, but
patient left AMA.
# GOALS OF CARE: Patient actively drinking, not eligible for
transplant list, guarded life expectancy. Patient states ___
would like to stop drinking to become eligible. If patient chose
to go with palliative care, ___ may be eligible to PleurX
catheter to reduce frequency of LVPs. Upon discussion with him
morning of discharge, the patient reported feeling very
frustrated that ___ was "lied to" about the effect of albumin and
was angry his creatinine had gone up. ___ left against medical
advice before ___ could be seen by palliative care.
# ANEMIA: H&H 7.2/23.8 on admission which was consistent with
discharge H&H during last hospitalization (7.5/25.5). Iron
studies consistent with anemia of chronic disease and no signs
of active bleeding. Of note, H/H drop to 6.___.9, however, the
patient refused blood transfusion and left AMA.
CHRONIC ISSUES
==============
# NUTRITION: Continued thiamine, multivitamin and folate. Seen
and counseled by nutrition.
# Diabetes: ISS
# h/o IVDU: Continued home methadone
# GERD: Omeprazole 20 mg PO BID
TRANSITIONAL ISSUES
===================
- Patient unable to be seen by palliative care over the weekend;
of note, initially the patient expressed desire to stop drinking
and the need for intensive resources to help him stop drinking.
Unfortunately, the patient then decided to leave AMA prior to
palliative care consult and a more organized, concerted effort
to help him.
- Please do not place PICC line during future hospitalizations
until the patient has been seen by the primary team and possibly
palliative care
- Blood/urine culture pending at the time of the discharge
- Discharge Hb of 6.7, slowly downtrending, no clear source -
patient refused blood transfusion
- Creatinine of 1.5 upon discharge, failed to respond to albumin
100g x2; HOLDING furosemide and spironolactone until follow up
with PCP
- ___ has a very difficult access and required PICC placement for
administration of IV albumin; given the patient's adamant desire
to leave abruptly in the morning, over the weekend, we were
unable to coordinate ___ line services
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 30 mL PO QID
4. Methadone 80 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO BID
7. Rifaximin 550 mg PO BID
8. Thiamine 100 mg PO DAILY
9. Nadolol 20 mg PO DAILY
10. Spironolactone 75 mg PO DAILY
11. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 30 mL PO QID
4. Methadone 80 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Nadolol 20 mg PO DAILY
7. Omeprazole 20 mg PO BID
8. Rifaximin 550 mg PO BID
9. Thiamine 100 mg PO DAILY
10.Outpatient Lab Work
Please draw CBC, BMP, hepatic panel, ___ and fax results
Attn Dr ___ to ___.
Diagnosis: cirrhosis
K 70.31
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
___ ascites
Anemia
Acute Kidney Injury, presumed hepatorenal syndrome
Secondary:
Alcoholic Cirrhosis
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 ___ at ___.
___ first came to the hospital because ___ were having much
worse ascites, or fluid in your belly. ___ had some of the fluid
removed. The fluid did not show any signs of infection.
We also kept ___ here because a measure of your kidney function,
your creatinine, looked a little worse than normal. We tried to
improve your kidney function with a medication called albumin.
Unfortunately, your kidney function did not improve. The next
steps would be to try either a blood transfusion to treat your
low blood counts or a medication to help with the kidneys. ___
were frustrated that your kidney function did not improve and
did not want to stay in the hospital to receive these
treatments. Please STOP taking the medications named furosemide
and spironolactone as these can affect your kidneys. Do not
start taking these medications again until ___ speak to your
doctors.
Because your kidney function is worse than before, we discussed
that failing to treat this problem could cause worsening liver
or kidney problems and may even lead to death. ___ understood
these risks and chose to leave the hospital at this time,
against medical advice.
Please take all of your medications as prescribed. Please follow
up with Dr. ___ as soon as ___ can, preferably next week, so
___ can recheck your blood counts
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19774387-DS-29
| 19,774,387 | 26,747,502 |
DS
| 29 |
2161-11-08 00:00:00
|
2161-11-10 17:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril / simvastatin
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy tube placement
History of Present Illness:
___ p/w weakness and lower back pain. The patient reports he
began to have low back pain that began at approximately 11 pm
the day prior to admission. He notes associated pain in his feet
conisistent with his prior neuropathy. He denies pain radiating
down his legs or saddle anesthesia. Pt had episode of urinary
incontinence today, which son states has happened in the past.
Bowel movements have been regular and formed, last yesterday. Pt
Denies falls, head injury, headache, changes in vision, or
numbness/tingling. No CP, sob, fever, chills, abd pain. Pt has
ataxia and peripheral neuropathy at baseline and remains
unchanged at this time. Pt did not eat lunch today but son
reports normal PO intake lately. The patient also notes total
body weakness. He describes it as feeling "unable to lift feet"
as he walks with his walker. Pt reports he did not did sleep
last night but does not think this contributed to his weakness.
Of note patient recently presented to ED on ___ for weakness
and leg pain and was admitted. CXR, UA, and head CT were all
clear and pt was discharged on ___. Felt fine yesterday and then
weakness returned as above. He reports weakness is similar
however back pain is new.
In the ED, initial vs were: 98.6 83 93/45 13 93%. Exam was
notable for an inability to ambulate independently. He was also
found to have normal rectal tone. Labs were remarkable for a Cr
of 1.4 from a baseline of 1 and a WBC of 11.9 with 84% bands. UA
showed 10 WBC and few bacteria. Xray of the spine showed normal
degenerative changes. Patient was given 1L NS, 500 mg of cipro
and admitted to medicine for further evaluation. Vitals on
Transfer:81 127/68 28 96%
On the floor, patient denies any back pain, he reports feeling
better but only endorses being tired.
Past Medical History:
PMHx:
CAD s/p CABG ___ with a LIMA to the LAD and SVG to the PDA, SVG
to the OM, cardiac cath ___ w/Hepacoat stent of the
SVG-OM, and the SVG to the PDA was noted to be occluded at this
time, most recent p-MIBI ___ w/mild inferior fixed defect
and EF 61%, diastolic dysfunction, and chronic DOE
HTN
HL
carpal tunnel syndrome
colonic polyps
B12 deficiency
hearing impairment, but stopped wearing hearing aids for unclear
reasons
degenerative joint disease C-spine
h/o ankle fracture
h/o nummular eczema
peripheral neuropathy
Cholestasis c/b cholangitis s/p ERCP
BPH s/p TURP in ___
Cataracts s/p surgery
PSHx:
CABG
Hemorrhoidectomy
TURP
ERCPs
Social History:
___
Family History:
Denies h/o cancer, liver disease
Physical Exam:
PHYSICAL EXAM:
Vitals: 98.2 135/80 95 18 96% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild ttp in the RUQ
Back: no spinal or paraspinal tenderness to palpation
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, strength ___ in bilateral lower
extremities, sensation decreased over feet but in tact in upper
legs, gait deferred. 1+ edema to the ankles R> L.
PHYSICAL EXAM:
Vitals:
HR 66, RR 20, Temp ___, BP 99/40, SpO2 97% on 2L NC
General: A somnolent gentleman in mild distress from pain.
Lungs: Nasal cannula in place, CTAB, no wheezes or crackles.
CV: Regular rate and rhythm, ___ SEM loudest at RUSB
Abdomen: soft, mildly tender over drain site. The stopcock for
the drain was pressing into the patient's skin; a towel was
placed to protect the skin. Drain in place with dry, clean gauze
overlying.
Ext: Warm, well perfused, 2+ pulses
Neuro: Somnolent but able to answer questions.
Pertinent Results:
___ 09:00PM BLOOD WBC-11.9* RBC-4.08* Hgb-12.7* Hct-37.9*
MCV-93 MCH-31.2 MCHC-33.6 RDW-13.8 Plt ___
___ 05:45AM BLOOD WBC-13.9* RBC-3.82* Hgb-11.8* Hct-35.7*
MCV-93 MCH-30.7 MCHC-32.9 RDW-14.0 Plt ___
___ 06:30PM BLOOD WBC-18.2* RBC-3.87* Hgb-12.0* Hct-35.8*
MCV-93 MCH-30.9 MCHC-33.4 RDW-13.7 Plt ___
___ 05:35AM BLOOD WBC-17.4* RBC-3.82* Hgb-11.9* Hct-36.1*
MCV-94 MCH-31.2 MCHC-33.0 RDW-13.8 Plt ___
___ 05:20AM BLOOD WBC-11.3* RBC-3.48* Hgb-10.7* Hct-32.7*
MCV-94 MCH-30.7 MCHC-32.7 RDW-13.8 Plt ___
___ 06:40AM BLOOD WBC-7.5 RBC-3.61* Hgb-11.0* Hct-34.2*
MCV-95 MCH-30.5 MCHC-32.2 RDW-14.0 Plt ___
___ 06:35AM BLOOD WBC-6.9 RBC-3.47* Hgb-10.8* Hct-33.1*
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.9 Plt ___
___ 09:00PM BLOOD Glucose-204* UreaN-23* Creat-1.4* Na-138
K-5.1 Cl-97 HCO3-28 AnGap-18
___ 05:45AM BLOOD Glucose-124* UreaN-19 Creat-1.2 Na-138
K-4.1 Cl-100 HCO3-28 AnGap-14
___ 06:30PM BLOOD Glucose-135* UreaN-19 Creat-1.3* Na-137
K-4.5 Cl-100 HCO3-24 AnGap-18
___ 05:35AM BLOOD Glucose-148* UreaN-18 Creat-1.2 Na-138
K-4.1 Cl-101 HCO3-26 AnGap-15
___ 05:20AM BLOOD Glucose-112* UreaN-24* Creat-1.5* Na-139
K-4.5 Cl-104 HCO3-24 AnGap-16
___ 06:40AM BLOOD UreaN-31* Creat-1.6* Na-140 K-4.4 Cl-104
HCO3-26 AnGap-14
___ 06:35AM BLOOD Glucose-108* UreaN-29* Creat-1.5* Na-138
K-4.4 Cl-104 HCO3-27 AnGap-11
___ 09:00PM BLOOD ALT-14 AST-36 LD(LDH)-405* CK(CPK)-71
AlkPhos-80 TotBili-0.4
___ 06:30PM BLOOD CK-MB-3 cTropnT-<0.01
___ 09:00PM BLOOD 25VitD-22*
Radiology:
Lumbar XRAY:
IMPRESSION: No evidence of acute fracture or dislocation.
Degenerative
changes.
RUS Ultrasound ___:
IMPRESSION:
Distended gallbladder with sludge and stones. Areas of wall
thickening,
overall improved since ___. These findings are nonspecific and
if clinical suspicion exists for acute cholecystitis, a HIDA
scan could be performed.
CT Abdomen ___:
IMPRESSION:
1. Gallbladder wall edema and surrounding fat-stranding,
similar in
appearance to ___. No common bile duct dilatation.
2. Pancolonic diverticulosis without evidence of
diverticulitis.
3. Stable 15 mm indeterminate right kidney lesion which, if
indicated, can be further evaluated by ultrasound.
Perc Cholecystostomy ___:
IMPRESSION:
Technically successful CT-guided percutaneous cholecystostomy
with placement of an 8 ___ ___ catheter.
CXR ___:
FINDINGS: The cardiomediastinal contours are within normal
limits. The lungs are clear except for linear atelectasis at
the left base. No new areas of consolidation to suggest the
presence of pneumonia, but standard PA and lateral chest
radiographs may be helpful for more complete evaluation of the
lung bases if the patient's symptoms persist.
Brief Hospital Course:
___ yo male with CAD, HTN, HL and cholangitis s/p temporary CBD
stent removal ___ who presents with new back pain and
progressive weakness, initially treated with PO cipro for UTI,
but then found to have acute cholecystitis.
# Acute cholecystitis complicated by sepsis and toxic metabolic
encephalopathy, now resolved: RUQ ultrasound and CT scan showed
gallbladder edema, stranding and stones c/w acute cholecystitis.
LFTs wnl to suggest no component of cholangitis. S/p perc
chole drain placement by ___ so source control achieved. Treated
initially with cefepime/flagyl then narrowed to cipro, last day
___. Pain improved, but not resolved. Pain likely ___
recent cholecystostomy tube placement. Delerious on ___ felt
secondary to pain, placed on ATC tylenol with improvement in
delerium. Perc drain needs to stay in place till 6 weeks post
discharge, at which time it can be removed by scheduling an
appointment with interventional radiology. He will f/u with
general surgery as an outpatient for consideration of
cholecystectomy.
# Acute on chronic dCHF: Occurred after receiving 750 cc's of
bolused fluids in the setting of hypotension ___ fentanyl/versed
in recovery after perc chole drain placement. Diuresed for one
day with resolution of pulmonary edema and hypoxia.
# Weakness/back pain- Weakness likely was occult presentation of
acute cholecystitis. Back pain likely referred from GB.
# Acute on chronic kidney injury- Currently Cr. 1.5. Baseline
varies a lot between 1.0 and 1.5. Suspect this is likely
muti-factorial in nature. Trend.
# CAD S/P CABG WITH DIASTOLIC DYSFUNCTION, CHRONIC DOE, HTN,
HYPERLIPIDEMIA: cont on ASA, metoprolol, and atorvastatin. Was
previously on plavix as an outpatient, discontinued after his
last admission when he underwent ERCP. Will f/u with his
cardiologist in ___ to consider restarting if surgery is not
an option.
# BPH S/P TURP: Cont finasteride. Tolteradine held given
anti-cholinergic effects and evidence of retention in the ED.
# PERIPHERAL NEUROPATHY: Patient was continued on gabapentin
(renally dosed).
Transitional Issues:
- f/u with general surgery
- removal of percutaneous cholecystostomy tube 6 weeks post
discharge by interventional radiology or surgery
- physical therapy
- continue ciprofloxacin till ___
- Code Status: DNR, Ok to intubate for short term, no not
resuscitate if codes during intubation, pressors OK
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Citalopram 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Gabapentin 200 mg PO TID
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Tolterodine 4 mg PO HS
9. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Citalopram 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Gabapentin 200 mg PO TID
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Ciprofloxacin HCl 500 mg PO Q12H
last day ___
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acalculous cholecystitis
Sepsis
Deconditioning
Acute toxic metabolic encephalopathy
Congestive heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with weakness, found to have cholecystitis
(infection of your gallbladder). You were placed on antibiotics
and a drain was placed in the gallbladder to drain the
infection. You did markedly better with this therapy and
improved. Physical therapy evaluated you and felt that you were
in need of rehab.
Followup Instructions:
___
|
19774387-DS-30
| 19,774,387 | 20,728,381 |
DS
| 30 |
2161-12-06 00:00:00
|
2161-12-13 22:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril / simvastatin
Attending: ___.
Chief Complaint:
Dislodged percutaneous cholecystostomy tube
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year gentleman with a history of
cholecystitis s/p ___ guided perc drain, who presents with perc
chole tube dislodgement. He has a recent history of
cholecystitis treated with percutaneous cholecystostomy as he
was not an operative candidate. He was discharged to ___
___. On the day of presentation to the ED he was at
rehabilitation when he stood up and accidentally pulled out his
percutaneous cholecystectomy tube. He presented to ___
___ for further evaluation. On admission he denied any
complaints, specifically denied abdominal pain. Per
rehabilitation report, Mr. ___ drain had continued to drain
100cc+ daily since placement.
In the ED, VS 100.0 90 122/56 22 95% 2L Nasal Cannula. RUQ US
and CXR performed. CBC was notable for lack of WBC count, Cr 1.5
near recent baseline. He was given vancomycin/cefepime and
admitted for Left lower lobe pneumonia in spite of final read on
CXR without any acute process.
Upon review of ___ records, it appears that Mr ___ has been
diagnosed in the past few days with a reported ESBL-e.coli UTI.
Initially he was treated with ciprofloxacin, which was changed
to bactrim on the day of admission. On the floor he had
suprapubic tenderness, but otherwise no complaints. On the night
of admission, ___ noted that the urine culture was
preliminary and had not returned with sensitivities; they had no
record of a positive ESBL culture although all their notes
stated +ESBL.
Past Medical History:
CAD s/p CABG ___ with a LIMA to the LAD and SVG to the PDA, SVG
to the OM, cardiac cath ___ w/Hepacoat stent of the
SVG-OM, and the SVG to the PDA was noted to be occluded at this
time, most recent p-MIBI ___ w/mild inferior fixed defect
and EF 61%, diastolic dysfunction, and chronic DOE
HTN
HL
carpal tunnel syndrome
colonic polyps
B12 deficiency
hearing impairment, but stopped wearing hearing aids for unclear
reasons
degenerative joint disease C-spine
h/o ankle fracture
h/o nummular eczema
peripheral neuropathy
Cholestasis c/b cholangitis s/p ERCP
BPH s/p TURP in ___
Cataracts s/p surgery
Social History:
___
Family History:
Denies history of cancer or liver disease
Physical Exam:
ON ADMISSION:
Vitals: 100.9 123/68 95 20 98%3L
General: NAD, tachypneic but not in respiratory distress
HEENT: PERRL EOMI OP clear
Neck: JVD ~3cm above clavicle @ 60 degrees
Lungs: CTAB -wrr
CV: RRR s1/s2 -mrg
Abdomen: soft, ttp over suprapubic otherwise non ttp
Ext: ___ pitting edema b/l lower extremities to the mid shin,
R>L
Skin: -rash
Neuro: AOx3, grossly intact
ON DISCHARGE:
General: Lying comfortably in bed, in no acute distress,
breathing comfortably
HEENT: PERRL, oropharynx clear, sclera anicteric
Neck: Supple with full ROM, no JVD
Lungs: CTAB, bibasilar crackles
CV: RRR s1/s2, no m/r/g
Abdomen: soft, normoactive BS, nontender to palpation
Ext: Warm and well perfused, no edema
Skin: no rash
Neuro: AOx3, grossly intact
Pertinent Results:
ON ADMISSION
___ 07:49PM WBC-10.4# RBC-4.07* HGB-12.4* HCT-37.8*
MCV-93 MCH-30.6 MCHC-32.8 RDW-14.3
___ 07:49PM NEUTS-87.0* LYMPHS-4.4* MONOS-5.0 EOS-3.3
BASOS-0.4
___ 07:49PM GLUCOSE-157* UREA N-27* CREAT-1.5* SODIUM-141
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-30 ANION GAP-15
___ 09:01PM LACTATE-1.7
___
White Blood Cells 8.9 4.0 - 11.0 K/uL
Red Blood Cells 3.81* 4.6 - 6.2 m/uL
Hemoglobin 11.3* 14.0 - 18.0 g/dL
Hematocrit 34.4* 40 - 52 %
ON DISCHARGE
___ 07:10AM BLOOD WBC-7.4 RBC-3.39* Hgb-10.3* Hct-31.2*
MCV-92 MCH-30.4 MCHC-33.1 RDW-14.2 Plt ___
___ 07:00AM BLOOD WBC-7.3 RBC-3.47* Hgb-10.3* Hct-32.0*
MCV-92 MCH-29.6 MCHC-32.2 RDW-14.0 Plt ___
___ 07:35AM BLOOD WBC-9.2 RBC-3.56* Hgb-10.8* Hct-32.8*
MCV-92 MCH-30.4 MCHC-33.0 RDW-14.2 Plt ___
___ 07:10AM BLOOD Glucose-108* UreaN-27* Creat-1.2 Na-140
K-4.1 Cl-104 HCO3-30 AnGap-10
___ 07:00AM BLOOD Glucose-108* UreaN-24* Creat-1.1 Na-142
K-4.1 Cl-103 HCO3-34* AnGap-9
___ 07:35AM BLOOD Glucose-104* UreaN-22* Creat-1.1 Na-142
K-4.8 Cl-102 HCO3-33* AnGap-12
IMAGING:
___: Video swallow
Barium passes freely through the oropharynx and esophagus
without evidence of obstruction. There was evidence of
retention versus reflux within the distal esophagus. After
ingestion of thin liquids there was evidence of penetration
without aspiration. For details, please refer to speech and
swallow division note in the ___ medical record.
IMPRESSION:
Penetration with thin liquids. No evidence of aspiration.
___ CXR
FINDINGS: Portable AP chest radiograph. Mild interstitial
edema is
unchanged, but small bilateral pleural effusions have slightly
increased in the interim. Median sternotomy wires are intact.
There is no pneumothorax. Heart size remains normal.
IMPRESSION: Stable mild interstitial pulmonary edema with
slight interval increase in pleural effusions.
___: CXR
Mild interstitial edema has been developing over the past two
days, though does not look severe enough to explain respiratory
insufficiency. Nevertheless, there is a small right pleural
effusion that was not present three days ago and there is
bibasilar peribronchial opacification in areas that were
previously clear. Heart size remains normal. Consideration
should be given to noncardiac causes of edema, which can produce
more profound respiratory insufficiency than the radiographic
findings would suggest. These include pulmonary drug reactions,
or sequelae to transfusion of blood products.
___: ECHO
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF = 45 %). The right ventricular free wall
thickness is normal. Right ventricular chamber size is normal
with depressed free wall contractility. The number of aortic
valve leaflets cannot be determined. The aortic valve leaflets
are moderately thickened. There is mild aortic valve stenosis.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion. Compared with the
prior study (images reviewed) of ___ right ventricular
contractile function now appears depressed.
___: ___
No evidence of deep vein thrombosis in the right or left lower
extremity. Limited assessment of the calf veins.
___ CXR
Cardiomediastinal contours are stable allowing for patient
rotation. Patchy and linear bibasilar opacities are present,
most likely
represent atelectasis. Other superimposed process such as
aspiration or early infectious pneumonia are less likely, but
followup radiographs may be helpful in this regard.
___ CT to evaluate for abcess/phlegmon
1. Cholelithiasis with a decompressed gallbladder with wall
edema without
significant pericholecystic fluid or adjacent fat stranding. No
evidence of intra-abdominal abscess
2. Pancolonic diverticulosis without evidence of diverticulitis.
3. Heavy atherosclerotic disease of the abdominal aorta with
aneurysmal
dilatation up to 2.8 cm of the infrarenal portion and dilatation
of the left common iliac artery to 1.7 cm.
4. Small bilateral pleural effusions with adjacent compressive
atelectasis that are new from the prior exam.
___ Chest X Ray
No acute cardiopulmonary disease including pneumonia
___ RUQ US IMPRESSION:
1. No fluid collection identified within the liver and no
subhepatic
collection identified. No biliary dilatation.
2. Cholelithiasis. Gallbladder wall edema is noted but is
likely due to low albumin. The gallbladder is only minimally
distended and this lack of volume within the lumen suggests this
does not represent cholecystitis.
3. Stomach and duodenum are noted to be distended and the
duodenum
demonstrates symmetrical but slightly thickened walls. This is
of
undetermined clinical significance.
4. No ascites. Small right pleural effusion noted.
___ ___ US
FINDINGS:
The liver shows no evidence of focal lesions or textural
abnormality. There is no evidence of intra or extrahepatic
biliary dilatation. There is an 8 mm gallstone. The
gallbladder is collapsed. Apparent wall thickening is likely a
function of underdistention. There is no pericholecystic fluid.
Sonographic ___ sign is negative. The partially imaged right
kidney appears mildly atrophic.
IMPRESSION:
Cholelithiasis without evidence of cholecystitis.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with a history of
cholecystitis s/p ___ guided perc drain, who presented with perc
chole tube dislodgement. He has a recent history of
cholecystitis treated with percutaneous cholecystostomy as he
was not an operative candidate due to multiple comorbidities. On
the day of presentation he was at ___ for the
Aged when he stood up and accidentally pulled out his perc chole
tube. He presented to ___ for further
evaluation regarding need for perc chole tube replacement and
was found to be septic on admission.
# Sepsis secondary to urinary tract infection vs HCAP: Patient
presented to the ED with fever and tachypnea, which is similar
to his previous episodes of sepsis per family. He has a history
of becoming tachypneic when septic (up to the ___. No pneumonia
noted on CXR on admission. Per ___ records, patient was
recently diagnosed with ESBL E.coli, initially treated with
Cipro and switched to Bactrim on day of admission. He was
started on Meropenem and Vancomycin on admission. His final
cultures from ___ revealed ESBL E.coli sensitive to
Bactrim and was continued on Bactrim. CXR on ___ revealed
pulmonary edema and Bactrim was broadened to Vanc/Meropenem to
cover possible HCAP. He completed a full course of meropenem and
his urine cultures at ___ were all negative. He was not
discharged on any further antibiotics.
# Hypoxia: Mr. ___ presented with tachypnea, which is his
typical presentation when he becomes septic per his family
report and per history of prior admission. CXR on ___ revealed
pulmonary edema and Bactrim was broadened to Vanc/Meropenem to
cover possible HCAP. From ___ he had tenuous fluid status
and on ___ was noted to be hypotensive with SBPs in the
___. He received 500cc bolux x2 without improvement. He was
then given 1L bolus and 650 cc into the bolus his SBPs improved
to the 110s, so the bolus was stopped. 30 minutes later he was
noted to be tachypneic, belly breathing with accessory muscle
use and RR in the ___. He was transferred to the ICU for further
management of respiratory distress and 10 mg IV lasix was given
prior to transfer. His EKG did not show signs of ischemia. Upon
arrival to the MICU he was placed on BiPAP and given lasix IV 20
mg. His respiratory status improved with BiPAP and saturated to
98-100%. He was managed in the ICU until ___ where he was
weaned off of non-invasive ventilation and was ultimately able
to ambulate out of bed with ___. He was transferred back to the
medicine floor on ___. Since his transfer back to the
floor he was noted to have bibasilar crackles on exam, and given
difficulty with weaning off of 02, clinical evidence of volume
overload, and stable SBPs, lasix 10mg IV administered. He was
weaned off oxygen completely for 24 hours before discharge from
the hospital.
# Cholecystitis s/p perc drain: Mr. ___ presented with
dislodgement of the drain, which was supposed to stay in place
until ___. He was evaluated by the surgery team who
determined that since the gallbladder is collapsed, there was no
need to replace the drain. On ___, CT Abdomen Pelvis was
negative for intraabdominal abscess/phlegmon. Mr. ___ denied
abdominal pain throughout his hospital course.
#CAD and new-onset Afib: Mr. ___ was continued on his home
statin, and aspirin. His beta blocker was held in the setting of
sepsis, but restarted on day 4 of his hospital stay. It was held
on ___ in the setting of hypotension. He restarted
metoprolol on ___ for Afib with RVR, although at a lower dose.
He had previously been on Plavix 75mg daily at home but Plavix
was stopped before his percutaneous choley drain procedure.
Plavix was restarted on ___ given that no further intervention
regarding his drain was necessary.
#Acute renal failure: Mr. ___ was elevated at the
beginning of his hospital stay, most likely due to pre-renal
etiology as he was hypovolemic. His creatine returned to
baseline (1.2-1.5) as his hypotension and sepsis resolved. It
remained at 1.1 for 3 days leading up to his discharge.
#Delirium: Mr. ___ did well with gentle reorientation. He was
given trazodone for sleep in the early evenings, which he did
well with. He received a dose of Zydis one evening and was noted
to be very lethargic throughout the next day. Zydis was
subsequently avoided and Trazodone prescribed instead.
#Back pain: Mr. ___ has a history of developing back pain
during his hospitalizations, per his family, secondary to long
hours in bed. He was frequently repositioned by the nursing
staff and encouraged to sit up in a chair. Oxycodone 2.5 mg was
prescribed for pain management and Mr. ___ endorsed
significant relief and minimal pain. His gabapentin was
continued at a lower dose, which can be increased if needed.
#Hx of silent aspiration: Mr. ___ underwent a video swallow
on ___ in the ICU and was recommended regular diet with thin
liquids, pills with puree. His esophagus was noted to be full at
the end which could represent reflux or dysmotility. Speech and
swallow recommended a barium swallow or UGI series to eval for
esophageal cause of aspiration. Mr. ___ did not show signs of
aspiration throughout his subsequent stay on the floor. His
breathing status improved, he denied cough, and there was no
evidence of leukocytosis on labs. The team did not pursue a
further workup given clinical and objective improvement.
#Dysuria: Mr. ___ presented with dysuria from ___
___ and was treated for ESBL urinary tract infection
with a full course of Meropenem. He endorsed dysuria again while
in the ICU, though all his urine cultures here have been
negative. He was prescribed a 3 day course of pyridium though
continued to endorse dysuria despite this. He had had a condom
catheter throughout his hospital stay, which was removed when he
was transferred back onto the floor. He denied any dysuria s/p
condom cath removal.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Citalopram 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Gabapentin 200 mg PO TID
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Sulfameth/Trimethoprim DS 1 TAB PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Tolterodine 4 mg PO HS
11. Nystatin 500,000 UNIT PO QID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Citalopram 10 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 1 TAB PO BID:PRN constipation
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
9. Vitamin D 400 UNIT PO DAILY
10. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
11. TraZODone 25 mg PO HS:PRN insomnia
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Gabapentin 200 mg PO Q12H
14. Clopidogrel 75 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Severe sepsis
ESBL secondary to urinary tract infection
___ complicated by pulmonary edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to meet you and your family and to take care
of you while you were in the hospital. You came to the hospital
because the tube that was draining your gallbladder became
dislodged. Fortunately, your gallbladder had already drained and
the surgery team did not feel it was necessary to put the tube
back in.
However, you were also found to have a urinary tract infection
that was causing you to feel weak and short of breath. We
treated this infection with antibiotics called meropenem and
vancomycin. You have finished all the antibiotics you need for
this infection.
During your hospitalization you also developed shortness of
breath. This was because you had some fluid in your lungs. You
were transferred to the intensive care unit where you were given
a breathing mask. You soon felt better with the treatment and
were transferred back to the medical floor where were slowly
able to wean you off of the oxygen. We feel that you are now
back to your usual state and are safe for discharge to ___
___.
Followup Instructions:
___
|
19774387-DS-33
| 19,774,387 | 28,115,555 |
DS
| 33 |
2163-08-24 00:00:00
|
2163-08-24 23:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril / simvastatin
Attending: ___.
Chief Complaint:
Chief Complaint: Dyspnea
Reason for MICU transfer: Dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old male, with past history of CAD s/p
CABG, aspirations, presenting with increased dyspnea, shortness
of breath and respiraotry distress. Patient was initially
hypoxic to the ___ by EMS, and placed on NRB with improvement to
93%. Patient is admitted to the FICU for hypoxemic respiratory
distress.
In report, patient was seen earlier in the evening, after
vomiting choking/gaged with dinner. Patient had chicken pot pie
and pudding. Per son, patient was eating dinner, and felt full,
and thn vomiting. Patient then had a syncopal episode, where he
was unresponsive to questions for about 5 minutes. During this
time, family notes that he did not appear cyanotic, was still
breathing, however was unable to respond to verbal stimuli, and
then recovered. EMS was initially called, and reportedly vitals
were fine, and patient was able to walk with his walker, and
therefore EMS left. Overnight, son noted that that the patient
was having difficulty sleeping ___ to coughing and dyspnea, and
therefore called EMS. Upon arrival, EMS found patient to be
hypoxic, and tachypneic to the ___. Patient was then placed on
NRB, continued to tachhypneaic and hypoxic on RA. Reportedly
course breath sounds bibasilar, and then started on BiPAP. Only
awakening to stimuli and appropriate.
Patient is a DNR, however if needed intubation is ok for short
term. Per son, patient was on a thin liquid diet from the rehab
after piror discharge, however resolved. Patient on full diet at
home.
In the ED, initial vitals: - Initial Vitals/Trigger: 0 99.5 125
183/90 36 93% In the ED, patient was placed on NIV PSV 8/PEEP
8, FIO2 40%. Initial labs with leukocytosis to 18.1, with PMN
predominance. Patient also signficant for elevated BUN 34/Cr
1.8. Patient had proBNP 465, neg Trop <0.01. Lactate elevated to
5.6. Patent underwent chest and abdominal plain films.
On arrival to the FICU, patient was placed on NIPPV, and
reponding to verbal stimuli. Patient was able to nod yes/no to
questions, however unable to speak to questions, and continued
to fall asleep during interview. Therefore discussed with son.
Patient denied any pain, denied any shortness of breath,
abdominal pains, chest pains, palpitations.
Past Medical History:
1. CAD: status post CABG in ___ (LIMA to LAD and SVG to the
PDA, and SVG to the OM) and cardiac catheterization in ___
with Hepacoat stent of SVG-OM (SVG-PDA was noted to be occlued
at
this time). Most recent persatine-mibi ___ demonstrated a
mild inferior fixed defect, with EF 61%.
# PCI ___ w/Hepacoat stent of the SVG-OM and the SVG to
the PDA was noted to be occluded at this time, most recent
p-MIBI ___ w/mild inferior fixed defect
# Congestive heart failure (LVEF 45% on ___, chronic DOE
# HTN
# HL
# Peripheral neuropathy
# H/o paroxysmal afib in the setting of infection
# BPH s/p TURP in ___
# Cataracts
# Cholestasis c/b cholangitis s/p ERCP
# Degenerative joint disease C-spine
# Hearing impairment
# B12 deficiency
# Carpal tunnel syndrome
# H/o colonic polyps (___)
# Prior admissions for urosepsis.
Social History:
___
Family History:
Denies history of cancer or liver disease
Physical Exam:
>> Admission Physical Exam:
Vitals- 101.3 axillary, BP 93/47 O2 98 on BIPAP 40% FIO2, 8PEEP.
HR 101
General: Mask, responding with nodding. Patient appears stated
age. Lower lip is purple, with skin abrasion on left cheek
superficailly. PERRL. EOMI.
Neck: Supple, no LAD apprecaited.
Lungs: Difficult to auscultate breath sounds bialterally on
anterior. Unable to auscultated posterior.
CV: Distant, S1, S2. No rub, extra sounds heard.
Abdomen: DIstended, Hyperactive BS+. No rebound, guarding, no
grimacing to palpation.
Extremities: Lower extremities cool to touch L > R. Hands warm
to touch. Pulses 2+ .
.
>> Discharge Physical Exam:
VSS
GEN: NAD frail-appearing
CV: RRR, Nl S1/S2, ___ SEM
PULM: CTA B
GI: +BS, mild TTP in RUQ
EXT: WWP, no CCE bilat pedal edema R>L
SKIN: no rashes
NEURO: aao x3, CNs ___ intact, strength ___ throughout
PSYCH: appropriate, normal affect, not depressed
Pertinent Results:
>> Admission Labs :
___ 11:20PM BLOOD WBC-18.1*# RBC-4.57* Hgb-14.1 Hct-43.7
MCV-96 MCH-30.9 MCHC-32.3 RDW-14.3 Plt ___
___ 06:27AM BLOOD WBC-16.3* RBC-3.63* Hgb-11.4* Hct-34.0*
MCV-94 MCH-31.5 MCHC-33.6 RDW-13.7 Plt ___
___ 11:20PM BLOOD Neuts-83.0* Lymphs-12.5* Monos-3.5
Eos-0.7 Baso-0.3
___ 06:27AM BLOOD Neuts-85* Bands-7* Lymphs-2* Monos-5
Eos-0 Baso-0 ___ Myelos-1*
___ 11:20PM BLOOD Glucose-159* UreaN-34* Creat-1.8* Na-145
K-4.5 Cl-98 HCO3-28 AnGap-24*
___ 06:27AM BLOOD Glucose-135* UreaN-38* Creat-1.7* Na-140
K-4.3 Cl-104 HCO3-26 AnGap-14
___ 06:27AM BLOOD Albumin-3.4* Calcium-8.3* Phos-2.2*
Mg-1.9
___ 04:18AM BLOOD Type-ART Temp-39.7 pO2-93 pCO2-52*
pH-7.32* calTCO2-28 Base XS-0 Intubat-NOT INTUBA
___ 11:37PM BLOOD Lactate-5.6*
___ 11:37PM BLOOD Lactate-5.6*
___ 04:18AM BLOOD Lactate-2.7*
.
>> Pertinent Reports:
___: Blood Culture x 1: pending.
Images:
___ CXR
Minimal interval improvement in bibasilar
left-greater-than-right opacities.
___ CXR
Substantial iimprovement in bibasilar opacities since 1 day ago.
___: CXR: Low lung volumes with bibasilar opacities which
may represent atelectasis or infection in the appropriate
clinical setting.
___: Abdominal X-ray: Non specific bowel gas pattern with
minimally dilated bowel of small bowel seen in the mid abdomen
however gas and stool are seen throughout the colon and rectum.
Possible small bowel obstruction can't be completely excluded.
___ Cardiovascular ECHO: Suboptimal image quality. No
intracardiac source of syncope identified. Globally preserved
biventricular systolic function in the setting of regional wall
motion abnormalities, as described above. Mild aortic stenosis.
Mild mitral regurgitation. Borderline pulmonary artery systolic
hypertension. Left Ventricle - Ejection Fraction: >= 60%
Hypokinesis of the basal and mid inferior and inferoseptal
segments is seen
EKG: ED EKG: SInus, 130, ST depressions, in V4-V6.
.
>> Discharge Labs:
___ 07:50AM BLOOD WBC-8.9 RBC-3.67* Hgb-11.1* Hct-33.8*
MCV-92 MCH-30.3 MCHC-32.9 RDW-13.7 Plt ___
___ 07:50AM BLOOD Glucose-95 UreaN-22* Creat-1.4* Na-138
K-4.3 Cl-103 HCO3-27 AnGap-12
___ 07:50AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ year old male, with prior history of
aspirations by history, CAD s/p CABG, who presented to ___
acute respiratory distress and hypotension after vomiting.
ACUTE ISSUES
# Sepsis ___ Aspiration Pneumonia: Patient briefly febrile with
leukocytosis on admission. Lactate elevated and there was a new
infiltrate noted in b/l bases concening for aspiration pneumonia
vs pneumonitis. Hypoxic on arrival, briefly requiring NIPPV, but
rapidly down-titrated to NRB and then NC. Initially treated with
vancomycin/zosyn. Zosyn later changed to cefepime/metronidazole
given a penicillin allergy and vancomycin discontinued. After
24 hours, patient no longer had on oxygen requirement, was
afebrile, had appropriate urine output and lactic acidosis had
resolved. Patient's blood pressures remained lower than reported
baseline however improved and home bblocker was restarted. He
was called out of the ICU where he was transitioned to
levo/flagyl with continued improvemnt. ___ompleted while in the hospital.
# Aspirations: Patient with aspiration pneumonia in the setting
of recurrent aspiration and dysphagia. Originally evaluated by
speech and swallow who recommended he remain NPO, but on
re-evaluation he was deemed safe to place on a modified diet.
On further discussion with the patients family, they do not want
to pursue further w/u for this. Per family request, patient was
seen by palliative care in the hospital for discussions about
end of life and DNH, however ultimately pt was discharged to
rehab with ongoing discussions about goals of care.
# Delerium: pt with AMS while in the hospital, likely due to
infection. Pt was aaox 3 throughout and was improved at the
time of discharge although is intermittently somnolent.
# Heart Failure with preserved EF: Patient appeared euvolemic on
examination. BNP 465 on admission, not concerning for
exacerbation of diastolic CHF.
# ___ on CKD: Patient with baseline creatinine of 1.3, presented
with 1.8. Improved with IVF hydration to 1.4.
# Paroxysmal Atrial fibrillation: Occured in the setting of
infection, no recurrent tachycardia.
CHRONIC ISSUES:
# depression: cont citalopram
# CAD s/p CABG: Negative cardiac biomarkers on admission.
Continued home aspirin, atorvastatin, clopidogrel. Metoprolol
was held in the setting of hypotension.
# BPH: held finasteride and tolteradine in the setting of
hypotension, restarted on arrival to the floor
# Peripheral Neuropathy: Continued home neurontin at decreased
dose due to confusion
# Constipation: Provided with bowel regimen
# Paroxysmal Atrial fibrillation: Occured in the setting of
infection. Continued patient's aspirin, but held metoprolol as
detailed above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Citalopram 10 mg PO QHS
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Gabapentin 200 mg PO Q12H
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Tolterodine 4 mg PO QHS
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Citalopram 10 mg PO QHS
4. Clopidogrel 75 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Gabapentin 100 mg PO BID
7. Tolterodine 4 mg PO QHS
8. Vitamin D 1000 UNIT PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Metoprolol Succinate XL 25 mg PO DAILY
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth once Disp
#*1 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aspiration ___
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after vomiting with aspiration
and were treated with antibiotics with improvement in your
symptoms. You experienced some confusion while in the hospital
which improved. You were discharged to ___ for
rehabilitation.
Followup Instructions:
___
|
19774387-DS-35
| 19,774,387 | 25,811,083 |
DS
| 35 |
2165-05-01 00:00:00
|
2165-05-01 17:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / lisinopril / simvastatin / oxycodone
Attending: ___
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy - ___
History of Present Illness:
___ with history of CAD s/p CABG, HFpEF, recent d/c for proteum
mirabilis UTI, from ___ for eval of 1 day of RUQ pain
and leukocytosis.
In the ED, initial vitals:
- Exam notable for T98, HR 86, BP 80/45, RR 23, 97% RA.
- Labs were notable for: WBCs 19.7, Hb 10.3, HCT 32.2, LFTs
within normal limits, BUN 42, Cr 1.8, Trop ___, lactate 1.6, UA
with 100 protein, trace blood, few bacteria.
- Imaging: RUQ US distended gall bladder with moderate
gallbladder wall thickening c/w acute or chronic cholecystitis.
- Patient was given: Vanc, Zosyn, 1.5L NS.
- Consults: Surgery consulted, patient favoring non-operative
management. ___ consulted for perc cholecystostomy.
On arrival to the MICU, patient reports pain on his right side
that come on this morning at ___. The pain felt similar
to when he had problems with his gallbladder in the past. He
also reports pain over his sacrum from decubitus ulcer. He
denies fevers, chills, nausea or vomiting.
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:
1. CAD: status post CABG in ___ (LIMA to LAD and SVG to the
PDA, and SVG to the OM) and cardiac catheterization in ___
with Hepacoat stent of SVG-OM (SVG-PDA was noted to be occlued
at
this time). Most recent persatine-mibi ___ demonstrated a
mild inferior fixed defect, with EF 61%.
# PCI ___ w/Hepacoat stent of the SVG-OM and the SVG to
the PDA was noted to be occluded at this time, most recent
p-MIBI ___ w/mild inferior fixed defect
# Congestive heart failure (LVEF 45% on ___, chronic DOE
# HTN
# HL
# Peripheral neuropathy
# H/o paroxysmal afib in the setting of infection
# BPH s/p TURP in ___
# Cataracts
# Cholestasis c/b cholangitis s/p ERCP
# Degenerative joint disease C-spine
# Hearing impairment
# B12 deficiency
# Carpal tunnel syndrome
# H/o colonic polyps (___)
# Prior admissions for urosepsis.
Social History:
___
Family History:
Denies history of cancer or liver disease
Physical Exam:
Admission exam:
VITALS: AF, HR 80, BP 109/56, RR 28, O2 95% on RA.
GENERAL: Resting comfortably in bed
HEENT: AT/NC, EOMI, PERRL
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, TTP in RUQ with right sided guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Discharge exam
Vitals: Tmax afebrile, Tcurrent 97.3, BP 103/59, HR 59, RR 18,
O2 sat 94% on RA
Lines/tubes: PIV, R PTBD
Gen: frail elderly man, hard of hearing, lying in bed, alert,
cooperative, NAD
HEENT: anicteric, PERRL, MMM
Chest: equal chest rise, CTAB, no WOB or cough
Heart: RRR, no m/r/g
Abd: NABS, R sided PTBD with brownish/greenish tinged clear
fluid with slight blood tinge, with associated appropriate TTP
there, all as before, no signs of complications, soft, otherwise
NTND
GU: condom catheter with clear yellow urine
Extr: WWP, no edema
Skin: no rashes on limited exam
Neuro: hard of hearing, no facial droop, moving arms equally
Psych: normal affect
Pertinent Results:
Admission labs:
___ 01:37PM BLOOD WBC-19.7*# RBC-3.21* Hgb-10.3* Hct-32.3*
MCV-101* MCH-32.1* MCHC-31.9* RDW-13.0 RDWSD-48.2* Plt ___
___ 01:37PM BLOOD Neuts-88* Bands-0 Lymphs-9* Monos-3*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-17.34*
AbsLymp-1.77 AbsMono-0.59 AbsEos-0.00* AbsBaso-0.00*
___ 01:37PM BLOOD Glucose-99 UreaN-42* Creat-1.8* Na-137
K-4.6 Cl-97 HCO3-26 AnGap-19
___ 01:37PM BLOOD ALT-13 AST-18 CK(CPK)-60 AlkPhos-80
TotBili-0.6 DirBili-0.2 IndBili-0.4
___ 01:37PM BLOOD Albumin-3.1* Calcium-8.4 Phos-4.8* Mg-2.6
___ 01:37PM BLOOD CK-MB-2 proBNP-___*
___ 01:37PM BLOOD cTropnT-0.08*
___ 04:01AM BLOOD CK-MB-2 cTropnT-0.07*
___ 01:47PM BLOOD Lactate-1.6
Imaging:
Gallbladder US (___):
Distended gallbladder containing sludge with gallbladder wall
thickening and positive sonographic ___ sign. Acute
cholecystitis is difficult to exclude in the correct clinical
setting.
CXR (___):
No acute cardiopulmonary process
___ PTBD placement: IMPRESSION: Successful ultrasound-guided
placement of ___ pigtail catheter into the gallbladder.
Samples was sent for microbiology evaluation.
MICRO
___ BILE GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY
{ESCHERICHIA COLI, ENTEROCOCCUS SP.}; ANAEROBIC
CULTURE-PRELIMINARY
___ URINE CULTURE-FINAL
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
___ 9:09 pm BILE BILE.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Preliminary):
ESCHERICHIA COLI. HEAVY GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
DISCHARGE LABS
___ 06:35AM BLOOD WBC-8.2 RBC-3.04* Hgb-9.6* Hct-30.9*
MCV-102* MCH-31.6 MCHC-31.1* RDW-13.0 RDWSD-48.8* Plt ___
___ 06:35AM BLOOD Glucose-92 UreaN-28* Creat-1.4* Na-139
K-4.1 Cl-104 HCO3-26 AnGap-13
___ 06:35AM BLOOD ALT-15 AST-19 AlkPhos-62 TotBili-0.2
___ 06:35AM BLOOD Calcium-7.8* Phos-3.6 Mg-2.2
___ 08:40AM BLOOD calTIBC-134* VitB12-212* Hapto-350*
Ferritn-609* TRF-103*
Brief Hospital Course:
Mr. ___ is a ___ with history of CAD s/p CABG, HFrEF, recent
admission for Proteus UTI, presented from ___ with
1 day of RUQ pain and leukocytosis with ultrasound demonstrating
cholecystitis.
On the day of discharge, he was doing well. No new issues. He
felt ok and had no concerns. I spoke with his daughter at the
bedside. We reviewed his clinical course, his medications, and
the plan moving forward. I answered all of her questions.
# Acalculous cholecystitis
Given his goals of care, the family declined surgical
intervention. He was admitted to the ICU where a bedside
percutaneous chole drain was placed by ___ with light conscious
sedation. Pus drained from the drainage site, which was sent for
culture. He was covered with Zosyn (and initially 1 dose of
vancomycin, though this was held thereafter given his clinical
appearance and lack of prior microbiologic data suggestive of
need for vancomycin). Zosyn was deescalated to Unasyn on ___
given low suspicion for resistant GNRs. Bile culture grew E.
coli sensitive to amoxicillin/clavulanic acid so he was changed
to this on ___. After discussion with Surgery the decision
was made to leave in the percutaneous biliary drain, get a tube
check in ~2 weeks and follow-up with Surgery in the outpatient
setting. Please see the appointments scheduled below -- Surgery
is working to find an earlier appointment and will call the
rehab with this information. He should continue antibiotics
through that time with possible extension. It is likely Surgery
will recommend keeping the drain in for a total of ~6 weeks. No
plans for CCY -- he had a similar episode a few years ago and at
that time ___ recommended against that, and family agree
again with not doing CCY. Getting APAP standing, and tramadol
PRN for pain control. Gets sedated with oxycodone.
# ___ on Stage III CKD:
Baseline creatinine 1.4 and was 1.8 on admission. Likely
prerenal in setting of infection. Improved to baseline with IVF.
# CAD s/p CABG, chronic diastolic heart failure with mild
baseline hypotension
Patient s/p CABG in ___ (LIMA to LAD and SVG to the PDA, and
SVG to the OM) and cardiac catheterization in ___. Had mild
troponin elevation thought ___ increased demand and CKD. Kept
euvolemic. Continued ASA, atorvastatin, and did not add a BB or
ACE-I to his home medications given relative hypotension (SBP
___. Recent TTE ___ and showed stable EF at >55% with
mild AS, mild
MR, stable inferior wall hypokinesis, all stable from prior
study in ___.
# Megaloblastic anemia likely due to B12 deficiency
B12 was found to be low, doesn't appear iron deficient or to be
hemolyzing. Got IM/SC while here but will change to daily PO
for ease of dosing in the ambulatory setting.
# BPH - continued finasteride, held tolterodine given risk of
somnolence but will restart on discharge
# Depression - continued citalopram
# GERD - home omeprazole
# Peripheral neuropathy - restarting home gabapentin on
discharge, was initially held given somnolence
# Consipation - bowel regimen
# Other - vit D
# Recent admission for proteus UTI
# Advance care planning
- HCP as per WebOMR, has scanned copy
- Care preferences: see ACP notes in WebOMR from Dr. ___ --
currently DNR but ok to intubate
On the day of discharge I spent >30min in discharge day services
and coordination of care. The patient was safe to discharge
_____________________________
___, MD
___
pager ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO HS
3. Citalopram 10 mg PO QHS
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Gabapentin 200 mg PO Q12H
7. Omeprazole 20 mg PO DAILY
8. Tolterodine 4 mg PO QHS
9. Vitamin D 1000 UNIT PO DAILY
10. Bisacodyl ___AILY:PRN constipation
11. Senna 17.2 mg PO HS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Continue at least until ___ Surgery follow-up appointment, may
extend longer.
3. Cyanocobalamin 1000 mcg PO DAILY
4. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth Q4H:PRN Disp #*10
Tablet Refills:*0
5. Gabapentin 200 mg PO Q12H
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO HS
8. Bisacodyl ___AILY:PRN constipation
9. Citalopram 10 mg PO QHS
10. Docusate Sodium 100 mg PO BID
11. Finasteride 5 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Senna 17.2 mg PO HS
14. Tolterodine 4 mg PO QHS
15. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Acalculous cholecystitis
# Acute kidney injury, resolved
# B12 deficiency with megaloblastic anemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to ___ with abdominal pain and found to have
an infection in your gallbladder. You had a procedure to drain
the infection and you received antibiotics. The drain should
stay in, and the antibiotics should continue. We also found you
were B12 deficient so we began repletion for that. It's
important to follow-up as noted below and to continue to take
the medications prescribed.
Followup Instructions:
___
|
19774701-DS-13
| 19,774,701 | 26,642,566 |
DS
| 13 |
2177-10-18 00:00:00
|
2177-10-19 15:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
concern for agitation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presenting with agitation, confusion. Patient denies any of
those symptoms. Stated that went to nephrologist today and went
home. Took a nap and woke up to an ambulance arriving. Per
Atrius records pt's care giver, ___, called to report "unable
to control patient, "very agitated" with periods of confusion.
Unable to sit still, wandering , trying to escape. Heavy
smoking with sob. Not eating, will not take any medication".
In ED case discussed with covering doctor. Caretaker cannot take
care of patient anymore, per report. Discussed with Dr. ___,
___ oncologist. Seen by psychiatrist, who felt that he did not
have capacity on ___. Guardianship to nephew. This expired
in ___. Had another caretaker thereafter, who expressed some
agitation.
ROS: +as above, weakness in R leg that is chronic, otherwise
reviewed and negative
Past Medical History:
# ___ s/p VATS RLL lobectomy and adjuvant chemotherapy
- CT abd (___) 7mm RML nodule
- f/u chest CT (___): RML nodule unchanged, new RLL 6.6 mm
nodule
- Repeat CT chest (___) RLL nodule increased to 9mm, RML
nodule stable at 8mm.
- PET scan (___) 8mm RLL long nodule with mild FDG avidity.
RML nodule is not FDG avid. No FDG avid mediastinal LAD.
- VAT RLL ___. Path: 1.0 cm adenocarcinoma, mod
differentiated, predominantly acinar pattern (65%) with
micropapillary (30%) and solid 95%) components. LVI is present.
Metastatic adenocarcinoma involving 1 of 4 peribronchial LNs.
TTF-1 focally positive. 2 Level 11 LNs were negative for tumor.
- adjuvant chemo ___, second course ___.
# Esophageal CA ___
- EGD: mass mid-esophagus, bx: squamous cell carcinoma
- s/p LMS bronchus stent ___, s/p esophageal stent
___
# HTN/HLD
# DM2 poorly controlled
# COPD
# BPH with chronic obstruction
# GERD
# Thalassemia trait
# CKD
# B12 deficiency
# R ptosis
# chronic hearing loss
Social History:
___
Family History:
his maternal uncle had lung cancer at his ___. One niece had
lung cancer in her ___. Also has a sister with DM.
Physical Exam:
Vitals: T:97.7 BP:126/84 P:82 R:18 O2:100%ra
PAIN: 0
wt. 108lb
General: nad, cachectic
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: no rash
Neuro: sleeping, easily arousable, follows commands, oriented to
person and place
Pertinent Results:
___ 06:10PM GLUCOSE-266* UREA N-20 CREAT-1.2 SODIUM-137
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
___ 06:10PM WBC-6.0 RBC-3.67* HGB-8.9* HCT-27.2* MCV-74*
MCH-24.3* MCHC-32.8 RDW-17.7*
___ 06:10PM NEUTS-61.1 ___ MONOS-6.8 EOS-2.6
BASOS-0.5
___ 06:10PM PLT COUNT-421
___ 06:10PM ___ PTT-29.6 ___
CXR IMPRESSION: No evidence of acute cardiopulmonary disease.
Brief Hospital Course:
___ year old male with history NSCLC s/p VATS RLL lobectomy and
adjuvant chemotherapy and esophageal cancer not undergoing
therapy presenting from home with report of agitation.
#Weakness Generalized
#Lung cancer/Esophageal cancer:
h/o NSCLC, esophageal CA (with MOLST form apparently indicating
DNR/DNI, do not hospitalize prior to admission). Mr. ___ was
admitted with initial concerns of agitation. Upon arrival here,
there were no signs of agitation, confusion, or encephalopathy.
He was fully cognizant of his medical condition, poor prognosis
from cancer, his functioning capabilities, and support options
at home. Upon further history, there arose concern of potential
elderly abuse by his caretaker ___ (a nephew of a close
friend of his).
___ protective services were contacted and it was indeed
confirmed that there was evidence of emotional abuse. SW was
consulted and the facility (Mandeal Housing) was notified - and
their security contacted to ensure that ___ had left the
vicinity and that the locks to the door were changed.
Communications with the PCP, primary care team had indicated
concerns for patients safety and his ability to take care of
self. There was also concern of patients capacity to make
decision (since he required a guardian in the hospitalization in
___. Full assessments by ___, myself, nursing staff, and
psychiatry indicated that pt had reasonable rationale, logic,
and expectations of going home - and understood the implications
of being home alone. As a former ___ at ___, he
knew what it meant to die within the hospital (he did not want
that).
Ultimately, he was determined to have capacity to make
decisions regarding his DNR/DNI, do not hospitalization status.
He was also found to have capacity to make decisions regarding
going home. There was evidence of mild cognitive deficits - but
given his poor prognosis and strong desire to go home (with
appropriate rationale), emphasis was placed on respecting his
wishes and providing him the opportunity to die with dignity.
OT and ___ cleared the patient for discharge.
# COPD on Advair, albuterol PRN, Guaifenesin ER
# DM2: on insulin glargine 20u QHS, ISS
# CV: HTN/HLD - stabl
# GERD: on PPI
# OTHER ISSUES AS OUTLINED.
#COMMUNICATION: Contacts: ___ (NP taking care of him as
outpatient). ___. ___ PCP (Cell: ___
___ (nephew) Home: ___ Cell phone:
___
___ (senior residence coordinator at ___
___.
#CONSULTS: ___, SW, Elder Protective Services, CM
#CODE STATUS: DNR/DNI/Do not rehospitilize
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation twice daily
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
4. Mirtazapine 15 mg PO QHS
5. Omeprazole 20 mg PO DAILY
6. Senna 17.2 mg PO BID
7. Lactulose 15 mL PO Q8H:PRN constipation
8. Glargine 20 Units Bedtime
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO DAILY:PRN constipation
2. Glargine 20 Units Bedtime
3. Lactulose 15 mL PO Q8H:PRN constipation
4. Mirtazapine 15 mg PO QHS
5. Omeprazole 20 mg PO DAILY
6. Senna 17.2 mg PO BID
7. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation twice daily
8. Lisinopril 20 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Guaifenesin ER 600 mg PO Q12H
RX *guaifenesin 600 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
11. Lorazepam 0.5-1 mg PO Q4H:PRN discomfort
RX *lorazepam [Ativan] 0.5 mg ___ tabs by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
12. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen [Percocet] 5 mg-325 mg ___ tablet(s)
by mouth every four (4) hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Esophageal carcinoma
Non-small cell lung cancer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure looking after you, Mr. ___. As you know,
you were admitted for concerns of your ability to manage at
home. There was also concerns about your living situation with
(and emotional abuse from) ___. Numerous services were
involved in ensuring your safety at home - and services were
arranged to ensure you are able to manage at home alone. You
will have hospice, ___, and Meals-on-Wheels following you at
home.
You had no evidence of active medical issues requiring
hospitalization.
Followup Instructions:
___
|
19775175-DS-5
| 19,775,175 | 23,960,767 |
DS
| 5 |
2185-10-24 00:00:00
|
2185-10-24 10:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left eye pain
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of left orbital floor
fracture; repair of left lateral canthotomy wound; left
tarsorraphy suture (___)
History of Present Illness:
___ s/p assault who was pushed from behind by an unknown
assailant and fell forward onto his face. He endorses LOC. He
was seen at OSH where CT revealed a L orbital floor blowout
fracture with a L retrobulbar hematoma s/p L lateral canthotomy.
CT head otherwise was negative for intracranial process.
Transferred to ___ for further management. He denies any
additional injuries, no headache, no neck pain.
Ophthalmology was consulted for his retrobulbar hematoma and
performed a revision extension of his L lateral canthotomy for
concern on exam for decreased visual acuity in the L eye, with
decrease in IOP from 40 to 20. Plastic Surgery was consulted for
evaluation of his L orbital floor blowout fracture.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
On Admission
Vitals: 96 88 142/91 18 98%
General: Alert, oriented, NAD
Neuro: CN II XII intact
Scalp: No lacerations on scalp. No step-offs.
Face: There is moderate ___ bruising. There is no
flattening of the malar eminences. There is no nasal deviation.
The midface stable to palpation, jaw occlusion normal by exam
and by direct questioning of the patient, no palpable stepoffs
but these are difficult to assess due to marked swelling. L
lateral canthotomy incision c/d/i. Superficial abrasions to the
R cheek. No Battle sign or bilateral raccoon eyes.
Eyes: PERRLA, EOM grossly intact, with mild impairment with
upward gaze. Significant periorbital swelling. +subconjunctival
hemorrhage, no visible corneal injury, no enophthalmos or
exophthalmos on the left or right.
Nose: Symmetrical without palpable stepoffs with no obvious
nasal fracture, septum midline, no septal hematoma, no
rhinorrhea
Mouth: No intraoral lacerations, fair dentition, no loose teeth,
normal occlusion, maxilla and mandible stable w/o palpable step
offs, TMJ stable
On Discharge
T 98.3 HR 86 BP 143/88 RR 18 99% on RA
General: Awake and alert. NAD. Oriented x 3. Sitting up in bed.
Cranial Nerves: II - XII grossly intact.
Left Eye: Significant ___ ecchymosis present.
Tarsorraphy suture in place. Extra-ocular movements intact.
Visual acuity and color vision intact. Non-tender to palpation.
Pupil reactive to light.
Face: Superficial abrasions to the right cheek.
Pertinent Results:
___ 11:15AM BLOOD WBC-5.8 RBC-4.06* Hgb-13.1* Hct-38.3*
MCV-95 MCH-32.4* MCHC-34.3 RDW-13.3 Plt ___
___ 11:15AM BLOOD Glucose-122* UreaN-7 Creat-0.7 Na-138
K-3.6 Cl-97 HCO3-31 AnGap-14
CT Maxillofacial (___) - Per Radiology
1. Status post ORIF of left orbital floor fracture as described
above.
2. Persistent hemorrhagic opacification of the left maxillary
sinus.
CXR (___) - Per Radiology
No acute cardiopulmonary process
Brief Hospital Course:
The patient was evaluated by the plastic surgery team in the
emergency department and found to have a left orbital floor
fracture and retrobulbar hematoma with increased intraocular
pressures for which ophthalmology performed a revision extension
of his left lateral canthotomy. He was subsequently admitted to
the plastic surgery service on ___ and went to the OR on
___ for open reduction and internal fixation of left
orbital floor fracture; repair of left lateral canthotomy wound;
and left eye tarsorraphy suture. The patient tolerated the
procedure well. For full details, please see the separately
dictated operative report.
The patient underwent routine post procedure recovery in the
PACU and was subsequently transferred to the plastic surgery
floor. Patient was transitioned to oral pain medications and
tolerated a regular diet. He was given heparin sc for DVT
prophylaxis.
His visual acuity continued to improve in the left eye; his
extraocular movements were intact; and his color vision was
intact. Erythromycin ointment was applied to the left eye,
including the lateral canthotomy wound, QID.
Ophthalmology followed the patient during this admission and
felt that his IOPs were stable; his left afferent pupillary
defect had resolved; his left eye visual acuity improved. He was
also found to have a large flat retinal lesion inferotemporally
in the right eye. The patient will follow up with ophthalmology
within 1 week.
There was concern for alcohol withdrawal since the patient
endorsed drinking ___ to 1 pint of vodka daily and reported that
he experiences alcohol withdrawal if he does not drink for a few
days. The patient exhibited no signs or symptoms of alcohol
withdrawal during this admission.
At the time of discharge on POD#1, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled. He will return to clinic tomorrow, ___ ___,
for removal of his tarsorraphy suture.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
Never exceed 4000 mg in 24 hours.
2. Erythromycin 0.5% Ophth Oint 0.5 in LEFT EYE QID
RX *erythromycin 5 mg/gram (0.5 %) 0.5 (One half) in OS four
times a day Refills:*0
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left orbital floor fracture
Left retrobulbar hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted on ___ for repair of an orbital floor
fracture. Please follow these discharge instructions:
Medications:
* Resume your regular medications.
* You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
* Take prescription pain medications for pain not relieved by
tylenol.
* Use your antibiotic ointment as prescribed.
* Take Colace, 100 mg by mouth 2 times per day, while taking the
prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
Activities:
* No strenuous activity
* Exercise should be limited to walking; no lifting, straining,
or excessive bending.
* Unless directed by your physician, do not take any medicines
such as Motrin, Aspirin, Advil or Ibuprofen, etc.
Comments:
* Please sleep on several pillows and try to keep your head
elevated to help with drainage.
* Please avoid blowing your nose.
* Sneeze with your mouth open
* Keep your eye clean from any drainage. You may cleanse using
warm water and soft cloth.
* You may use some cold, light ice packs to your right eye area
to help with swelling over next ___ hours. Place ice pack over
site gently and do not apply pressure. Recommend small bag of
frozen peas
Followup Instructions:
___
|
19775873-DS-17
| 19,775,873 | 29,997,974 |
DS
| 17 |
2180-10-31 00:00:00
|
2180-10-31 11:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
R leg pain
Major Surgical or Invasive Procedure:
___ ORIF R Femur
History of Present Illness:
___ transferred from ___ complaining of R leg pain.
Patient was driving on Rte 135 at approximately 10PM last night
when a driver in the oncoming ___ swerved and struck her
vehicle head on. + airbag deployment, + headstrike with
uncertain LOC. Patient was taken to ___ where ED
workup included L femur plain films that revealed a midshaft
femur fracture. She was transferred to ___ for further
management.
Past Medical History:
ADHD
Social History:
HS senior, denies tobacco, alcohol and illicits
Physical Exam:
admit:
AFVSS
Right lower extremity:
Skin intact. Diffuse swelling about the R femur with
significant tenderness to palpation
Severe tenderness to palpation about the R thigh
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
d/c:
AFVSS
RLE
dressing c/d/i
___
SILT
DP2+, wwp
Pertinent Results:
___ 06:07AM URINE HOURS-RANDOM
___ 06:07AM URINE HOURS-RANDOM
___ 06:07AM URINE UCG-NEG
___ 06:07AM URINE GR HOLD-HOLD
___ 06:07AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:07AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:07AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 06:07AM URINE HYALINE-7*
___ 06:07AM URINE MUCOUS-RARE
___ 05:00AM GLUCOSE-130* UREA N-10 CREAT-0.6 SODIUM-136
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-12
___ 05:00AM estGFR-Using this
___ 05:00AM CALCIUM-9.4 PHOSPHATE-4.6* MAGNESIUM-1.9
___ 05:00AM WBC-16.9* RBC-4.40 HGB-13.0 HCT-38.4 MCV-87
MCH-29.5 MCHC-33.8 RDW-12.2
___ 05:00AM NEUTS-88.8* LYMPHS-7.2* MONOS-3.8 EOS-0
BASOS-0.1
___ 05:00AM PLT COUNT-312
___ 05:00AM ___ PTT-31.6 ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R midshaft femur fx and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIL R femur, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the RLE extremity, and
will be discharged on lovenox 40mg x2wks for DVT prophylaxis.
The patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge.
Medications on Admission:
Concerta 54mg PO daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4hrs Disp #*84 Tablet
Refills:*0
4. Enoxaparin Sodium 40 mg SC DAILY Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subQ daily Disp #*14 Syringe
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
R femur fx
Discharge Condition:
stable
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
ACTIVITY AND WEIGHT BEARING:
- WBAT RLE
Followup Instructions:
___
|
19776064-DS-16
| 19,776,064 | 21,814,525 |
DS
| 16 |
2116-10-22 00:00:00
|
2116-10-23 12:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cold and painful left foot
Major Surgical or Invasive Procedure:
1. Right-sided ultrasound-guided vascular access of the
common femoral artery.
2. Placement of catheter in the contralateral ___ order
lower extremity artery.
3. Left lower extremity angiogram.
4. Abdominal aortogram.
5. Contralateral femoral-popliteal percutaneous
transluminal angioplasty and stenting.
6. Left Below Knee Amputation
History of Present Illness:
Ms. ___ is a very pleasant ___ woman from the
___ with a history of diabetes
poorly-controlled. She first noticed that a couple weeks ago
her left foot started becoming painful. She went to the
hospital in ___ and was treated with antibiotics and with
blood sugar control. However, she continued to experience
increasing pain in her foot. Her son flew her to ___ where
she was then seen here at the ___ emergency department on ___.
On ___, she had a diagnostic angiogram and is status post
SFA stents. After considerable thought and conversation with
the ___ and her family, a negative Infectious disease
work-up for another source of infection beyond the foot,
elevating WBC and fevers, the decision was made to proceed with
a left below-knee amputation on ___.
Past Medical History:
PMH: NIDDM II
PSH: None
Social History:
___
Family History:
Grandmother -DM, father - strokes.
Physical Exam:
Physical Exam:
Alert and oriented x 3
VS: AFVSS
Carotids: 2+, no bruits or JVD
Resp: Lungs clear
Abd: Soft, non tender, non distended
Ext: R p/d/p/d L p/d/BKA
Feet warm, well perfused. No open areas
BKA c/d/i with staples. no erythema or drainage.
Left Right groin puncture site: Dressing clean dry and intact.
Soft, no hematoma or ecchymosis
Pertinent Results:
___ 5:50 am BLOOD CULTURE # 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:14 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 10:46 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ ECHOCARDIOGRAPHY REPORT
___ ___ MRN: ___ Portable TTE
(Complete) Done ___ at 11:04:18 AM FINAL
Referring Physician ___
___ Status: Inpatient DOB: ___
Age (years): ___ F Hgt (in): 66
BP (mm Hg): 164/68 Wgt (lb): 140
HR (bpm): 110 BSA (m2): 1.72 m2
Indication: Preoperative assessment. Cold left foot. Cardiac
source of embolism.
ICD-9 Codes: 785.0, 424.0
___ Information
Date/Time: ___ at 11:04 ___ MD: ___.
___, MD
___ Type: Portable TTE (Complete) Sonographer: ___
Doppler: Full Doppler and color Doppler ___ Location: ___ Floor
Contrast: None Tech Quality: Adequate
Tape #: ___-0:00 Machine: E9-2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.0 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.2 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.4 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.3 cm
Left Ventricle - Fractional Shortening: 0.48 >= 0.29
Left Ventricle - Ejection Fraction: >= 65% >= 55%
Left Ventricle - Stroke Volume: 48 ml/beat
Left Ventricle - Cardiac Output: 5.30 L/min
Left Ventricle - Cardiac Index: 3.08 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 12 < 15
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 17
Aortic Valve - LVOT diam: 1.9 cm
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.11
Mitral Valve - E Wave deceleration time: *131 ms 140-250 ms
Pulmonic Valve - Peak Velocity: 1.1 m/sec <= 1.5 m/sec
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). Estimated cardiac
index is normal (>=2.5L/min/m2). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No masses or vegetations on aortic valve. No AR.
MITRAL VALVE: Normal mitral valve leaflets. No mass or
vegetation on mitral valve. Mild mitral annular calcification.
Calcified tips of papillary muscles. Physiologic MR ___
normal limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or vegetation on tricuspid valve. Indeterminate PA
systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR. No PS.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor suprasternal
views. Resting tachycardia (HR>100bpm).
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). 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
structurally normal. No mass or vegetation is seen on the mitral
valve. Physiologic mitral regurgitation is seen (within normal
limits). The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Aortic valve sclerosis. No definite structural cardiac source of
embolism identified.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
___ 07:58AM BLOOD WBC-16.2* RBC-2.80* Hgb-7.6* Hct-25.0*
MCV-89 MCH-27.2 MCHC-30.5* RDW-17.1* Plt ___
___ 06:45AM BLOOD WBC-17.2* RBC-2.76* Hgb-7.5* Hct-24.3*
MCV-88 MCH-27.3 MCHC-31.0 RDW-16.7* Plt ___
___ 07:40AM BLOOD WBC-17.2* RBC-2.71* Hgb-7.4* Hct-24.0*
MCV-88 MCH-27.4 MCHC-31.0 RDW-16.2* Plt ___
___ 07:45AM BLOOD WBC-19.7* RBC-2.80* Hgb-7.6* Hct-24.4*
MCV-87 MCH-27.1 MCHC-31.1 RDW-16.1* Plt ___
___ 06:48AM BLOOD WBC-22.7* RBC-2.92* Hgb-7.8* Hct-25.3*
MCV-87 MCH-26.8* MCHC-30.9* RDW-15.7* Plt ___
___ 02:35PM BLOOD WBC-32.7* RBC-3.12* Hgb-8.7* Hct-26.2*
MCV-84 MCH-27.9 MCHC-33.3 RDW-15.3 Plt ___
___ 06:48AM BLOOD WBC-22.7* RBC-2.92* Hgb-7.8* Hct-25.3*
MCV-87 MCH-26.8* MCHC-30.9* RDW-15.7* Plt ___
___ 02:35PM BLOOD WBC-32.7* RBC-3.12* Hgb-8.7* Hct-26.2*
MCV-84 MCH-27.9 MCHC-33.3 RDW-15.3 Plt ___
___ 07:05AM BLOOD WBC-33.8* RBC-3.56*# Hgb-9.6*# Hct-30.1*
MCV-85 MCH-27.0 MCHC-31.9 RDW-14.9 Plt ___
___ 06:21AM BLOOD WBC-28.6* RBC-2.65* Hgb-7.1* Hct-22.4*
MCV-84 MCH-26.9* MCHC-31.9 RDW-13.4 Plt ___
___ 04:00AM BLOOD WBC-27.2* RBC-3.05* Hgb-7.9* Hct-25.4*
MCV-83 MCH-25.8* MCHC-31.1 RDW-13.2 Plt ___
___ 02:05PM BLOOD WBC-26.1* RBC-3.03* Hgb-7.8* Hct-25.1*
MCV-83 MCH-25.8* MCHC-31.2 RDW-13.0 Plt ___
___ 05:45AM BLOOD WBC-30.2* RBC-3.44* Hgb-9.0* Hct-28.3*
MCV-82 MCH-26.3* MCHC-31.9 RDW-13.0 Plt ___
___ 05:45AM BLOOD Neuts-83.6* Lymphs-11.9* Monos-3.7
Eos-0.6 Baso-0.2
___ 07:58AM BLOOD Plt ___
___ 06:45AM BLOOD Plt ___
___ 07:40AM BLOOD Plt ___
___ 07:45AM BLOOD Plt ___
___ 06:48AM BLOOD Plt ___
___ 02:35PM BLOOD Plt ___
___ 07:05AM BLOOD Plt ___
___ 07:05AM BLOOD PTT-68.1*
___ 04:55PM BLOOD PTT-63.9*
___ 06:21AM BLOOD Plt ___
___ 06:21AM BLOOD PTT-62.0*
___ 11:42PM BLOOD PTT-75.4*
___ 05:00PM BLOOD PTT-65.9*
___ 11:15AM BLOOD PTT-57.4*
___ 04:00AM BLOOD Plt ___
___ 04:00AM BLOOD PTT-49.6*
___ 09:20PM BLOOD PTT-45.4*
___ 02:05PM BLOOD Plt ___
___ 02:05PM BLOOD PTT-87.1*
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD ___ PTT-29.5 ___
___ 06:45AM BLOOD Glucose-64* UreaN-6 Creat-1.0 Na-139
K-3.9 Cl-100 HCO3-29 AnGap-14
___ 07:40AM BLOOD Glucose-47* UreaN-8 Creat-1.0 Na-140
K-4.2 Cl-99 HCO3-30 AnGap-15
___ 06:48AM BLOOD Glucose-202* UreaN-7 Creat-0.8 Na-137
K-4.1 Cl-98 HCO3-29 AnGap-14
___ 02:35PM BLOOD Glucose-125* UreaN-9 Creat-0.9 Na-141
K-4.0 Cl-102 HCO3-29 AnGap-14
___ 07:05AM BLOOD Glucose-282* UreaN-10 Creat-1.0 Na-136
K-3.9 Cl-95* HCO3-29 AnGap-16
___ 06:21AM BLOOD Glucose-185* UreaN-6 Creat-0.6 Na-130*
K-3.5 Cl-92* HCO3-30 AnGap-12
___ 04:00AM BLOOD Glucose-143* UreaN-7 Creat-0.6 Na-134
K-4.3 Cl-97 HCO3-27 AnGap-14
___ 09:20PM BLOOD Creat-0.7 Na-133 K-3.4 Cl-97
___ 02:05PM BLOOD Glucose-223* UreaN-12 Creat-0.7 Na-136
K-3.4 Cl-98 HCO3-27 AnGap-14
___ 02:05PM BLOOD Glucose-223* UreaN-12 Creat-0.7 Na-136
K-3.4 Cl-98 HCO3-27 AnGap-14
___ 05:45AM BLOOD Glucose-344* UreaN-20 Creat-0.9 Na-127*
K-3.9 Cl-87* HCO3-26 AnGap-18
___ 02:35PM BLOOD CK(CPK)-137
___ 11:15AM BLOOD CK(CPK)-119
___ 04:00AM BLOOD CK(CPK)-95
___ 09:20PM BLOOD CK(CPK)-82
___ 02:05PM BLOOD CK(CPK)-85
___ 02:35PM BLOOD cTropnT-<0.01
___ 06:45AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.8
___ 07:40AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.8
___ 06:48AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9
___ 02:35PM BLOOD Calcium-8.8 Phos-2.7 Mg-2.2
___ 07:05AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.3
___ 06:21AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.7
___ 04:00AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.1
___ 02:05PM BLOOD Calcium-8.5 Phos-2.4* Mg-1.6
___ 04:20PM BLOOD CK-MB-1 cTropnT-<0.01
___ 02:35PM BLOOD cTropnT-<0.01
Brief Hospital Course:
Ms. ___ was first taken to the angio suite on ___ for an
emergent angio and a subsequent SFA stent. She was brought to
the floor in stable condition. She did well, tolerated a
regular diet, voided without difficulty, and her pulses were
good. It seemed that her left foot was warmer, but she spiked
fevers almost daily, and had elevated WBCs to the ___. After an
ID workup which ruled out other causes for her fever spikes and
blood cultures still pending, it was determined that her
gangrenous foot was indeed the source of infection as
anticipated. She was brought to the OR on ___ for a left BKA.
She received 2 units of blood the night before. She tolerated
the procedure well, and her post-op crits remained stable. Her
antibiotic regimen of Vanc/Zosyn was continued. She no longer
spiked fevers post op and her WBC came down dramatically.
___ Diabetes continued to see her to adjust her diabetic meds
to ensure good blood glucose controls. Her blood pressure
medications were adjusted slightly. Physical therapy was
consulted and worked with Ms. ___ starting on POD #1, and
continued to work with her thereafter. She continued to
progress, her antibiotics were discontinued. She had a couple
episodes of nausea, and emesis, EKGs were negative. Cardiac
enzymes were negative. She was discharged home in good
condition on ___.
Medications on Admission:
Metformin 1000mg TID
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
2. Docusate Sodium 100 mg PO BID
hold for loose stools
3. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
4. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
5. GlipiZIDE 7.5 mg PO DINNER
7.5 mg before supper
RX *glipizide 5 mg Take half of a tablet before breakfast. Take
one and one half tablet before dinner. tablet(s) by mouth
daily Disp #*90 Tablet Refills:*3
6. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth q4
Disp #*30 Tablet Refills:*1
7. GlipiZIDE 2.5 mg PO BREAKFAST
2.5 mg before breakfast daily
8. Metoprolol Tartrate 25 mg PO TID
hold for SBP < 100, HR < 50
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*60 Tablet Refills:*3
9. Famotidine 20 mg PO Q12H
10. Ondansetron 8 mg PO BID:PRN nausea
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Left foot gangrene
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:
DIVISION OF VASCULAR AND ENDOVASCULAR SURGERY
AMPUTATION DISCHARGE INSTRUCTIONS
ACTIVITY:
On the side of your amputation you are non weight bearing for
___ weeks.
You should keep this amputation site elevated when ever
possible.
You may use the opposite foot for transfers and pivots.
No driving until cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 3 weeks.
BATHING/SHOWERING:
You may shower when you get home
No tub baths or pools / do not soak your foot for 4 weeks from
your date of surgery
WOUND CARE:
Sutures / Staples may have been removed before discharge. If
they are not, an appointment will be made for you to return for
staple removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
CAUTIONS:
If you smoke, please make every attempt to quit. Your primary
care physician can help with this. Smoking causes narrowing of
your blood vessels which in turn decreases circulation.
DIET:
Low fat, low cholesterol / if you are diabetic follow your
dietary restrictions as before
CALL THE OFFICE FOR: ___
Bleeding, redness of, or drainage from your foot wound
New pain, numbness or discoloration of the skin on the
effected foot
Fever greater than 101 degrees, chills, increased redness, or
pus draining from the incision site.
Followup Instructions:
___
|
19776290-DS-5
| 19,776,290 | 27,768,546 |
DS
| 5 |
2157-08-31 00:00:00
|
2157-09-02 22:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
gait unsteadiness
Major Surgical or Invasive Procedure:
lumbar puncture was attempted twice unsuccessfully
History of Present Illness:
The pt is a ___ ___ man who does not receive
regular medical care, who presents with difficulty walking and
getting up after tripping today. He is unhappy about being here
and denies any and all symptoms, which is likely because he has
a strong desire to go home. However he does report that he had
stayed home from work yesterday due to not feeling well. He
reports only fevers, no other specific infectious symptoms. He
reports that today he was walking to work, when he tripped on
the sidewalk. He denies any loss of consciousness and reports
that he fell forward, catching himself with his hands. He denies
head strike. When asked about the red marks on his forehead, he
denies that these were fall related. Per the EMS report, he was
found sitting on his buttocks, on the ground, unable to get up.
Mr. ___
is unable to provide any details about this and just repeats "I
was fine, I am fine." He denies any leg weakness.
.
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 reports recent fever
yesterday. 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:
- DM II, diagnosed in ___ ___ years prior, was prescribed
medication, which he never took
Social History:
___
Family History:
-Denies any neurological disease.
-Mother has ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: Tm: 104, initially 99 P: ___ ___
RR: 16 SaO2: 98% RA
General: Awake, somewhat cooperative, asks repeatedly to go
home.
HEENT: NC with a few red marks on forehead. No scleral icterus,
MMM, Mildly erythematous oropharynx with no exudates
Neck: Supple, no nuchal rigidity. No carotid bruits
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions
Neurologic:
-Mental Status: Alert, oriented x 3. Mildly inattentive,
requires directions to be repeated several times. Relates only a
short history with some contradictions between his report and
EMS. Language is fluent with intact repetition and
comprehension. 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. Prominent agnosia/denial for deficits, even
when pointed out to him, which appears out of proportion to his
strong desire to go home.
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 3mm 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 ___ bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline and has symmetric strength.
.
-Motor: Normal bulk, tone throughout. No pronator drift. Mild
action/postural tremor in bilateral hands
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ ___ 4 5 4 4 5
R 5 ___ ___ 5 5 5 5 5
.
-Sensory: No deficits to light touch, pinprick throughout.
.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor bilaterally.
.
-Coordination: Mild dysmetria on left FNF and ___,
which improves with practice with the hand, in the leg it is
limited by weakness. Normal on right.
.
-Gait: Severe truncal ataxia. He has a difficult time sitting at
the side of bed. If helped, he sits, but immediately falls back
into bed, primarily falling to the right. Once he stands, he is
only slightly unsteady, much improved compared to sitting. He
walks with a narrow base, taking shortened steps with the left
foot only. Unsteady.
.
DISCHARGE PHYSICAL EXAM:
VS - 98.0 114/72 70 18 92%RA
General: NAD
HEENT: no scleral icterus, OP clear.
Neck: supple, JVD not elevated
CV: RRR, nl S1 S2, no r/m/g appreciated.
Lungs: scant exp wheezes
Abdomen: Obese, soft, NT, +BS.
Ext: WWP, +2 pulses. trace ankle edema.
Neuro: A+Ox3, grossly intact.
.
Pertinent Results:
ADMISSION LABS:
___ 12:10PM BLOOD ___
___ Plt ___
___ 12:10PM BLOOD ___
___
___ 12:10PM BLOOD ___
___
___ 12:10PM BLOOD ___
___ 05:55AM BLOOD ___
___
___ 12:10PM BLOOD ___
.
PERTINENT LABS:
___ 06:00AM BLOOD ___ LD(LDH)-634*
___ 05:55AM BLOOD ___
___ 10:55AM BLOOD ___
___ 05:55AM BLOOD ___
___ 05:30AM BLOOD ___
___ 09:05PM BLOOD ___
___ 05:55AM BLOOD ___
___ 05:55AM BLOOD ___
___
___ 05:55AM BLOOD ___
___ 06:29PM BLOOD HIV ___
___ 12:10PM BLOOD ___
___
___ 08:00PM BLOOD ___
___ 09:00AM BLOOD ___
.
MICROBIOLOGY:
___ STOOL CDIFF TOXIN: negative
___ URINE CULTURE: negative
___ BLOOD CULTURES: negative
.
DISCHARGE LABS:
___ 06:25AM BLOOD ___
___ Plt ___
___ 06:25AM BLOOD ___
___
___ 06:25AM BLOOD ___
.
IMAGING:
LENIs ___: No evidence of deep vein thrombosis.
.
CXR ___
FRONTAL PORTABLE CHEST: Low lung volumes result in
bronchovascular crowding. Bibasilar opacities have improved
since ___, particularly on the right with mild residual
left opacity, due to improvement in pneumonia and/or pulmonary
edema. There are no substantial pleural effusions or
pneumothorax. Mild cardiomegaly is unchanged. Mediastinal
silhouette and hilar contours are stable.
.
CXR ___
IMPRESSION: Improving pulmonary edema.
.
CT CHEST ___
Mediastinum: Numerous scattered mediastinal lymph nodes are top
normal in size such as a 1 cm right paratracheal node (3, 9),
likely reactive. There is no axillary lymphadenopathy.
Heart: The heart is mildly enlarged. There is trace
physiologic pericardial effusion. Coronary artery
calcifications are noted in the LAD.
Lungs and pleura: Bilateral dependent ___ opacities
with paraseptal thickening are compatible with pulmonary edema.
On top of this, there are more confluent opacities in both lower
lobes, right more so than left along with a trace right pleural
effusion. Tracheobronchial tree is patent centrally.
Osseous structures: No suspicious lytic or sclerotic lesions.
Upper abdomen: Unremarkable
IMPRESSION:
Bilateral ___ opacities in the dependent gradient
compatible pulmonary edema which is superimposed on bibasilar
confluent opacities compatible with pneumonia. Trace right
pleural effusion.
.
ECHO: ___
The left atrium is elongated. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is low normal (LVEF 50%)
secondary to apical hypokinesis with focal apical dyskinesis.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). 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. Mild (1+) mitral regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
If clinically indicated, a transthoracic study with
transpulmonic microbubble contrast is recommended to better
define the endocardium of the left ventricle and to exclude an
apical thrombus.
.
MRI head ___
IMPRESSION:
With in the right frontal lobe there is a nonenhancing focal
area that is DWI hyperintense, ADC isointense, and T2/FLAIR
hyperintense. Findings may reflect subacute/chronic infarct.
No hemorrhage or abnormal enhancement.
Nonspecific white matter abnormalities, likely sequela of
chronic small vessel ischemic disease.
Paranasal sinus disease.
.
ECHO ___:
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. No late
contrast is seen in the left heart (suggesting absence of
intrapulmonary shunting). There is no pericardial effusion.
IMPRESSION: No evidence of ASD, PFO or significant
intrapulmonary shunting.
.
Brief Hospital Course:
Mr. ___ is a ___ y/o male from ___ with h/o DMII, (no regular
medical care), who presented on ___ following a mechanical
fall, subsequently developed fevers, found to have multifocal
PNA with course further c/b pulmonary edema. Initially admitted
to Neurology for w/u AMS w/ concern for meningoencephalitis
given fevers. He was started on empiric treatment for this,
until diagnosis of PNA at which point he was transferred to
medicine.
# Hypoxia
Felt secondary to diffuse interstitial pneumonitis with
superimposed pulmonary edema, likely secondary to some component
of diastolic CHF as well as inflammation. Patient developed a 6L
oxygen requirement. He responded well to IV diuresis with
furosemide but further improvement following resolution of
pulmonary edema was delayed. He was evaluated by pulmonary who
felt that his hypoxia was largely due to persistent VQ mismatch
secondary to alveolar inflammation with PNA. Bilateral ___ venous
dopplers were negative for DVT. CTA was not pursued as there was
overall low suspicion for PE given more likely alternative
diagnosis. Prior to discharge, patient's oxygen saturation was
92% at rest but ranging ___ with ambulation (2L oxygen
requirement with ambulation). Patient declined home oxygen. He
should have follow up chest imaging in ___ weeks to ensure
resolution of imaging findings.
.
# PNA
Patient with fevers, cough, and note of bibasilar opacities on
chest CT suggestive of pneumonia. While his overall course is
more consistent with a viral or atypical pneumonia at onset, he
was ultimately treated for HCAP. He completed a course of
Vancomycin (___), as well as 8 days of cefepime and
levofloxacin (___). Fevers resolved as of ___. HIV
antibody was negative as was ___. Patient will need
f/u imaging, as noted above.
.
# DMII
Prior to this admission, the patient had not seen a physician in
the ___. He reported taking an oral medication for DM from ___.
Hgb A1C here was 12. ___ was consulted for management. He was
initially maintained on Lantus 14 unit QHS and insulin sliding
scale. He was ultimately transitioned to an oral regimen and
discharged on Glipizide XL 10 mg daily and Metformin 1,000mg
twice daily. Follow up with ___ was not established at the
time of discharge, but would encourage patient to schedule
appointment with ___ outpatient.
.
# CAD
Patient noted on echo to have low normal left ventricular
systolic function with LVEF 50% secondary to apical hypokinesis
with focal apical dyskinesis. Also note of increased left
ventricular filling pressure with PCWP>18mmHg. A repeat TTE with
transpulmonic microbubble contrast revealed no apical thrombus;
and no PFO. In setting of acute respiratory illness, considered
stress cardiomyopathy; however, patient does have risk factors
for vascular disease with evidence of likely demand ischemia
with peak troponin of 0.08. Started on statin, ASA. Would
consider repeat echocardiogram for further evaluation in 6
weeks.
.
# Subacute CVA
Patient was initially admitted to the neurology service
following fall. His initial exam was apparently notable for ___
weakness of the left IP and hamstrings and mild LUE dysmetria,
although these abnormalities resolved. Given fever to 104, fall,
there was concern for meningoencephalitis. 2 failed attempts at
LP, and patient refused ___ guided LP. He was started on empiric
antibiotic coverage for this (vancomycin, ceftriaxone,
ampicillin, acyclovir), until discovery to PNA. EEG showed no
seizurse or encephalopathy. His NCHCT/MRI showed small
hypodensity in the right frontal/temporal white matter c/w
subacute vs chronic infarct. Patient refused follow up with
neurology, but this should be discussed further outpatient.
Patient started on ASA and atorvastatin.
.
# OSA
Started nocturnal CPAP inpatient, although patient often
refused. Would benefit from formal sleep study outpatient for
further assessment.
.
# Social issues
Patient denied any close contacts or social support. Early
during his course, he refused to engage with his medical team.
Ethics and SW were helpful in delineating patient's frustration
and difficulty accepting his medical illness. He ultimately
cooperated with medical care and was quite engaging and thankful
as he began to improve clinically. Given patient's overall
reluctance to seek medical care, scheduled follow up with PCP
only at the time of discharge, from which further ___
care can be established as needed.
.
# Diarrhea
Patient developed loose stools, possibly secondary to
antibiotics. CDIFF toxin was negative ___. Improved with
Loperamide.
.
TRANSITIONAL ISSUES:
#CODE STATUS: Full
#HCP: none
- establish care with new PCP
- establish future f/u with neurology
- f/u w/ ___
- repeat A1C outpatient on PO regimen
- repeat CXR and echocardiogram in 6 weeks
- outpatient sleep study
Medications on Admission:
The patient was taking unknown oral medication for diabetes
obtained from ___ (suspect Metformin).
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 (One) tablet,delayed release (___) by
mouth once a day Disp #*30 Tablet Refills:*0
2. Atorvastatin 40 mg PO HS
RX *atorvastatin 40 mg 1 (One) tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
3. GlipiZIDE XL 10 mg PO DAILY
RX *glipizide 10 mg 1 (One) tablet extended release 24hr(s) by
mouth once a day Disp #*30 Tablet Refills:*0
4. MetFORMIN (Glucophage) 1000 mg PO BID
RX *metformin 1,000 mg 1 (One) tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
acute diastolic heart failure
Diabetes mellitus II, uncontrolled
cannot exclude meningoencephalitis
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 ___,
You were admitted on ___ with fevers to ___t home.
Our initial concern was for a possible infection of your brain
that caused a seizure. We gave you antibiotics and your fevers
improved. 2 unsuccessful attempts at lumbar puncture were made,
and you refused further attempts. CT/MRI showed a small right
frontal infarct that appeared to be recent and that may have
accounted for a portion of your symptoms. Echocardiogram showed
normal function and no obvious cardiac source of your condition.
By ___ your chest xray appeared to showsigns of pneumonia and
we changed your antibiotics to cover for the possibility of a
resistant infection. You improved quickly with treatment for
your pneumonia and we gave you medications to remove fluid from
your lungs. You were still requiring some oxygen with activity
prior to discharge, but you were not interested in having oxygen
at home.
You heart function was found to be mildly depressed, suggesting
a small heart attack. We started you on medications to protect
your heart. You will need to follow up with your primary care
doctor for further assessment.
You were also found to have poorly controlled Diabetes. We
started you on new medications with improvement. You should
follow up with your PCP for ongoing management.
Followup Instructions:
___
|
19776335-DS-15
| 19,776,335 | 28,429,765 |
DS
| 15 |
2182-07-20 00:00:00
|
2182-07-23 09:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
coronary arteriography
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: ___ year old male with PMH of CAD
s/p multiple stenting of RCA and LCX, DM2, HTN, GERD transfered
from ___ with worsening epigastric chest pain x 1 week. Pt
reports intermittent pressure-like pain that starts in the
epigastric region and occasionally travels to the left shoulder.
The episodes are similar to both CP and GERD discomfort that
he's had in the past, but more intense. Pain is not entirely
relieved with Maalox/Tums. He denied SOB or orthopnea. Denies
fever, chills, cough or recent illnesses.
In the ED, pt was pain free. Vitals Temp: 98.2 HR: 53 BP:
145/67 Resp: 18 Sat: 100% RA. Initial EKG abnormal with inverted
twaves in the inferior lateral leads. Trops were 0.03 and 0.12.
He was given gi coctail, 1 nitro, 4 baby asa pta. Started on IV
heparin and sent for cardiac catheterization. Found to have
distally occluded RCA and diffuse disease of the LAD, no
stenting was performed. No plavix loading. Pt was hypertensive
to the 190s and required a nitro drip.
On arrival to the floor, patient was alert, oriented x3, in NAD.
Vitals were T 98.5 , BP 150/61 , HR 72 , RR 18 , 98% SpO2
REVIEW OF SYSTEMS:
Positive for hematuria noted at OSH.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
Coronary artery disease : ___ PCI RCA; ___ Stent RCA; ___ LCx
stent; known residual mild-moderate LAD disease
DM2
GERD
BPH
Hypertension
Hyperlipidemia
Diverticulosis
Cataract surgery
Herpes Zoster ___ - facial involvement affecting taste
R cheek melanoma with local metastasis tx'd with
surgery/radiation - no recurrence x ___ years
Social History:
___
Family History:
FAMILY HISTORY:
non-contributory.
Physical Exam:
PHYSICAL EXAMINATION on Admission
VS: T 98.5 , BP 150/61 , HR 72 , RR 18 , 98% SpO2
GENERAL: WDWN Male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Hearing aids in
place.
NECK: Supple without JVD.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. 2+ DPs
NEURO: CN II-XII grossly intact, strength ___ throughout,
sensation grossly normal. Gait not tested.
PHYSICAL EXAMINATION on Discharge:
VS: T 98.3 , BP 147/62 , HR 62 , RR 18 , 97% RA
GENERAL: WDWN Male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Hearing aids in
place.
NECK: Supple without JVD.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. 2+ DPs
NEURO: CN II-XII tested and intact, strength ___ throughout,
sensation grossly normal. Gait not tested.
Pertinent Results:
___ 01:55PM BLOOD WBC-4.4 RBC-4.52* Hgb-13.4* Hct-39.8*
MCV-88 MCH-29.5 MCHC-33.6 RDW-12.7 Plt ___
___ 09:30PM BLOOD ___ PTT-31.7 ___
___ 01:55PM BLOOD Glucose-97 UreaN-22* Creat-1.0 Na-142
K-4.2 Cl-105 HCO3-29 AnGap-12 Albumin-4.3 Calcium-9.5 Phos-3.5
Mg-2.2
___ 01:55PM BLOOD ALT-19 AST-30 CK(CPK)-199 AlkPhos-57
TotBili-0.2
___ 01:55PM BLOOD Lipase-45
___ 01:55PM BLOOD CK-MB-14* MB Indx-7.0*
___ 01:55PM BLOOD cTropnT-0.12*
___ 12:15AM BLOOD CK-MB-24* cTropnT-0.16*
___ 10:50AM BLOOD CK-MB-29* MB Indx-8.2*
Labs on Discharge:
___ 10:50AM BLOOD WBC-5.7 RBC-4.20* Hgb-12.5* Hct-37.1*
MCV-88 MCH-29.7 MCHC-33.7 RDW-12.9 Plt ___
___ 10:50AM BLOOD Plt ___
___ 10:50AM BLOOD Glucose-196* UreaN-18 Creat-0.9 Na-138
K-4.1 Cl-103 HCO3-29 AnGap-10
___ 10:50AM BLOOD CK(CPK)-355*
___ 10:50AM BLOOD CK-MB-29* MB Indx-8.2*
___ 12:15AM BLOOD CK-MB-24* cTropnT-0.16*
___ 10:50AM BLOOD Calcium-9.0 Phos-2.4* Mg-2.2
___ 01:09PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
CXR: no acute cardiopulmonary process
EKG: unchanged from yesterday, abnormal with inverted twaves in
the inferior lateral leads.
Cardiac Cath: distal stenosis of RCA and diffuse disease of the
LAD, however stenting not performed.
Brief Hospital Course:
___ year old male with PMH of CAD s/p MI and stenting (___),
DM2, HTN, and GERD presented with chest pain, EKG changes and
troponin elevation consistent with NSTEMI, s/p cath without
stenting.
Active Diagnoses
# Acute coronary syndrome/NSTEMI: Pt's worsening chest pain, T
wave changes on EKG and troponin elevation was highly consistent
with NSTEMI. He was taken to the cath lab where he was found to
have distal stenosis of the RCA along with diffuse disease of
the LAD. the likely culprit was the RCA occlusion. NO PCI was
performed due to robust collaterals from left to right and the
difficult with restenting the RCA. The thought was that if he
continues to have significant anginal symptoms, bypass surgery
should be considered. He was continued on Clopidogrel, Aspirin
and Simvastatin, Lisinopril, Metoprolol. Imdur was also started
for increased medical management of CAD and angina.
Chronic Diagnoses
# Hypertension: Pt has a history of hypertension requiring
multiple antihypertensives. In the post cath, period he
required a short period of Nitro drip for SBPs into the 190s.
Thereafter his SBPs ranged 130-150s. He continued Lisinopril,
Metoproplol. Imdur 30mg was started.
# GERD: Pt has chronic GERD for which he received an extensive
GI workup in the past. He continued to have some post-prandial
dyspepsia during the admission. We increased his omeprazole to
40mg BID.
# DM: History of NIDDM. We held his home meds (metformin and
glypizide) and started an insulin sliding scale coverage. BS
remained well control.
#Hyperlipidemia: stable, continued simvastatin
#BPH: stable, Continued Finasteride
Transitional Issues
#Code Status: Full code
#Follow up PCP visit schedule to readdress BP control and GERD
(possibly start on H2 blocker if doubling the dose of omeprazole
is not helpful)
#Follow-up Cardiology visit
#Pt would benefit from smoking cessation advice. He was in
contemplation stage during admission.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientAtrius.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. Lorazepam 0.5 mg PO HS
3. Clopidogrel 75 mg PO DAILY
4. Simvastatin 40 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Metoprolol Tartrate 50 mg PO QID
8. Lisinopril 20 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN Chest pain
10. glipiZIDE *NF* 5 mg Oral BID
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Lorazepam 0.5 mg PO HS
5. Metoprolol Tartrate 50 mg PO QID
6. Nitroglycerin SL 0.4 mg SL PRN Chest pain
7. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 Capsule(s) by mouth twice daily Disp #*60
Capsule Refills:*3
8. glipiZIDE *NF* 5 mg Oral BID
9. MetFORMIN (Glucophage) 500 mg PO BID
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP<100
RX *Imdur 30 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
11. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 Tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
12. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 Tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
-NSTEMI
-Distal occlusion of the right coronary artery
-diffuse occlusions of the left anterior descending artery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you while you were in the
hospital. You were admitted for evaluation of your abdominal
discomfort and found to have a slight elevation in your cardiac
biomarkers suggesting you had has some slight damage to your
heart. You were taken for cardiac cath which showed coronary
artery disease in both your right and left coronary arteries,
due to technical considerations we were notable to stent these
lesions. You will need to follow up with your primary care
doctor and cardiologist for further medical management of this
problem.
Followup Instructions:
___
|
19776335-DS-17
| 19,776,335 | 26,295,868 |
DS
| 17 |
2183-03-17 00:00:00
|
2183-03-20 21:20:00
|
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:
none
History of Present Illness:
___ with h/o CAD s/p multiple stenting of RCA and LCX, DM2, HTN,
GERD, metastatic melanoma to neck s/p Right radical neck
dissection and XRT, with carotid artery stenosis, who initially
admitted ___ to the vascular service for stenting of R carotid
artery for crescendo TIA and retinal embolus, done ___,
transferred to the CCU with post-procedure CP and found to have
inferior STEMI that was medically managed due to patient's
refusal of c. cath re-presenting with chest pain.
During his hospitalization from ___ to ___, he had
post-procedure CP associated with ECG changes suggestive of
mostly an inferior and posterior infarction. His prior c. cath
showed RCA with known ___ % distal occlusion with distal RCA
filled by L to R collaterals based on c. cath from ___. It was
thought that this could have suggested collateral insufficiency
possibly in the setting of phenylephrine usage which was started
before ECG changes showing STE vs. a more proximal lesion. The
patient repeadly refused c. cath, and he was medically managed
for his STEMI on transfer to the CCU for which he received ASA
325 mg PO daily, plavix, and a heparin infusion for at least 48
hours. TTE was performed and revealed mild regional
biventricular systolic dysfunction consistent with CAD with mild
mitral regurgitation and moderate pulmonary hypertension with
LVEF 40 % His troponin peaked at 3.25. His hospitalized was
complicated by new onset atrial fibrillation. Anti-coagulation
was discussed multiple times, but the patient refused to start
warfarin and wanted to discuss this issue with his outpatient
provider. He was started on metoprolol succinate with decent
rate control with spontaneous conversion back to sinus rhythm on
___.
The evening prior to presentation (day of discharge) patient
noted onset of chest "discomfort." He reports the sensation was
throughout his chest, accompanied by dyspnea, denied radiation.
He states his symptoms were much less severe than occured during
his STEMI, which involved severe pain and chest pressure
accompanied by N/V. He reports discomfort persisting throughout
the night (hours) and resolved this AM after taking aspirin,
plavix and nitro X2. No associated fevers/cough. His discomfort
was positional, worse when supine. Denied palpitations.
In the ED, initial vitals were: ___ 66 124/60 18 96% ra
EKG at 09:32 on ___ shows 65 bpm in NSR, QRS 102 ms, QTc 414
ms. ___ STD in I, TWF in V1, STD in V4-V6 ~ 1 mm at maximum.
There are q-waves in III, aVF (diagnostic in III). Poor R-wave
progression present with transition point at V3-V4, ? prior
anteroseptal infarct.
Compared with prior dated ___, rhythm is no longer atrial
fibrillation, STD in V4-V6 are less pronounced (prior ~ 2 mm
STD).
Labs were performed:
- lactate 1
- TropnT 3.96 [Prior hospitalization 0.63 - 3.13 (on discharge)]
- CK 85 CK-MB 5
- Na 137 K 4.9 Cl 105 HCO3 24 BUN 20 Cr 1 Glc 240
- WBC 5.7 Hgb 11.9 Hct 35.4 MCV 91 Plt 141 Diff N 79.8
CXR showed (prelim) small bilateral pleural effusion, RLL
opacity concerning for pneumonia in appropriate setting.
A bedside US was performed and negative for pericardial
effusion.
DRE was heme negative.
The patient received vancomycin 1 gm IV x 1, cefepime 2gm IV x
1, heparin infusion started at 850 units/hr with 4000 units IVP
bolus. He had taken aspirin/plavix at home.
Vitals on transfer were: 12:00 0 97.4 67 135/69 16 97
On arrival to the floor, patient denied any chest pain or
discomfort.
Serial ECG was performed showing persistent V4-V6 at ~ 1 mm with
similar findings to prior performed this morning. PVC are noted
x 2.
REVIEW OF SYSTEMS
On review of systems, He denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
CARDIAC RISK FACTORS: +Diabetes, +Hyperlipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: Coronary artery disease
-- ___ PCI RCA; ___ RCA stent; ___ LCx stent; known residual
mild-moderate LAD disease; ___ DES to mid-RCA; ___ cath
revealing 100% distal RCA occlusion
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
GERD
BPH
Diverticulosis
Cataract surgery
Herpes Zoster ___ - facial involvement affecting taste
R cheek melanoma with local metastasis tx'd with
surgery/radiation - no recurrence x ___ years
Carotid stenosis s/p R ICA stent ___
Social History:
___
Family History:
non-contributory.
Physical Exam:
Admission Physical:
VS: T= 97.9 BP= 124/61 HR= 76 RR= ___ O2 sat= 97% on RA
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Coarse crackles at bases, L>R. No chest wall deformities,
scoliosis or kyphosis. Resp were unlabored, no accessory muscle
use.
ABDOMEN: Soft, NTND. No HSM or tenderness. Mild HJR.
EXTREMITIES: No c/c/e.
Discharge Physical:
PHYSICAL EXAM: see intern note
Vitals - Tm/Tc:98.5/97.6 ___ 02
sat:95% RA
In/Out:
Last 24H: 180/920
Last 8H:
Weight: 70.1 kg
GENERAL: Pleasant in NAD. Alert and interactive.
NECK: supple without lymphadenopathy, JVD at clavicle.
___: RRR. No S3 or S4 no rubs or gallops.
RESP: No accessory muscle use. Lungs CTA, decreased at bases.
ABD: soft, NT/ND, normoactive bowel sounds.
EXTR: no edema. Feet warm
NEURO: Alert and oriented x 3. Denies pain. MAE.
Pertinent Results:
Admission labs:
___ 05:11AM BLOOD WBC-5.0 RBC-3.59* Hgb-10.9* Hct-32.0*
MCV-89 MCH-30.3 MCHC-34.0 RDW-13.7 Plt ___
___ 09:45AM BLOOD ___ PTT-34.5 ___
___ 05:11AM BLOOD Glucose-135* UreaN-18 Creat-1.0 Na-137
K-3.8 Cl-103 HCO3-27 AnGap-11
___ 09:45AM BLOOD cTropnT-3.96*
___ 02:37PM BLOOD CK-MB-4 cTropnT-3.47*
___ 05:44AM BLOOD CK-MB-4 cTropnT-3.28*
___ 05:11AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.1
___ 11:48AM BLOOD Lactate-1.0
Discharge labs:
___ 06:35AM BLOOD WBC-5.3 RBC-3.63* Hgb-10.9* Hct-32.8*
MCV-90 MCH-29.9 MCHC-33.2 RDW-13.3 Plt ___
___ 06:35AM BLOOD ___ PTT-91.6* ___
___ 06:35AM BLOOD Glucose-255* UreaN-14 Creat-1.0 Na-139
K-4.1 Cl-104 HCO3-31 AnGap-8
___ 06:35AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.2
Imaging:
TTE ___:
Conclusions
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is an inferobasal left ventricular aneurysm.
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. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. An eccentric, anteriorly directed
jet of (at least) 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
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of ___, left ventricular contractile function is
further reduced, with new focal wall motion abnormalities and
worsening mitral regurgitation, consistent with multiple vessel
obstructive coronary artery disease. Dr ___ notified by
telephone.
CXR ___:
FINDINGS: The heart is mildly enlarged with a left ventricular
configuration.
Indistinct prominent pulmonary vascularity suggests mild fluid
overload. The lungs are hyperinflated. Small bilateral pleural
effusions are suspected. In addition, referring medial right
lower lobe, and perhaps with medial left lower lobe opacity as
well, there is a fairly confluent opacity suggestive of
pneumonia in the appropriate clinical setting, although
substantial atelectasis could be considered. Fissures appear
thickened. Findings are new since the recent prior examination.
IMPRESSION: Findings suggesting vascular congestion. Basilar
opacities,
pneumonia versus atelectasis.
CXR ___:
IMPRESSION:
Stable small bilateral effusions with unchanged bibasilar
opacities.
Infection cannot be excluded given the appropriate clinical
circumstance.
Lateral views of the chest would help to distinguish the extent
of parenchymal opacities over effusion.
Microbiology:
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
Blood cultures ___: pending x2
Brief Hospital Course:
Brief Course:
___ with h/o CAD s/p multiple stenting of RCA and LCX, DM2, HTN,
GERD, metastatic melanoma on neck s/p R radical neck dissection
and XRT, with carotid artery stenosis sp ___ stent to R carotid
artery on ___, with that hospitalization complicated by STEMI,
medically managed given pt refused catheterization. Pt now
represented given chest pain and elevated troponins.
# Chest pain: Differential included ACS vs. GERD vs.
pericarditis vs. infection, such as pneumonia. His ECG showed no
significant changes and troponins were elevated but CK-MB was
flat. He remained chest pain free on arrival to CCU. Pt
initially given Vancomycin/Cefepime/Cipro for hospital-acquired
pneumonia given possible opacities at bases on CXR and pleuritic
chest pain. However, he remained afebrile, without leukocytosis
or cough, making pneumonia unlikely and antibiotics were
discontinued on hospital day #2. Considered pericarditis, but no
friction rub and pt chest pain free on admission. TTE showed
worsening EF and wall motion abnormalities, most likely
suggestive of progression of disease from recent STEMI. Given
concern for GERD pain, pt's PPI was increased. He was continued
on Atorvastatin, Clopidogrel, ASA, and metoprolol, and started
on Lisinopril 5mg daily. Pt continued on heparin drip despite
low suspicion for reinfarction, as pt w/paroxysmal afib, not
otherwise anticoagulated. Pt continued to refuse cardiac
catheterization despite extensive discussions, and he was sent
home w/ medical management to follow up with his outpatient
cardiologist.
# Acute systolic heart failure: Last LVEF during recent
admission was 40 % with biventricular systolic dysfunction from
CAD with some component of moderate pulmonary hypertension. TTE
demonstrated new LVEF 30 % with worsening focal wall motion
abnormalities. Admission weight 72.1 kg (discharge weight: 73.3
kg). CXR showing vascular congestion. He was diuresed initially
and started on low dose lasix 10mg daily, which was continued at
discharged, along w/ metoprolol, and ACEI as above.
# Rhythm: In NSR during most of hospital stay with short runs of
A. fib and A. flutter overnight on hospital day 1. He had new A.
fib during the last hospital admission and converted at end of
prior (CHADS2 score of 4). He was continued on heparin as
above; discussed anticoagulation with pt and wife, and pt agreed
to try it at least for a few months. ASA was decreased to ___ischarged on 3 mg of coumadin with a prescription for labs
to be drawn and INR monitored.
# Normochromic, normocytic anemia: Stable. No evidence of
bleeding.
# R carotid artery stenosis s/p stenting: Initially admitted to
vascular surg service and went for R carotid artery stenting
___. Vascular surgery was notified of his admission. No acute
issues during this admission.
# DM2 (last A1c unknown): Held oral hypoglycemics -- metformin
and glipizide, placed on ISS in house.
- HISS in house
# Thrombocytopenia: Mild thrombocytopenia between 110-140 and at
baseline on admission.
- continue to trend while on ___
# HLD: Continued atorvastatin 80
# GERD: Continue PPI -- protonix instead of omeprazole given
contraindications of omeprazole w/ plavix. Increased dose of
protonix.
# BPH: Continued terazosin and finasteride
TRANSITIONAL ISSUES:
-INR should be monitored closely given initiation of coumadin
-Pt should continue to be encouraged to undergo cardiac
catheterization
Medications on Admission:
1. Atorvastatin 80 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Lorazepam 0.5 mg PO HS:PRN insomnia
5. Terazosin 4 mg PO HS
6. Aspirin 325 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. GlipiZIDE *NF* 5 mg ORAL BID
9. MetFORMIN (Glucophage1. ) 500 mg PO BID
10. Nitroglycerin SL 0.4 mg SL PRN cheat pain
11. Omeprazole 40 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Lorazepam 0.5 mg PO HS:PRN insomnia
6. Terazosin 4 mg PO HS
7. Enoxaparin Sodium 100 mg SC DAILY
Take once daily until the ___ clinic tells you to
stop.
RX *enoxaparin 100 mg/mL one syringe SC daily Disp #*5 Syringe
Refills:*2
8. Furosemide 10 mg PO DAILY
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*2
9. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
10. Warfarin 3 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 1.5 tablet(s) by mouth daily Disp
#*45 Tablet Refills:*2
11. GlipiZIDE 5 mg PO BID
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Nitroglycerin SL 0.4 mg SL PRN chest pain
14. Outpatient Lab Work
Please check chem-7 and INR on ___ ___ results to
the ___ clinic ___ and Dr. ___ at
Phone: ___
Fax: ___
ICD-9: 427
15. Omeprazole 40 mg PO BID
16. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
chest pain
Acute on Chronic systolic heart failure
anemia
Atrial fibrillation with rapid ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at ___.
You had chest pain at home and was readmitted. You did not have
a heart attack and the chest pain may have been from irritation
of the heart muscle from the previous heart attack.
You had another episode of atrial fibrillation and was started
on a heparin drip. You will start taking warfarin at home and
will need to take enoxaparin injections once daily until the
warfarin has started to work and your blood level is more than
2. The visiting nurse ___ give you the injections every day and
will check your blood level on ___. The ___
clinic at ___ will tell you how much warfarin to
take every day from now on depending on your blood level. They
will contact you at home.
Please weigh yourself in the morning before breakfast, call Dr.
___ weight increases more than 3 pounds in 1 day or 5 pounds
in 3 days.
Followup Instructions:
___
|
19776335-DS-19
| 19,776,335 | 21,906,421 |
DS
| 19 |
2183-10-23 00:00:00
|
2183-10-23 23:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness, weakness
Major Surgical or Invasive Procedure:
- Continuous bladder irrigation
History of Present Illness:
___ y/o M with metastatic melanoma on coumadin presenting with
dizziness, chest pressure, and overall feeling unwell.
Family states patient also seems a bit more confused than
baseline. He has some abdominal pain although this is unchanged
from baseline. Also reports nausea and decreased po intake for
the last sevral days. He feels overall dizzy and week. States
that his chest has felt tight over the last few hours with
palpitations. Over the last few days he also intermittently had
discomfort with exertion which improved with rest. No fevers or
chills. Denies nausea, vomiting, blood in stools, or melena.
Of note, patient was recently admitted from ___. He
presented with epigastric pain and nausea, weight loss, fatigue
for several months. He had an EGD which showed a large fungating
malignant looking gastric mass which was found to be melanoma on
path. He had scans which show mets to liver and lungs. He was
scheduled to follow up with Dr. ___.
In the ED intial vitals were: 97.8 144 ___ 96%.
He was noted to be in Afib with RVR.
He was given metoprolol x 2 with improvement in rates to the
___. He chest discomfort improved with the resolution of the
RVR.
Rectal showed brown guiac positive stool.
Labs significant for H/H of 8.1/23.9 (down from 10.2/29.5 in
___, INR 5.3, Na of 132.
CT abdomen and pelvis was done which showed no change in burden
of metastatic disease, interval development of moderate to large
bilateral pleural effusions. CXR showed concern for bibasilar
regions of consolidation. CT head showed no acute process.
She was given 10 IV vitamin K and 2 units of FFP.
She was given vancomycin and ceftriaxone for possible
pneumonia.
Vital signs prior to transfer 97.8 95 101/58 26 98% Nasal
Cannula.
Currently, he is chest pain free.
Past Medical History:
diabetes
hyperlipidemia
hypertension
CAD (3VD on most recent cath)
- ___ PCI RCA; ___ RCA stent; ___ LCx stent; known residual
mild-moderate LAD disease; ___ DES to mid-RCA; ___ cath
revealing 100% distal RCA occlusion
GERD
BPH
Diverticulosis
Cataract surgery
Herpes Zoster ___ - facial involvement affecting taste
metastatic melanoma
Carotid stenosis s/p R ICA stent ___
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM:
=====================================
Vitals- 97.5 137/86 100 22 98% 3L
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, slightly dry MM, oropharynx clear
Neck- supple, no LAD
Lungs- Bibasilar crackles R>L
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, tender to palpation in epigastric and RUQ.
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Rectal - normal rectal tone, no stool or blood
GU- no foley
Ext- warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro- A&Ox3. able to say days of week backwards. CNs2-12
intact, motor function grossly normal
DISCHARGE EXAM:
=====================================
Vitals: 97.4 125/68 (SBPs 110-139) 70 (HRs ranging ___
20 97% RA
General: Alert, oriented. In no distress, looks good today
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: CTAB.
CV: RRR, normal S1 + S2, no murmurs appreciated
Abdomen: soft, minimally tender to palpation in epigastric/RUQ.
No rt/guarding. No organomegaly.
GU: Foley cath in place, some golden urine with very small blood
Ext: warm, well perfused. Bilateral pedal edema.
Pertinent Results:
ADMISSION LABS:
.
___ 11:43PM CK(CPK)-90
___ 11:43PM CK-MB-4 cTropnT-0.16*
___ 11:43PM HGB-8.7* HCT-25.2*
___ 11:43PM ___
___ 01:25PM WBC-5.5 RBC-2.96* HGB-8.1* HCT-23.9* MCV-81*
MCH-27.5 MCHC-34.0 RDW-14.5
___ 01:25PM NEUTS-80.5* LYMPHS-9.0* MONOS-9.5 EOS-0.7
BASOS-0.3
___ 01:25PM PLT COUNT-348
___ 01:08PM LACTATE-3.1*
___ 01:00PM GLUCOSE-245* UREA N-24* CREAT-0.7 SODIUM-132*
POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-24 ANION GAP-19
___ 01:00PM estGFR-Using this
___ 01:00PM ALT(SGPT)-32 AST(SGOT)-20 CK(CPK)-39* ALK
PHOS-97 TOT BILI-0.4
___ 01:00PM CK-MB-3 cTropnT-0.10*
___ 01:00PM ALBUMIN-3.2*
___ 01:00PM ___ PTT-44.5* ___
.
IMAGING:
.
CT abd/prev (___):
IMPRESSION:
1. No evidence of retroperitoneal or mesenteric hemorrhage.
2. No significant interval change in burden of metastatic
disease, compared with CT scan from ___, although
the interval is less than two
weeks and the current exam is a non-contrast study. Multiple
metastases at the lung bases as well as the dominant liver
metastasis are unchanged.
3. Interval development of moderate to large non hemorrhagic
bilateral
pleural effusions, right worse than left.
4. Incidental findings include: coronary artery calcifications,
atherosclerotic calcifications of the abdominal aorta,
significant
atherosclerotic plaque at the origin of the renal arteries,
prostatic
enlargement, degenerative changes of the lumbar spine, sigmoid
diverticulosis.
___ ___: IMPRESSION: The previously detected foci of
susceptibility artifact on MR have no clear CT correlate. No
evidence of acute intracranial process.
ECHO (___):
The left atrium is mildly 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 and
cavity size are normal. There is severe left ventricular
hypokinesis with relative preservation of the lateral wall (LVEF
= 25 %). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. Right ventricular
chamber size is normal. with mild global free wall hypokinesis.
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. An eccentric, anteriorly directed jet of Mild to
moderate (___) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Severe left ventricular systolic dysfunction with
regional variation (c/w multivessel CAD given regionality on
prior studies). Mild to moderate mitral regurgitation. Moderate
pulmonary hypertension.
Compared with the prior study (images reviewed) of ___ the
mid to distal anterior septum and possibly the anterior wall
(less well seen) are now hypokinetic. The lateral wall remains
relatively preserved. Other findings are similar.
DISCHARGE LABS:
___ 08:30AM BLOOD WBC-9.4 RBC-4.33* Hgb-11.8* Hct-37.7*
MCV-87 MCH-27.2 MCHC-31.2 RDW-16.5* Plt ___
___ 01:00PM BLOOD Glucose-138* UreaN-48* Creat-1.2 Na-134
K-4.5 Cl-98 HCO3-23 AnGap-18
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
=========================================================
___ y/o M with hx of CAD (known 3VD), DM2, HTN, metastatic
melanoma who presents feeling unwell found to have NSTEMI and
pulmonary edema, with hospital course complicated by delirium
and hematuria.
ACTIVE ISSUES:
=========================================================
# NSTEMI: Patient was reported to have ECG changes in the
setting of Afib with RVR in the ED, however ST-depressions did
not resolve despite conversation to sinus rhythm and improvement
in rate. Patient noted to have continued STD in V4-V6 and TWI/F
in I and aVL. Troponin positive at 0.1, tending up to .22. Of
note Plavix recently discontinued on recent admission out of
concern for GI bleed. Patient has known 3VD on last cath;
currently refusing repeat catheterization (has done so in
setting of prior NSTEMIs). Atrius Cardiology was consulted.
Transfused to Hct > 30 out of concern for demand ischemia in
setting of blood loss and paroxysmal afib w/RVR. On heparin drip
for 48hrs, with no plans to restart Plavix given bleed (urinary
and GI source). Continued on aspirin, atorvastatin, SLN,
metoprolol and placed on isosorbide mononitrate for symptomatic
relief. Chest pain pain eventually resolved, and EKG returned to
baseline. TTE on this admission showed EF of 30%, with new
hypokineses in the anterior septum and anterior wall.
# Atrial Fibrillation with RVR: CHADS2 of ___ w/crescendo TIAs
in early ___ s/p R carotid stent; rate controlled with IV
metoprolol in the ED; INR 5.7 on admission (likely in setting of
decreased PO intake). Coumadin held, reversed in setting of Hct
drop. Patient continued to have episodes of RVR while on floor,
which were concerning for further demand ischemia and flash
pulmonary edema, so patient was rate controlled with increased
doses of metoprolol (50mg q6hrs) and the addition of amiodarone
400mg initially TID, tapered to BID. Discharge regimen was
Metoprolol Succinate XL 25 mg PO DAILY and Amiodarone 400mg BID.
In setting of high bleeding risk, Coumadin was not restarted on
discharge.
# ___: Cr rose to 1.5 from baseline of 0.7, most likely
pre-renal in setting of poor forward flow w/CHF/MI. Cr
stabilized at 1.3, which was thought to be his new baseline.
# Hematuria: developed in setting of urethral trauma (patient
attempting to pull out his catheter while delirious) while on
heparin drip. He had continued clots/bleed requiring CBI,
urology was consulted. Patient underwent CBI for several days,
with continued bleeding; eventually CBI was stopped though
bleeding had not. An attempt was made to take out Foley,
however, he was unable to void. The Foley was replaced and
decision made to keep the Foley in until hematuria resolved. At
that time a trial of voiding can be attempted.
# Delirium: patient has mild dementia at baseline; per family,
father's confusion had been increasing at home over the week
prior to admission. Patient sundowned on several occasions,
requiring multiple doses of haloperidol and physical restraints,
No focal neurologic defects. Likely toxic/metabolic
encephalopathy in setting of multiple illnesses and hospitalized
setting. Delirium-reducing measures were put in place, he was
initially given haloperidol 1mg q8hrs, with some success. The
patient had difficulty sleeping during the night. Several
different regimens were tried. Eventually trazodone and Seroquel
HS allowed him a night of sleep. Patient will need to have QTc
monitored as an outpatient as he is on several QTc-prolonging
agents.
# afib with RVR: This was controlled with metoprolol 50mg q6hrs,
later tapered to Metoprolol Succinate XL 25 mg PO DAILY, and
amiodarone 400mg TID, later tapered to BID. He had been on
warfarin prior to presentation, with a CHADS2 score of ___ (h/o
previous TIAs). However, given his history of GI bleed (likely
from GI involvement of his melanoma), as well as hematuria this
hospitalization, the warfarin was held and not restarted.
# Metastatic melanoma: H/o melanoma diagnosed in ___, resected,
with local recurrence in ___. He recently presented with
abdominal pain and nausea found to have gastric mass and mets to
liver and lungs. His decreased PO intake, nausea, and pain are
all likely related to malignancy. He is followed by Dr.
___ has told family that current treatment of his
melanoma is not possible given his functional status and current
medical comorbidities.
# SOB/CHF: Was noted to have ?consolidation on CXR. however, CT
abdomen showed bilateral pleural effusions. Patient without
fevers or leukocytosis and only mild nonproductive cough. He was
treated with vanc/ceftriaxone in ED. On exam he had bibasilar
crackles, R>L without pedal edema. Effusions may be malignant in
nature from known mets or ___ to Afib with RVR and CHF. Diuresed
gently with improvement with respiratory status and exam. He was
discharged on PO Lasix 20mg daily.
# Diabetes: held metformin, glipizide while in hospital;
maintained on SSI. On discharge his metformin was restarted,
however, the glipizide was not (this can be evaluated as an
outpatient).
# BPH: held terazosin in setting of feeling dizzy and
lightheaded, continued finasteride. His terazosin was not
restarted.
# ANXIETY: Continued home sertraline.
# GERD: continue his PPI BID. He was discharged on once daily
dosing.
# GOALS OF CARE: Several discussions regarding goals of care
were held between the primary team, patient, family, social
work, palliative medicine, and case management. A health care
proxy was designated (patient's daughter) and form was signed.
During the hospitalization. the children of the patient
struggled with fact that their father will likely die from
NSTEMI/CHF/GI or GU Bleed before he dies from melanoma; they
also struggled with the fact that given his medical
comorbidities, his medical oncologist is unable to offer
treatment for his metastatic melanoma. Family discussed hospice
care/taking father home, but no official CMO decision was made.
TRANSITIONAL ISSUES:
=========================================================
- If no hematuria for several days, can remove catheter and try
trial of voiding with assistance of VNS (plan to attempt ___
- The following preadmission medications were stopped: warfarin,
terazosin.
- Will need QTc monitoring given on several prolonging agents.
- Chem 7 to be drawn on ___ with results faxed to Dr. ___
- plan for daily weights, HR, BP monitoring with ___
- home glipizide held on discharge for concern of hypoglycemia
with poor PO intake and initiation of lasix (possibly affecting
creatinine). Consider resuming at outpatient PCP visit if
creatinine stable ___ to monitor blood glucose)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Nitroglycerin SL 0.3 mg SL PRN chest pain
6. Omeprazole 40 mg PO BID
7. Sertraline 75 mg PO DAILY
8. Warfarin 4 mg PO DAILY16
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Senna 1 TAB PO BID:PRN constipation
12. GlipiZIDE 5 mg PO BID
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Terazosin 2 mg PO HS
15. Maalox/Lidocaine 5 mL ORAL ASDIR abdominal pain
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
2. Nitroglycerin SL 0.3 mg SL PRN chest pain
3. Senna 2 TAB PO BID constipation
RX *sennosides [senna] 8.6 mg 2 tabs by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Sertraline 75 mg PO DAILY
5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet,delayed release (___) by mouth
daily Disp #*60 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth daily
Disp #*30 Each Refills:*0
7. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Finasteride 5 mg PO DAILY
9. Amiodarone 400 mg PO BID
RX *amiodarone 400 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
10. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*30
Tablet Refills:*0
11. QUEtiapine Fumarate 25 mg PO QHS
RX *quetiapine 25 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
14. Omeprazole 40 mg PO DAILY
15. Please provide hospital bed due to difficulty lying flat.
Please provide hospital bed due to difficulty lying flat. ICD9:
78___.02
16. Please provide shower chair due to requiring 2-person assist
for mobility
Please provide shower chair due to requiring 2-person
assist/immobility. ICD9: 780.72
17. Please provide bedside commode due to requiring 2-person
assist for mobility
Please provide bedside commode due to requiring 2-person
assist/immobility. ICD9: 780.72
18. Wheelchair
Please provide wheelchair. ICD-9: 781.2.
19. Walker
Please provide walker. ICD-9: 781.2
20. TraZODone 50 mg PO HS anxiety
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
21. Haloperidol 2 mg PO DAILY:PRN severe agitation
RX *haloperidol 1 mg 2 tablet(s) by mouth daily Disp #*20 Tablet
Refills:*0
22. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
23. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
24. Outpatient Lab Work
Please check chem 7 on ___. Fax results to Dr. ___
___: ___ Fax: ___.
25. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every 8
hours Disp #*12 Tablet Refills:*0
26. Ipratropium Bromide Neb 1 NEB IH Q4H
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 0.2 mg IH q4hrs Disp
#*30 Unit Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# PRIMARY: Myocardial Infarction (NSTEMI), acute decompensated
systolic heart failure
# SECONDARY: atrial fibrillation, delirium, pulmonary edema,
gastrointestinal bleed, hematuria, acute kidney injury,
metastatic melanoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive, most of the time.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted for confusion and
fatigue at home, and here were found to be having a heart
attack.
You did not wish to have aggressive treatment of your heart
attack, so you were treated with a blood thinning medication.
Unfortunately this was complicated by bleeding within your
urinary tract, requiring the insertion of a catheter for
continuous bladder irrigation. Your bleeding is improving off of
the blood thinner, and we removed the catheter. Unfortunately,
you were not able to urinate and another catheter was placed
because of urinary retention. We recommend keeping this catheter
in for another 5 days then doing a trial void with the help of
your visiting nurse. If you experience bladder pain or if you
stop seeing urine coming out of the catheter bag, your catheter
may need to be flushed. Please use only sterile water for
catheter flushes.
Your hosptial stay was complicated by delerium, which is not
uncommon in very sick hospitalized elderly patients. We used
several medications to help you establish a healthy sleeping
schedule.
Again, it was a pleasure to care for you. We wish you all the
best.
-Your ___ team
Followup Instructions:
___
|
19776354-DS-19
| 19,776,354 | 23,578,146 |
DS
| 19 |
2173-12-06 00:00:00
|
2173-12-09 19:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
-Esophagogastroduodenoscopy with banding for varices ___
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a history of HCV
cirrhosis decompensated by ascites, now admitted with abdominal
pain, and found to have complete occlusion of the splenic,
superior mesenteric and left branch of the portal veins per
imaging.
Mr. ___ has had recurrent episodes of bilateral lower
abdominal pain over the past four months, with episodes becoming
more frequent and increasing in severity. Pain starts in
epigastric area, travels to bilateral lower quadrants with
radiation to the flanks, sometimes relieved with defecation or
passing gas. This has been accompanied by some increasing
abdominal distention, sensation of early satiety, decreased
appetite, and involuntary weight loss of nine pounds over three
months. Pepto-Bismal, ranitidine and Gas-Ex was used at home
with some effect.
Over the two days prior to admission, patient had an acute
exacerbation of his abdominal pain, with pain ___ out of 10 in
severity at worst, waking him from sleep at night. Pain is again
starting in epigastric area travelling to the bilateral lower
quadrants with radiation to flanks/back. It is a crampy/fullness
pain that comes and goes. He notes that drinking water helped
minimally, and also endorses abdominal bloating. He had a CT
abdomen/pelvis performed as an outpatient after a ___ clinic
visit, and this showed: complete occlusion of the splenic veins,
SMV, and left branch of the portal vein, along with new moderate
ascites and gastric/esophageal varices. He was then instructed
to go to the ED.
On arrival to the ED, pain was rated as ___ out of 10. In the
___ ED, initial vitals were: VS: 96.7 HR 117 BP 140/86 RR 15
100% RA. Exam was notable for tachycardia, a distended abdomen,
and a 5-cm ecchymosis on left inner thigh. Labs were notable
for: CBC with H/H 13.1/38.1 (baseline Hct low ___, plt 76
(baseline ___ ALT 89, AST 140, ALK 179, TBil 1.3; INR 1.0;
HCO3 20, with normal chem panel (including Na 138); UA with spec
___ > 1.050. Abdominal ultrasound did not show any pocket of
ascites large enough to tap. Patient was given 150cc/h NS for 2L
given high spec gravity on UA, and morphine IV x2.
Hepatology consult in the ED recommended: diagnostic
paracentesis to rule out SBP given abdominal pain; no urgent
need for anticoagulation; EGD to assess varices prior to
decision to anticoagulation; keeping patient NPO for possible
EGD tomorrow; admission to ET. Vital signs prior to transfer
were: 98.2 71 122/79 18 100%.
On arrival to the floor, the patient's pain was well-controlled.
Morphine had good effect in the ED. He was a good historian, and
had no other complaints.
Past Medical History:
# Cirrhosis: Diagnosed by biopsy (not in BI system) in
___, with history of ascites and jaundice at the time of
diagnosis. Most likely from hepatitis C infection. Had been
well-compensated until development of ascites very recently. No
prior EGDs.
- Hepatitis C: Most recent VL on ___ was 1,920,280 IU/mL.
High VL's going back to ___ in OMR. Not treated due to side
effects of medications.
- Hypertension: well-controlled
- Hyperlipidemia: not treated
- Chronic renal insufficiency with baseline Cr 1.1-1.3
- Cyst in head of pancreas
- BPH
- H. pylori: partially treated in the past
- Cholelithiasis
- Epistaxis
- Contact dermatitis
Social History:
___
Family History:
Mother deceased from ___ at age ___. Father deceased from unknown,
aggressive cancer at age ___. Sister with CABG x2 at age ___,
still living.
Physical Exam:
ADMISSION PHYSICAL EXAM
===================================
VS: 97.7 126/89 104 16 100%RA, I/O: NPO/1200
GENERAL: Well appearing, ___ yo M who appears stated age.
Comfortable, appropriate and in good humor. No jaundice.
HEENT: Sclera anicteric. PERRL, EOMI. Clear oropharynx.
NECK: Supple with low JVP. No cervical LAD or thyromegaly.
CARDIAC: slightly tachycardic, regular rhythm, S1 and S2 clear
and of good quality without murmurs, rubs or gallops. No S3 or
S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: distended but soft, non-tender to palpation. +dullness
to percussion over flanks. No HSM or tenderness.
EXTREMITIES: Warm and well perfused, no cyanosis or edema.
SKIN: 5cm ecchymosis on left inner thigh. Several prominent
superficial veins on upper thigh, some scattered excoriated
areas of broken skin. No spider angiomata.
NEURO: A, A+O x3. Speech fluent. CNs II-XII intact and
symmetric, no asterixis.
DISCHARGE PHYSICAL EXAM
VS Tc 98 BP 120/73 HR 72 RR 16 O2sat 100%/RA
General: Alert, oriented x3, in no acute distress
HEENT: Sclera icteric, pupils equally reactive to light
Neck: JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear breath sounds bilaterally, no crackles/wheezes
Abdomen: soft, non-tender to palpation, distended, bowel sounds
present
Ext: warm, well perfused, 2+ pulses, no edema, no clubbing,
cyanosis or edema
Skin: No spider angiomata, no palmar erythema
Neuro: CNII-XII intact, strength grossly intact, no asterixis
Pertinent Results:
ADMISSION LABS
====================================
___ 05:05PM ASCITES TOT PROT-0.4 GLUCOSE-111 ALBUMIN-<1.0
___ 05:05PM ASCITES WBC-255* RBC-200* POLYS-14* LYMPHS-43*
___ MESOTHELI-2* MACROPHAG-41*
___ 09:33AM LACTATE-1.0
___ 07:50AM GLUCOSE-88 UREA N-19 CREAT-1.1 SODIUM-138
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
___ 07:50AM ALT(SGPT)-76* AST(SGOT)-125* ALK PHOS-148*
TOT BILI-1.5
___ 07:50AM CALCIUM-9.2 PHOSPHATE-3.2 MAGNESIUM-1.9
___ 07:50AM WBC-7.1 RBC-4.03* HGB-13.5* HCT-39.8* MCV-99*
MCH-33.5* MCHC-33.9 RDW-14.0
___ 07:50AM PLT COUNT-74*
___ 07:50AM ___ PTT-33.2 ___
___ 11:30PM GLUCOSE-104* UREA N-20 CREAT-1.1 SODIUM-136
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-20* ANION GAP-14
___ 11:30PM ALT(SGPT)-77* AST(SGOT)-122* ALK PHOS-157*
TOT BILI-1.1
___ 11:30PM ALBUMIN-3.5
___ 11:30PM WBC-7.8 RBC-3.89* HGB-13.1* HCT-38.1* MCV-98
MCH-33.6* MCHC-34.3 RDW-13.7
___ 11:30PM NEUTS-55.0 ___ MONOS-5.7 EOS-1.1
BASOS-0.4
___ 11:30PM PLT COUNT-76*
___ 08:45PM GLUCOSE-116* UREA N-20 CREAT-1.2 SODIUM-138
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-20* ANION GAP-18
___ 08:45PM estGFR-Using this
___ 08:45PM ALT(SGPT)-89* AST(SGOT)-140* ALK PHOS-179*
TOT BILI-1.3
___ 08:45PM ALBUMIN-4.0
___ 08:45PM WBC-UNABLE TO RBC-UNABLE TO HGB-UNABLE TO
HCT-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO
___ 08:45PM NEUTS-UNABLE TO LYMPHS-UNABLE TO
MONOS-UNABLE TO EOS-UNABLE TO BASOS-UNABLE TO
___ 08:45PM PLT COUNT-UNABLE TO
___ 08:45PM ___ PTT-23.8* ___
___ 08:45PM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 08:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
___ 08:45PM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
DISCHARGE LABS
___ 07:40AM BLOOD WBC-7.1 RBC-4.08* Hgb-13.5* Hct-39.9*
MCV-98 MCH-33.1* MCHC-33.9 RDW-14.0 Plt Ct-83*
___ 07:40AM BLOOD ___ PTT-35.8 ___
___ 07:40AM BLOOD Glucose-130* UreaN-21* Creat-1.3* Na-138
K-3.8 Cl-106 HCO3-26 AnGap-10
___ 07:40AM BLOOD ALT-83* AST-131* AlkPhos-113 TotBili-1.8*
___ 07:40AM BLOOD Calcium-9.5 Phos-2.7 Mg-1.7
MICROBIOLOGY
==================================
___ 1:01 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ASCITES FLUID
___ 05:05PM ASCITES WBC-255* RBC-200* Polys-14* Lymphs-43*
___ Mesothe-2* Macroph-41*
___ 05:05PM ASCITES TotPro-0.4 Glucose-111 Albumin-<1.0
IMAGING
==================================
___ CT ABD W/ CONTRAST: Complete occlusion of the splenic
vein, superior mesenteric vein and left branch of the portal
vein with shunting of blood and back filling of the main portal
vein. Chronicity cannot be determined as no recent studies are
available for comparison. A multi phasic mesenteric/liver CTA
scan or MRA is recommended for followup.
New moderate ascites. Cholelithiasis. Thickened and edematous
gallbladder wall without gallbladder distention is likely from
___ spacing. Gastric and esophagial varices.
___ MRI ABD W/O & W/ CONTRAST:
IMPRESSION:
1. Discrete 2-cm thrombus within the left portal vein at its
bifurcation to
the medial and lateral segments, which appears to demonstrate
subtle
enhancement post-contrast - these findings are suspicious for
tumor thrombus.
Given the filling of the splenic vein and SMV on the more
delayed images (with
nonopacification on early contrast-enhanced images), there is
likely a large
component of reversed portal vein flow throughout the liver.
2. Suspicious 3 cm hypoenhancing lesion on the prior CT in
segment 4B, with
signal abnormality on today's study and enlargement of this
region since the
prior MRI in ___. On the coronal reformations of the prior CT
there is some
suggestion that this may be contiguous with the central aspect
of the left
portal vein thrombus. Although this is not clearly
hyperenhancing on arterial phase images, the arterial phase
images are limited due to a large portal predominance, which may
be either due to contrast timing, or significant arterial-portal
shunting which appears to be present.
3. Diffuse abnormality within the left lobe and segment IVb of
the liver
appears somewhat suspicious for an infiltrative neoplastic
process, although some of the abnormal enhancement appears to be
secondary to arterio-portal shunting, as well as altered
hemodynamics due to the portal vein clot. A targeted ultrasound
of the left lobe of the liver may be of benefit for further
evaluation and to confirm that the arterial enhancing structures
represent dilated portal branches.
4. Cirrhotic liver with evidence of portal hypertension
(esophageal and
gastric varices).
5. Small volume ascites.
6. Cholelithiasis.
7. Hiatus hernia.
___ LIVER ULTRASOUND
IMPRESSION:
1. Nodular abnormal hepatic architecture consistent with
cirrhosis. No focal liver lesion identified.
2. Nonocclusive thrombus seen within the left portal vein,
however this
thrombus is not amenable to percutaneous biopsy.
3. Bidirectional flow which is predominantly hepatofugal seen in
the portal
veins. Again note is made of nonocclusive thrombus clot is seen
in the left portal vein.
4. Ascites.
5. Cholelithiasis.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with a history of HCV
cirrhosis decompensated by ascites, now admitted with abdominal
pain, and found to have complete occlusion of the splenic,
superior mesenteric and left branch of the portal veins.
#Abdominal pain: Patient presented with lower abdominal pain
lasting several months warranting outpatient CT notable for
splenic, portal and superior mesenteric vein occlusions. He was
subsequently admitted to the ___ service for
further management. Etiology of abdominal pain was thought to be
most likely secondary to these occlusions causing decreased
blood flow to the bowel. Occlusions were thought to be thrombi
formed as a result of stasis and retrograde blood flow secondary
to cirrhosis. Diagnostic paracentesis was performed and SBP was
ruled out. EGD was performed to assess the risk of bleeding and
showed grade III varices with stigmata of recent bleeding as
well as portal hypertensive gastropathy. These varices were
banded. MRI was done on ___ to determine chronicity of the
occlusions to determine need for anticoagulation, however the
MRI results showed findings that were suspicious for tumor
thrombus. In addition, MRI noted a 3cm hypoenhancing lesion in
segment 4B, and diffuse abnormality within the left lobe and
segment IVb of the liver that were suspicious for an
infiltrative neoplastic process. Elevated AFP in the setting of
HCV cirrhosis together with MRI findings were highly suspicious
for ___. Feasibility US was performed on ___ to further
evaluate possibility of malignancy and area for biopsy, which
showed no focal liver lesion, nonocclusive thrombus within left
portal vein (not amenable to percutaneous biopsy). Patient was
discharged with follow up with Dr. ___ following week. At
discharge, his abdominal pain was mostly epigastric and likely
secondary to recent variceal banding as it improved with
carafate slurry and PPI.
# grade III varices s/p banding: patient started on carafate
slurry, pantoprazole 40mg BID, and nadolol 20mg daily. Had few
episodes of emesis and epigastric pain post banding. Improved
with carafate and pantoprazole. He was kept in a soft/liquid
diet for three days and restarted on regular diet at discharge.
No signs of bleeding and hematocrit remained stable throughout
hospitalization.
# Cirrhosis: Secondary to untreated HCV with biopsy-proven
cirrhosis in ___. Only decompensated by ascites and jaundice
in the distant past. MELD was ___, ___ Grade A. During
current hospitalization, patient underwent EGD notable for grade
III esophageal varices requiring banding.
# GERD: Positive H. Pylori on ___ with recommended treatment,
but patient never picked up antibiotics. Patient moderately
symptomatic and no ulcers seen on EGD. Maintained on
Pantoprazole and carafate given grade III varices s/p banding.
# ___: Cr trended from 1.1 to 1.3 during this admission, likely
secondary to low intravascular volume in the setting of poor
oral intake and post-EGD emesis.
Patient received gentle IVF boluses and creatinine was monitored
closely.
# Hypertension: well controlled. Maintained on home dose of
lisinopril-hydrochlorothiazide
TRANSITIONAL ISSUES
=====================================
-Follow-up in clinic with Dr. ___ possible liver
biopsy given recent findings on imaging suspicious for
malignancy
-EGD showing grade III varices, started on carafate,
pantoprazole 40mg BID, and nadolol 20mg daily. Please follow up
with repeat EGD in 6 weeks
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. lisinopril-hydrochlorothiazide *NF* ___ mg Oral 2 tablets
daily
2. Ranitidine 150 mg PO BID
3. Omeprazole 20 mg PO BID Start: In am
4. TraMADOL (Ultram) 50-100 mg PO Q8H:PRN pain
Discharge Medications:
1. lisinopril-hydrochlorothiazide *NF* ___ mg Oral 2 tablets
daily
2. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Sucralfate 1 gm PO QID
RX *sucralfate [Carafate] 1 gram/10 mL 10 ml Suspension(s) by
mouth four times a day Disp #*500 Milliliter Refills:*0
4. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. TraMADOL (Ultram) 50-100 mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
- Left portal vein thrombosis
Secondary diagnosis
- Cirrhosis
- Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to ___ for abdominal pain. There were concerns of
thrombosis in one of the abdominal vessels connecting your
liver. You underwent upper endoscopy, and was found to have
significantly dilated veins that were at high risk of bleeding.
They were treated with banding, and you responded well. It is
currently not certain the exact cause of the thrombosis. You
will see Dr. ___ in the clinic for further evaluation. In
the meantime, you are doing well and can go home now.
There are a few changes in your medication. We also scheduled
you several appointments (see below).
Followup Instructions:
___
|
19776354-DS-20
| 19,776,354 | 24,502,459 |
DS
| 20 |
2174-01-01 00:00:00
|
2174-01-01 18:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
Progressive abdominal fullness, poor po intake
Major Surgical or Invasive Procedure:
Upper Endoscopy ___
Diagnostic Paracentesis ___
Therapeutic Paracentesis ___
History of Present Illness:
___ h/o HCV cirrhosis, c/b varices, with recent finding of
abdominal venous thrombosis admitted for abdominal distension.
Pt was recented admitted on ET service between ___/ to ___.
During last admission he was found to have new onset occlusion
of splenic/SMV/L branch of portal vein. MRI/MRV is concerning
for tumor thrombosis. EGD showed grade III varcies and he
underwent banding and initation of nadolol. Pt was arranged to
have followup with Dr. ___ on next ___ and Biopsy next
___. However, in the past three days, pt noticed worsening
abdominal distension, associated with ___ dull back pain, worse
at night. He took tramadol, but experienced auditory
hallucination afterwards. He also stated that his voice is
changing. He denies fever, but has constant chill. He has poor
appetite, only half his usual amount of food intake. He denies
N/V/D. He has bowel movement ___ times a day, brown formed
stool.
In the ED, initial VS were 97.4 66 129/77 18 100% RA. His lab
was notable for worsening ___ with Cr. 1.8 from baseline 1.1. A
diagnostic tap was performed which showed low PMN in peritoneal
fluid. RUQ US did not reveal acute changes.
REVIEW OF SYSTEMS:
(+)
(-) fever, night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- Cirrhosis: Diagnosed by biopsy (not in BI system) in
___, with history of ascites and jaundice at the time of
diagnosis. Most likely from hepatitis C infection. Had been
well-compensated until development of ascites very recently. No
prior EGDs.
- Hepatitis C: Most recent VL on ___ was 1,920,280 IU/mL.
High VL's going back to ___ in OMR. Not treated due to side
effects of medications.
- Hypertension: well-controlled
- Hyperlipidemia: not treated
- Chronic renal insufficiency with baseline Cr 1.1-1.3
- Cyst in head of pancreas
- BPH
- H. pylori: partially treated in the past
- Cholelithiasis
- Epistaxis
- Contact dermatitis
Social History:
___
Family History:
Mother deceased from MI at age ___. Father deceased from unknown,
aggressive cancer at age ___. Sister with CABG x2 at age ___,
still living.
Physical Exam:
On Admission:
VS - Temp 98.2F, BP 127/77, HR 62, R 20, O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT, mildly distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no pitting edema, 2+ peripheral pulses
(radials, DPs)
NEURO - awake, A&Ox3
Prior to discharge:
VS - 98.4, 53-71, 117-131/62-69, 18, 100 RA
BM x 6+, I:O 730/350+
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
LUNGS - CTA bilat
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft, distended, no masses or HSM, no
rebound/guarding. Slight tenderness to percussion over URQ
EXTREMITIES - WWP, no pitting edema, 2+ peripheral pulses
(radials, DPs)
NEURO - awake, A&Ox3, no asterixis
Pertinent Results:
Admission Labs:
======================
___ 03:35PM BLOOD WBC-8.2 RBC-4.09* Hgb-13.3* Hct-40.2
MCV-98 MCH-32.6* MCHC-33.2 RDW-13.4 Plt ___
___ 04:21PM BLOOD ___ PTT-33.9 ___
___ 03:35PM BLOOD ALT-58* AST-104* AlkPhos-124 TotBili-1.2
___ 03:35PM BLOOD Albumin-3.9
___ 07:40AM BLOOD Calcium-9.9 Phos-3.2 Mg-1.7
___ 07:40AM BLOOD AFP-109.1*
Discharge Labs:
========================
___ 05:05AM BLOOD WBC-5.4 RBC-3.36* Hgb-11.0* Hct-32.4*
MCV-97 MCH-32.7* MCHC-33.8 RDW-13.6 Plt Ct-56*
___ 05:05AM BLOOD ___ PTT-41.6* ___
___ 05:05AM BLOOD Glucose-114* UreaN-23* Creat-1.3* Na-138
K-3.8 Cl-101 HCO3-22 AnGap-19
___ 05:05AM BLOOD Calcium-9.8 Phos-2.4* Mg-1.7
Imaging:
=========================
___ EGD:
"Varices at the lower third of the esophagus and middle third of
the esophagus. Scars in the lower third of the esophagus.
Granularity, friability, erythema, congestion and abnormal
vascularity in the stomach body and fundus compatible with
Portal Gastropathy. Angioectasias in the first part of the
duodenum
Otherwise normal EGD to third part of the duodenum."
Microbiology:
=========================
__________________________________________________________
___ 12:08 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
__________________________________________________________
___ 9:20 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 1:23 am SWAB Source: Rectal swab.
**FINAL REPORT ___
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final ___:
No VRE isolated.
__________________________________________________________
___ 7:15 pm BLOOD CULTURE #1 SOURCE VENIPUNCTURE.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 7:30 pm BLOOD CULTURE #2 SOURCE: VENIPUNCTURE.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 7:59 pm PERITONEAL FLUID PERITONEAL FLUID.
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 (Preliminary): NO GROWTH.
__________________________________________________________
___ 4:30 pm URINE SOURCE: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
====================================
Mr. ___ is a ___ y/o male with a history of HCV cirrhosis,
c/b varices, with recent finding of abdominal venous thrombosis
who was admitted for abdominal distension.
ACTIVE ISSUES:
======================
# Abdominal distension/discomfort: This was likely secondary to
worsening ascites in the setting of recent portal vein
thrombosis. Although peritoneal fluid studies didn't meet
criteria for SBP by number of PMN's, elevated WBC count was
concerning for an atypical/subclinical SBP and therefore he was
treated with 5 days of ceftriaxone. His symptoms had resolved
prior to discharge.
# HepC cirrhosis: Pt is currently not on transplant list. His
MELD score is 11. Complications include ascites, varices without
bleeding, and now likely developing HCC, pending confirmation on
biopsy. AFP increased from 43 (___) to 109 this admission
which raises suspicion for HCC. If this is HCC he would not be a
transplant candidate due to portal vein involvement.
- He will follow-up as an oupatient on ___ for biospy of the
suspicious area along with fiducial seed placement as
recommended by interdisciplinary liver tumor board meeting.
- Will follow-up with Dr. ___ on ___ once biopsy results
are available to discuss treatment options
- Patient was started on aldactone 50mg daily after kidney
injury resolved. Will need lab check and further titration when
he sees Dr. ___.
# Shortness of breath: This was due to pressure from ascites
because it resolved after 2.5 liter paracentesis on ___
# Acute Kidney Injury: Presented with worsening Cr to 1.8 from
baseline of 1.1-1.2. This was likely prerenal in the setting of
worse po intake. Creatinine improved with 1.3 prior to discharge
with admininistration of albumin for 3 days.
- Lisinopril/HCTZ were stopped during this admission
# Diarrhea: Patient developed diarrhea in the hospital which was
most likely from ceftriaxone. Cdiff testing was negative. No
melena or hematochezia.
# Acute Anemia: The patient's Hgb dropped from baseline of 14 to
10 within 24 hours of admission. Unclear where blood went as
would not expect effect of this size from dilution alone. No
melena/hematochezia. Possible that patient bled from
paracentesis but no signs on exam to suggest such. Has portal
gastropathy and varices but Guaiac negative so far. He had no
further decline in hematocrit after the first day. Haptoglobin
was normal and nothing else to suggest hemolysis
# Varices: Pt had stage III varices on previous EGD. Rescoped on
___ which showed non-bleeding Grade 1 varices, no banding
required.
- Continued nadolol 20mg daily
TRANSITIONAL ISSUES:
==========================
# Will follow-up for biopsy with fiducial placement on ___.
He will see Dr. ___ on ___ to discuss treatment options
and to further titrate diuretics
# CODE: Full (confirmed)
# CONTACT: Patient, HCP/sister ___ ___.
Other emergency contact is ___ ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. lisinopril-hydrochlorothiazide *NF* ___ mg Oral 2 tablets
daily
2. Nadolol 20 mg PO DAILY
3. Sucralfate 1 gm PO QID
4. Pantoprazole 40 mg PO Q12H
5. TraMADOL (Ultram) 50-100 mg PO Q8H:PRN pain
Discharge Medications:
1. Nadolol 20 mg PO DAILY
2. Pantoprazole 40 mg PO Q12H
3. Sucralfate 1 gm PO QID
4. TraMADOL (Ultram) 50-100 mg PO Q8H:PRN pain
5. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Spontaneous Bacterial Peritonitis
-Acute Kidney Injury
Secondary:
-Ascites
-Esophageal Varices
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, it was a pleasure taking care of you here at ___.
You were admitted to the hospital because your abdomen was
becoming more swollen and uncomfortable. We removed fluid from
your abdomen to help relieve the discomfort. We also treated you
with antibiotics for an infection in the fluid.
During your stay you had an upper endoscopy which did not show
any further varices that would require banding at this time. You
will need another endoscopy in ___ months to monitor this.
On ___ you are scheduled to have a biopsy of an area in your
liver that is concerning for cancer. You should not eat anything
after midnight on ___ night.
We made some changes to your medications as detailed below. You
were started on spironolactone which is a diuretic (water pill)
to help remove extra fluid from your body by making you urinate
more.
Followup Instructions:
___
|
19776354-DS-24
| 19,776,354 | 29,428,937 |
DS
| 24 |
2174-02-15 00:00:00
|
2174-02-21 08:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending: ___.
Chief Complaint:
Positive blood culture on previous admission
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with history of HCV cirrhosis c/b ascites, esophageal
varices (unclear if had banding in ___, jaundice, and biopsy
proven HCC with evidence of malignant portal vein thrombosis
awaiting palliative Cyberknife, also with hx of HTN, HL, CKD
that has been called back to the hospital after blood culture
from ___ growing GNR, no speciation in 1 out of 4 bottles,
anaerobic. The patient feels well, no complaints. He does
promote some mild nausea, which he occasionally experiences. He
denies any episodes of vomiting, abdominal pain, diarrhea,
chills, sweats, or fevers.
In the ED, initial vitals were. WBC was wnl and chem 7 was at
baseline with cr of 1.6. Repeat diagnositic para in the ED was
negative for SBP, cultures pending. They also sent one set of
blood cultures from venipuncture. He was given vancomycin and
cefepime for empiric coverage.
Past Medical History:
- Cirrhosis: Diagnosed by biopsy (not in BI system) in
___, with history of ascites and jaundice at the time of
diagnosis. Most likely from hepatitis C infection. Had been
well-compensated until development of ascites very recently. No
prior EGDs.
- Hepatitis C: Most recent VL on ___ was 1,920,280 IU/mL.
High VL's going back to ___ in OMR. Not treated due to side
effects of medications.
- Hypertension: well-controlled
- Hyperlipidemia: not treated
- Chronic renal insufficiency with baseline Cr 1.1-1.3
- Cyst in head of pancreas
- BPH
- H. pylori: partially treated in the past
- Cholelithiasis
- Epistaxis
- Contact dermatitis
Social History:
___
Family History:
Mother deceased from ___ at age ___. Father deceased from unknown,
aggressive cancer at age ___. Sister with CABG x2 at age ___,
still living.
Physical Exam:
Admission:
VS: 97.9 BP 146/78 P57 RR16 100% RA
GENERAL: comfortable, male, appears stated age, mild temporal
wasting, A&Ox3. No jaudice
HEENT: Sclera aicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Distended but Soft, non-tender to palpation. Dullness
to percussion over dependent areas but tympanic anteriorly. No
HSM or tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.No
peripheral edema
Neuro: no asterixis, no focal deficits
Discharge:
VS: 97.8 BP 110/68 P76 RR18 100% RA
GENERAL: comfortable, male, appears stated age, mild temporal
wasting, A&Ox3. No jaudice
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple with low JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, S1 S2 clear and of good quality without murmurs, rubs
or gallops. No S3 or S4 appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use, moving air well and
symmetrically. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: non-distended, soft, non-tender to palpation. No HSM
or tenderness.
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis.No
peripheral edema
Neuro: No asterixis, exam grossly in tact
Pertinent Results:
Admission:
___ 02:20PM BLOOD WBC-8.2 RBC-4.30* Hgb-13.6* Hct-41.9
MCV-98 MCH-31.7 MCHC-32.5 RDW-14.2 Plt ___
___ 02:20PM BLOOD ___ PTT-31.9 ___
___ 02:20PM BLOOD Glucose-119* UreaN-33* Creat-1.6* Na-135
K-4.6 Cl-103 HCO3-19* AnGap-18
___ 06:00AM BLOOD ALT-52* AST-88* AlkPhos-145* TotBili-1.2
___ 06:15AM BLOOD WBC-6.6 RBC-3.30* Hgb-10.4* Hct-31.8*
MCV-96 MCH-31.6 MCHC-32.8 RDW-15.0 Plt Ct-93*
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD Glucose-96 UreaN-43* Creat-1.9* Na-134
K-4.0 Cl-106 HCO3-17* AnGap-15
___ 06:15AM BLOOD ALT-37 AST-77* AlkPhos-119 TotBili-1.1
CT abdomen ___:
IMPRESSION:
1.Lobulated liver contour, compatible with patient's known
history of
cirrhosis. Large areas of hypoattenuation involving the left
hepatic lobe was noted on prior CT and MRI, which most likely
relates to underlying mass lesion.
2. Splenomegaly and moderate-to-large ascites signify portal
hypertension.
3.Small hiatal hernia.
4. Cholelithiasis without evidence of acute cholecystitis.
Brief Hospital Course:
This is a ___ yo male with history of HCV cirrhosis complicated
by heptocellular carcinoma and evidence of malignant PVT only a
candidate for palliative cyberknife who presented after a blood
culture grew B. fragilis from prior admission.
#Bacteroides fragilis bacteremia: Blood cultures were drawn in
ED during his previous admission and 1 anaerobic bottle grew
bacteroides. He remained asymptomatic and denied any fevers,
chills, or sweats. A repeat diagnositic para was unrevealing for
infection and a chest xray was normal. He was intially started
on cefepime and transitioned to ciprofloxacin and flagyl for
total of 14 day course. ID was consulted and felt that this was
most likely a real bacteremia as bacteroides is rarely a
contaminate. An abdominal ct showed no abscess or findings of
GI infection. Infection most likely related to underlying
malignancy
# ___: Cratinine increased to 2.1 on admission, from a baseline
around 1.6. Urine electrolytes were consistent with prerenal
etiology with urine sodium less than 10, urine eosinophils
negative for AIN (had been on cefepime). Improved with
hydration.
# HCV Cirrhosis complicated by ___: Cirrhosis has been
previously complicated by ascites, esophageal varices (unclear
if had banding in ___.
Patient is in process of scheduling a palliative cyberknife. He
had a theraputic paracentesis this admission with 3L removed. He
was continued on nadaolol for his varices. His liver function
tests and MELD are at their recent baseline. He was continued on
nadolol and lactulose. He did promote excessive burping which
was relieved with removal of ascites.
# Back pain: He has right-sided back pain, which may be due to
capsular distention from ___. Work-up was performed during
recent admission was unrevealing and unlikely related to current
bacteremia since exam not consistent with bony tenderness or
superficial infection.
# Malnutrition: Chronic weight loss likely related to
malignancy. Goals of care would not emcompass tube feeds. He
will continue to take ensure.
Transitions of Care:
1. Pt will follow up with oncology and rad onc for palliative
cybernife
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nadolol 20 mg PO DAILY
2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
3. Pantoprazole 40 mg PO Q24H
4. Lactulose 30 mL PO BID
Discharge Medications:
1. Lactulose 30 mL PO BID
2. Nadolol 20 mg PO DAILY
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
4. Pantoprazole 40 mg PO Q24H
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
6. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every
six hours Disp #*30 Tablet Refills:*0
8. traZODONE 25 mg PO HS:PRN sleep
RX *trazodone 50 mg ___ tablet(s) by mouth at nighttime prn
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Bacteroides fragilis Bacteremia
Secondary Diagnosis:
Hepatocellular Carcinoma
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 ___.
___ asked you to come back to the hospital after one of the blood
cultures we collected on ___ grew bacteria. The name of the
bacteria was Bacteroides fragilis, and we believe this bacteria
entered your blood from your abdomen (belly). We started you on
antibiotics and you will continue them as an outpatient for 14
days.
Followup Instructions:
___
|
19776514-DS-10
| 19,776,514 | 28,873,984 |
DS
| 10 |
2147-02-10 00:00:00
|
2147-02-10 08:13:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
Intramedullary nail left tibia
History of Present Illness:
___ intoxicated pedestrian struck presents with left tibia
fracture. The circumstances of the accident are not clear, but
he was struck on his left side. He was hemodyanmically stable at
the scene and in the ED and on arrival was complaining only of
left leg pain. He had +headstrike, no LOC. Full trauma
evaluation in the ED was negative for other injuries. He denies
numbess or
paresthesias.
Past Medical History:
Brain cyst of unknonw etiology causing seizures, cerebral palsy
Social History:
___
Family History:
NC
Physical Exam:
Left lower extremity:
Incisions clean, dry, intact, no excessive, induration, drainage
SILT in DP/SP/S/S/T
___
Toes WWP
2+ DP pulse
Pertinent Results:
___ 05:35AM BLOOD WBC-11.0 RBC-4.40* Hgb-12.8* Hct-37.8*
MCV-86 MCH-29.2 MCHC-34.0 RDW-13.5 Plt ___
___ 02:17AM BLOOD ___ PTT-25.8 ___
___ 05:35AM BLOOD Glucose-119* UreaN-7 Creat-0.7 Na-136
K-3.5 Cl-102 HCO3-25 AnGap-13
___ Tib/Fib films: Displaced transverse tibial shaft
fracture. Comminuted fracture of the proximal fibula.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left tibia/fibula fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for an intramedullary nail of the
left tibia, which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
left lower extremity, and will be discharged on lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge.
Medications on Admission:
Keppra
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
Please take while taking prescription pain medication.
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*50 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC QPM
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC nightly Disp #*14 Syringe
Refills:*0
4. LeVETiracetam 500 mg PO BID
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*80 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left tibia/fibula fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks.
WOUND CARE:
- No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- Left lower extremity: weight bearing as tolerated
Physical Therapy:
Left lower extremity: weight bearing as tolerated
Treatments Frequency:
Wounds: Surgical incision
Location: Left lower extremity
Dressing: Inspect wounds and change dressing daily with dry
gauze. If non-draining, can leave open to air.
Followup Instructions:
___
|
19776663-DS-21
| 19,776,663 | 21,566,975 |
DS
| 21 |
2185-05-30 00:00:00
|
2185-05-31 17:41:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Optiray 350
Attending: ___.
Chief Complaint:
Atypical chest pain, progressive DOE
Major Surgical or Invasive Procedure:
Cardiac catheterization (no intervention performed) ___
History of Present Illness:
Mr. ___ is a ___ year old male with history of CAD s/p drug
eluting stents to LCx at ___ (___), small AAA,
OSA, HLD, who presents with progressive chest pain.
This started in ___ with episodes of right parasternal
jolting chest pain, ___, lasting for seconds at a time. Most
of these episodes would occur when he is at rest. These
initially occurred ___ times per week, but has been steadily
more frequent. He was able to use the treadmill ___ minutes at
a time at a speed of 3.5mph without any chest pain or dyspnea.
Two weeks ago, his exercise tolerance began to progressively
worsen and now he is only able to walk 5 minutes before becoming
dyspneic. He has had new peripheral edema in his feet and
ankles, and feels more bloating in his abdomen. He also reports
a 20 lb weight gain (217lb to 239lb) in one month despite 1500
calorie diet and watching his salt consumption. He denies PND or
orthopnea (he uses CPAP for OSA)
One week ago, he began experiencing intermittent sternal chest
"heaviness", which felt similar to the discomfort he experienced
in ___ that led to his PCI. This is also non-exertional, and
he was able to walk without chest discomfort, but did become
dyspneic more easily. He tried taking sublingual nitroglycerin
which did not relieve the chest heaviness. This feeling is
non-radiating, not associated with diaphoresis or dyspnea. Of
note, he has had periodic "hot flashes" lasting 5 minutes at a
time that started 1 month ago, but these episodes are not
associated with exertion, dyspnea, or his episodes of chest pain
or discomfort.
He presented to his cardiologist at ___ on ___ and was
ordered for an outpatient catheterization to be done ___. He was
instructed to go to the ED if he had worsening pain. Today, he
developed frequent jolting episodes of ___ chest pain and
chest heaviness, so presented to the ___ ED.
ED COURSE
In the ED intial vitals were:
97.6 57 146/77-->97/79-->115/60 20 100% RA
Past Medical History:
1. CARDIAC RISK FACTORS:
- HLD
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: DESx2 (at ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Iron deficiency anemia
___ esophagus
Small hiatal hernia
Cervical spondylosis
Colonic adenomatous polyps
AAA
OSA
HLD
Peptic Ulcer Disease
s/p Nissen fundoplication
Social History:
___
Family History:
Father with multiple MI's, first was at age ___. Passed from
cardiac complications in his ___.
Mother with MI at age ___. Passed away from lung cancer.
No family history of colon cancer.
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM
=========================
Admission weight: 107.3kg
VS: 98 (L arm 130/62, R arm 120/60) 68 20 100%ra
Tele: nsr ___
GENERAL: Alert and oriented, pleasant Caucasian male who relates
his history without difficulty
HEENT: EOMI. MMM.
NECK: Neck is obese. Supple with JVP estimated at 12cm, with
positive abdominojugular reflex
CARDIAC: Normal S1, S2, no MRG
LUNGS: Somewhat quiet breath sounds throughout, but lungs are
clear without adventitious sounds
ABDOMEN: Obese and distended, soft, non-tender, no palpable
pulsation
EXTREMITIES: Warm and well perfused, DP 2+ on L but not easily
palpable on R, however both feet appear equally well perfused,
there is trace pedal edema bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Radial pulses are 1+ and symmetric
==========================
DISCHARGE PHYSICAL EXAM
==========================
Admission weight: 107.3kg
Weight today: 107.6kg
Weight yesterday: 107.4kg
I/O: 24hr: 1880/575 8hr: 200/0
VS: 97.2 117/80 (104-134/57-66) 65 (65-87) ___ 97%ra
Tele: sinus ___
GENERAL: Alert and oriented, pleasant Caucasian male who relates
his history without difficulty
HEENT: EOMI. MMM.
NECK: Neck is obese. Supple with JVP estimated at 8cm
CARDIAC: Normal S1, S2, no MRG
LUNGS: Somewhat quiet breath sounds at bases, but lungs are
clear without adventitious sounds
ABDOMEN: Obese and distended, soft, non-tender, no palpable
pulsation
EXTREMITIES: Warm and well perfused, DP 2+ on L but not easily
palpable on R, however both feet appear equally well perfused,
there is trace ___ edema
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Radial pulses are 1+ and symmetric
Pertinent Results:
=======================
ADMISSION LABS
=======================
___ 12:58PM BLOOD WBC-6.4 RBC-4.51* Hgb-13.6* Hct-42.2
MCV-94# MCH-30.2# MCHC-32.2 RDW-14.9 RDWSD-51.5* Plt ___
___ 12:58PM BLOOD Neuts-63.3 ___ Monos-8.3 Eos-1.9
Baso-0.8 Im ___ AbsNeut-4.05 AbsLymp-1.61 AbsMono-0.53
AbsEos-0.12 AbsBaso-0.05
___ 12:58PM BLOOD Plt ___
___ 12:58PM BLOOD Glucose-98 UreaN-20 Creat-0.9 Na-138
K-4.8 Cl-104 HCO3-24 AnGap-15
___ 12:58PM BLOOD ALT-38 AST-32 LD(LDH)-391* AlkPhos-85
TotBili-0.3
___ 12:58PM BLOOD proBNP-74
___ 12:58PM BLOOD cTropnT-<0.01
___ 08:51PM BLOOD CK-MB-1 cTropnT-<0.01
___ 02:28AM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:58PM BLOOD Albumin-4.1 Mg-1.8
=======================
INTERVAL LABS
=======================
___ 04:55AM BLOOD TSH-1.6
___ 04:55AM BLOOD VitB12-310
=======================
DISCHARGE LABS
=======================
___ 05:05AM BLOOD WBC-7.4 RBC-4.60 Hgb-13.7 Hct-42.2 MCV-92
MCH-29.8 MCHC-32.5 RDW-14.4 RDWSD-48.0* Plt ___
___ 05:05AM BLOOD Neuts-85.6* Lymphs-9.8* Monos-3.8*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-6.35*# AbsLymp-0.73*
AbsMono-0.28 AbsEos-0.00* AbsBaso-0.01
___ 05:05AM BLOOD Plt ___
___ 05:05AM BLOOD Glucose-149* UreaN-22* Creat-0.9 Na-141
K-4.0 Cl-104 HCO3-22 AnGap-19
___ 08:51PM BLOOD ALT-37 AST-21 AlkPhos-81 TotBili-0.3
=======================
IMAGING
=======================
Chest PA/Lateral ___
No acute intrathoracic abnormality.
=======================
STUDIES
=======================
++Exercise Stress Test ___
INTERPRETATION: This ___ yo man with h/o CAD, s/p NSTEMI and LCx
stenting ___, with in-stent restenosis and occluded RCA on cath
___, and
AAA was referred to the lab from the inpatient floor following
negative
serial cardiac enzymes for evaluation of chest discomfort. The
patient
exercised for 9.5 minutes of a Modified ___ protocol and was
stopped
for fatigue. The estimated peak MET capacity was 7.6, which
represents
an average exercise tolerance for his age. At 8 minutes of
exercise, the
patient noted an intermittent ___ substernal chest discomfort,
lasting
for seconds. This sensation resolved by peak exercise. At peak
exercise,
0.5 mm slow upsloping ST depression was noted in leads V2-V4.
These
changes resolved back to baseline by 7 minutes of recovery.
Rhythm was
sinus with rare isolated APBs. There was a blunted heart rate
response
to exercise in the presence of beta blockade. There was an
appropriate
blood pressure response during exercise and recovery.
IMPRESSION: Non-anginal type symptoms in the absence of ischemic
EKG
changes. Average functional capacity. Nuclear report sent
separately.
++Cardiac Perfusion Test ___
IMPRESSION: 1. Moderate inferolateral wall perfusion defect
with partial
reversibility in the presence of excessive attenuation. 2.
Normal left
ventricular cavity size and systolic function, LVEF measured as
59%.
++TTE ___
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The 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 borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
There is an anterior space which most likely represents a
prominent fat pad.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. Compared with the prior study
(images reviewed) of ___, the findings appear similar.
++Cardiac Catheterization ___
Dominance: Right
* Left Main Coronary Artery
The LMCA is normal
* Left Anterior Descending
The LAD is normal.
* Circumflex
The Circumflex has a widely patent stent and is normal.
* Right Coronary Artery
The RCA is chronically occluded at its ostium with extensive
collaterals to the distal vessel from the left
coronary.
Brief Hospital Course:
Mr. ___ is a ___ year old male with history of CAD s/p drug
eluting stent to LCx at ___ (___), small AAA,
OSA, HLD, who presents with atypical chest pain and progressive
dyspnea on exertion.
# Atypical chest pain/hx of CAD:
Mr. ___ presented with 2 months of progressive "jolting"
chest pain, non-exertional, and episodes of non-exertional chest
heaviness, and subacute diminished exercise tolerance. EKG was
unchanged. Trops negative x 3. Stress MIBI showed partially
reversible moderate perfusion defect in infero-lateral region.
Based on this finding and his progressive dyspnea on exertion,
he was taken to catherization which showed a widely patent LCx
stent and redemonstrated totally occluded RCA at ostium with
extensive collateralization. No intervention was performed. TTE
showed mild symmetric LVH with good systolic function, LVEF
>55%. He was continued on medication management with aspirin,
Plavix, metoprolol succinate, and imdur (dose increased from 30
to 60mg to help alleviate possible angina).
# Bradycardia:
He was noted to be sinus bradycardic to high ___ so metoprolol
succinate was dose reduced from 100mg to 50mg on discharge. His
progressive exercise intolerance may be due to iatrogenic
chronotropic insufficiency from chronic beta blockade.
# Possible chronic diastolic heart failure:
Patient was noted to be hypervolemic on exam with elevated JVP
and peripheral edema. TTE showed mild LVH. He may have some
element of diastolic heart failure contributing to his dyspnea
on exertion. He was given Lasix 20mg IV once with subjective
improvement in his symptoms. He was discharged on a trial Lasix
20mg PO daily. He will have a chem10 check at next PCP visit on
___.
# AAA: He has a sub 5cm AAA and is enrolled in NTCAT trial (PI
Dr. ___. He was continued on study medication
(doxycycline/placebo BID)
Transitional Issues:
- B12 level borderline at 310. Consider testing methylmalonic
acid as an outpatient
- Metoprolol succinate decreased to 50mg daily from 100mg
- Imdur dose increased from 30mg to 60mg daily
- Started trial of Lasix 20mg PO daily for symptom relief for 2
weeks
- Please check chem 10 at next PCP ___ ___
- Consider starting ACE ___ as outpatient
# CODE STATUS: FULL CODE
# CONTACT: ___, wife, ___ (c),
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Ferrous Sulfate 65 mg PO BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. nitroglycerin 0.4 mg oral ONCE:PRN chest pain
7. Pantoprazole 40 mg PO Q12H
8. Sertraline 50 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Sertraline 50 mg PO DAILY
6. Doxycycline/Placebo Study Med 100 mg PO BID
7. Ferrous Sulfate 65 mg PO BID
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
10. nitroglycerin 0.4 mg oral ONCE:PRN chest pain
11. Furosemide 20 mg PO DAILY
Take this in the morning daily
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Atypical chest pain
- Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at ___. You came to the
hospital with episodes of chest pain that were becoming more
frequent. We performed a stress nuclear perfusion test, which
showed that there may be certain areas that did not have optimal
blood flow when you exercised. We decided to take you to
catheterization, which was unchanged from prior. Your stent had
good flow. You have a known ___ blockage of one of the arteries
in your right heart, but your blood supply has extensively
re-routed beyond this so there would be no benefit in "fixing"
the blockage.
An echo ultrasound of your heart was normal. Your chest pain is
likely not coming from your heart. You will need to follow-up
with your primary care doctor if your symptoms continue.
IMPORTANT INSTRUCTIONS:
- Decrease your metoprolol succinate dose from 100mg to 50mg
daily
- Increase your Imdur (isosorbide mononitrate) dose from 30mg to
60mg daily.
- Start furosemide (Lasix) 20mg daily for your shortness of
breath and weight gain
The above should help with your symptoms.
It was our pleasure to care for you. We wish you the best!
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19776663-DS-23
| 19,776,663 | 29,799,410 |
DS
| 23 |
2187-03-29 00:00:00
|
2187-03-28 10:50:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Optiray 350
Attending: ___.
Chief Complaint:
abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
___ ENDOVASCULAR AORTIC ANEURYSM repair
History of Present Illness:
___ w/ CAD (h/o 2 stents LCX ___ on Plavix), AAA (4.6x5cm
stable), OSA, HLD, GERD, p/w back pain that radiates around the
right side of his abdomen and under the right side of his ribs.
He notes that he has had diarrhea for the past month, but
otherwise reports that he is doing well.
Past Medical History:
1. CAD RISK FACTORS:
- Hyperlipidemia
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: DESx2 (at ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Iron deficiency anemia
-___ esophagus
-Small hiatal hernia
-Cervical spondylosis
-Colonic adenomatous polyps
-AAA
-OSA
-Hyperlipidemia
-Peptic Ulcer Disease
-s/p Nissen fundoplication
Social History:
___
Family History:
Father with multiple MI's, first was at age ___. Died from
cardiac complications in his ___.
Mother with MI at age ___. Passed away from lung cancer.
No family history of colon cancer.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: 97.8 73 125/61 20 93% RA
GENERAL: Well developed, well nourished male in NAD. Oriented
x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs,
or gallops
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored
ABDOMEN: Soft, obese; TTP right flank extending to RUQ
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or 1+
edema up to mid tibia.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric
Physical exam on discharge:
gen: alert, oriented, no distress
cv: rrr
pulm: nonlabored breathing on ra
abd: soft, nontender, nondistended, no pulsatile mass
vasc:R: P//P/P L: P//P/P
Pertinent Results:
___ 03:55AM BLOOD WBC-9.4 RBC-4.15* Hgb-12.7* Hct-38.5*
MCV-93 MCH-30.6 MCHC-33.0 RDW-13.9 RDWSD-47.5* Plt ___
___ 01:31PM BLOOD WBC-8.3 RBC-4.92 Hgb-15.1 Hct-45.7 MCV-93
MCH-30.7 MCHC-33.0 RDW-13.8 RDWSD-46.7* Plt ___
___ 01:31PM BLOOD Neuts-64.9 ___ Monos-6.4 Eos-4.1
Baso-0.8 Im ___ AbsNeut-5.37 AbsLymp-1.93 AbsMono-0.53
AbsEos-0.34 AbsBaso-0.07
___ 03:55AM BLOOD Plt ___
___ 03:55AM BLOOD ___ PTT-26.4 ___
___ 01:31PM BLOOD Plt ___
___ 03:55AM BLOOD Glucose-146* UreaN-17 Creat-0.7 Na-140
K-4.3 Cl-105 HCO3-23 AnGap-12
___ 01:31PM BLOOD Glucose-97 UreaN-21* Creat-0.8 Na-137
K-4.4 Cl-99 HCO3-22 AnGap-16
___ 01:31PM BLOOD ALT-24 AST-17 AlkPhos-78 TotBili-0.4
___ 01:31PM BLOOD Lipase-25
___ 03:55AM BLOOD Calcium-7.9* Phos-3.5 Mg-2.1
___ 01:31PM BLOOD Albumin-4.1 Calcium-9.3 Phos-4.3 Mg-1.7
Brief Hospital Course:
Mr. ___ is a ___ with an abdominal aortic aneurysm who was
admitted on ___ and underwent endovascular abdominal aortic
aneurysm repair on ___. Please see operative note for
details. He was transferred stable to PACU. His foley was
removed and he voided. He tolerated a regular diet. He was given
the appropriate follow up and instructions and was discharged
home on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Nitroglycerin SL 0.4 mg SL PRN CHEST PAIN CHEST PAIN
7. Pantoprazole 40 mg PO Q24H
8. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL PRN CHEST PAIN CHEST PAIN
8. Pantoprazole 40 mg PO Q24H
9. Sertraline 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal aortic aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ and underwent endovascular abdominal
aortic aneurysm repair. You are now stable for discharge.
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
MEDICATIONS:
Take Aspirin 81mg once daily
Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
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 AT HOME:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart (use ___
pillows or a recliner) every ___ hours throughout the day and at
night
Avoid prolonged periods of standing or sitting without your
legs elevated
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 go up and down stairs
You may shower (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 that is draining, as needed
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
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
FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
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:
___
|
19776663-DS-24
| 19,776,663 | 27,269,909 |
DS
| 24 |
2188-01-05 00:00:00
|
2188-01-05 15:42:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Optiray 350
Attending: ___.
Chief Complaint:
Abdominal discomfort, abdominal fullness, shortness of breath,
productive sputum
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male history of AAA, CAD status
post 2 stents of the left circumflex artery presents with ___
days of new onset dyspnea on exertion, 2 weeks of increased
abdominal fullness, productive cough for the last 3 days, and
back pain for the last 2 days.
He states that dyspnea on exertion is profound, and he has
difficulty with ADLs. Patient also notes that he has had
diarrhea for the last few days, nonbloody. He denies nausea,
vomiting, alcohol use, extremity weakness or paresthesia, recent
trauma, dysuria. Patient has a 20-pack-year smoking history,
denies a history of COPD or lung disease, and quit ___ years ago,
but now smokes occasionally. He was seen at his PCP today who
referred him here. He also notes several weeks of worsening
abdominal pain diffusely assoicated with abdominal distension
and 40 pound weight gain since his AAA surgery last year.Patient
had the AAA repaired in ___. Patient is also status
post remote ___ fundoplication and denies breakthrough
symptoms of heartburn since but continues on standing bid
protonix for known ___ esophagus. He has had loose stools
throughout this period of abdominal pain and distension. He has
been trying to lose weight and is on a diet though has continued
to gain weight despite this. He denies fevers or chills and
mainly came in after seeing his PCP who sent him in for his
respiratory symptoms but patient notes his abdominal pain and
distension is more distressing to him as he's been unable to lie
down at all from the pain. He has history of polyps and
typically undergoes annual ___ for his polyps and
___. More recently he has rescheduled his EGD/C-scope as
he's been feeling unwell. He describes his current amount of
diarrhea as similar to when he is actively prepping for a
colonoscopy. He otherwise denies chest pain, palpitations,
lightheadedness or increase in his chronic intermittent ___
edema.
In the ED: -VS: 96.0 92 136/75 28 97% RA -PE: slightly dyspneic
and tachypneic, Decreased breath sounds, scattered wheezes,
Distended abdomen, tympanitic, No clinically significant murmurs
-Bedside ultrasound reveals mild to moderate pericardial
effusion, moderately decreased ventricular function, globally.
-Negative fast exam -EKG: ST depressions in lateral leads,
similar to prior -Labs: Troponin, BNP-normal -Imaging: Chest
x-ray-no acute abnormality; CTA torso - no PE, no endoleak, +
multifocal pneumonia -Interventions: solumedrol/Benadryl for
contrast allergy, duonebs, zosyn and home meds
On arrival to the floor patient continued to endorse significant
abdominal pain and distension for which he was given a trial of
tramadol. He notes he hasn't been able to sleep for days due to
his abdominal pain and discomfort when he tries to lie down
flat.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
1. CAD RISK FACTORS:
- Hyperlipidemia
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: DESx2 (at ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
-Iron deficiency anemia
-___ esophagus
-Small hiatal hernia
-Cervical spondylosis
-Colonic adenomatous polyps
-AAA
-OSA
-Hyperlipidemia
-Peptic Ulcer Disease
-s/p ___ fundoplication
Social History:
___
Family History:
Father with multiple MI's, first was at age ___. Died from
cardiac complications in his ___.
Mother with MI at age ___. Passed away from lung cancer.
No family history of colon cancer.
Physical Exam:
ADMISSION EXAM:
==============
VITALS: reviewed in POE
___: Weight: 236
___: BMI: 39.0
GENERAL: Alert, sitting up and appears somewhat uncomfortable
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema. Oropharynx without
visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs with upper airway ronchi and scattered wheezes, dry
cough. Mild tachypnea when speaking
GI: Obese abdomen, firmly distended but without guarding or
signs
of peritonitis, mildly tender in all quadrants without guarding
or rebound. Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly
symmetric
SKIN: facial plethora
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
===============
Vitals: T 98.3 BP 122/68 HR 67 RR20 93% RA (93-95% with
ambulation)
GENERAL: pleasant, laying flat in NAD.
EYES: Anicteric sclera, EOMI
ENT: Ears and nose without visible erythema. Oropharynx without
visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: faint bilateral expiratory wheezes with otherwise good air
entry, intermittently coughing but able to speak full sentences.
No accessory muscle use.
GI: Obese abdomen, non tender to palpation.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly
symmetric
SKIN: no rashes, other lesionss
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
==========================
___ 09:00PM BLOOD WBC-11.1* RBC-4.86 Hgb-14.9 Hct-44.2
MCV-91 MCH-30.7 MCHC-33.7 RDW-13.5 RDWSD-45.3 Plt ___
___ 09:00PM BLOOD Neuts-69.6 ___ Monos-5.1 Eos-3.0
Baso-0.4 Im ___ AbsNeut-7.75* AbsLymp-2.39 AbsMono-0.57
AbsEos-0.33 AbsBaso-0.05
___ 09:00PM BLOOD Glucose-159* UreaN-18 Creat-1.0 Na-141
K-4.1 Cl-106 HCO3-19* AnGap-16
___ 09:00PM BLOOD ALT-38 AST-26 AlkPhos-98 TotBili-0.2
___ 09:00PM BLOOD proBNP-27
___ 09:00PM BLOOD cTropnT-<0.01
___ 02:45AM BLOOD cTropnT-<0.01
___ 07:33AM BLOOD Albumin-4.2 Calcium-9.2 Phos-3.1 Mg-1.9
___ 09:23PM BLOOD Lactate-2.6*
___ 02:57AM BLOOD Lactate-1.6
MICRO:
=====
___ -flu A/B PCR: Negative
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in infected patients the excretion of antigen in
urine may vary.
IMAGING:
=======
___ torso:
1. No pulmonary embolism.
2. Areas of multifocal ground-glass opacity in the right upper
and left lower lobes are demonstrated, which may represent
multifocal pneumonia. Mild bilateral airway thickening.
3. No large endoleak or evidence of extravasation within the
abdomen or pelvis. Grossly stable appearance of atherosclerotic
disease within the thoracic aorta.
4. Infrarenal abdominal aorta status post aorto bi-iliac
stenting
measuring up to 4.7 cm, previously 5.0 cm.
___:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
suboptimal image quality to assess regional left ventricular
function. Specifically, the inferior and posterior walls were
poorly visualized and regional wall motion abnormalities
involving these walls cannot be excluded. Overall left
ventricular systolic function is normal. The visually estimated
left ventricular ejection fraction is 65%. There is no resting
left ventricular outflow tract gradient. Normal right
ventricular size with normal free wall motion. The aortic sinus
diameter is normal for gender with normal ascending aortic
diameter for gender. Aortic arch diameter is normal. The
aortic
valve leaflets are markedly thickened. There is no aortic valve
stenosis. There is no aortic regurgitation. Mitral valve
mildly
thickened with no mitral valve prolapse. There is moderate
mitral annular calcification. There is mild mitral
regurgitation. Due to acoustic shadowing, severe mitral
regurgitation could be underestimated. The tricuspid valve
appears structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
Brief Hospital Course:
Mr. ___ is a ___ male history of AAA, CAD status
post 2 stents of the left circumflex artery presents with ___
days of new onset dyspnea on exertion, 2 weeks of increased
abdominal fullness, productive cough for the last 3
days, and back pain for the last 2 days found to have multifocal
pneumonia.
#Multifocal pneumonia:
#Dyspnea on exertion:
-Reassuring that he was for ACS with normal EKG and negative
serial troponins. He was also ruled out for PE with a negative
CTPA. Also ruled out for flu with a negative PCR. He was
treated with IV ceftriaxone and azithromycin and transition to
p.o. cefpodoxime/azithromycin. Given his ongoing dyspnea on
exertion, he also underwent a TTE which was grossly within
normal limits. The etiology of his dyspnea on exertion is
presumed to be secondary to ongoing recovery from multifocal
pneumonia. He was advised to follow-up with his primary care
physician as an outpatient. On the day of discharge, he
ambulated around the medical floor without significant issues.
Ambulatory sat ranged from 93-95%.
#Abdominal discomfort:
CT torso without evidence of any acute intra-abdominal findings.
Abdominal aorta following AAA repairs appears to be stable.
Given complex history of recent AAA repair, history of Nissen
fundoplication, advised patient to follow-up with his outpatient
providers.
TRANSITIONAL ISSUES:
===================
[ ] discharged to complete 10 days of cefpodoxime (last day
___ five days of azithromycin completed during
hospitalization.
[ ] please monitor for ongoing improvement in respiratory
status. If persistent symptoms, would recommend repeating chest
imaging looking for unresolved pneumonia or other complication
(ie effusion/empyema, abscess, etc).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
2. LORazepam 1 mg PO BID:PRN anxiety
3. Sertraline 100 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Pantoprazole 40 mg PO Q12H
7. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp
#*11 Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. LORazepam 1 mg PO BID:PRN anxiety
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Sertraline 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Multifocal pneumonia
Dyspnea on exertion
Abdominal fullness
Discharge Condition:
Discharge conditionstable
Mental statusalert and oriented x3
Ambulatory
Discharge Instructions:
You were admitted to the hospital for abdominal pain, abdominal
fullness, shortness of breath, productive cough and generalized
malaise. You had an extensive workup which did not show
evidence of heart attack or clots in your lungs. Further workup
with CT scan of your chest did show evidence of pneumonia. CT
scan also showed that you were stable and you did not have any
acute abdominal findings to explain your abdominal
pain/abdominal fullness. You were treated with IV antibiotics
and then transition to oral antibiotics. We do not have a full
explanation for your abdominal symptoms but you should follow-up
with your outpatient providers regarding further workup.
Please complete all antibiotics as prescribed.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19776704-DS-17
| 19,776,704 | 29,394,073 |
DS
| 17 |
2132-11-02 00:00:00
|
2132-11-09 18:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
codeine
Attending: ___.
Chief Complaint:
slurred speech
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year-old right-handed man with a
history of IDDM, HLD, and seizures who was had episodic slurred
speech for 3 days and was found to have a left frontotemporal
mass on MRI. The patient initially presented to an outside
hospital prior to transfer to ___ where Neurology is consulted
in the ED History is obtained from OSH records and the patient
himself.
The patient's recent neurologic history starts 3 days ago when
talking to his mother on the phone. His voice sound slurred and
he was mixing up syllables and making up some new words. He was
able to understand everything that was said. He did not have
focal weakness or other concerning symptoms at that time. He
then called his nurse who also noted the slurred speech on the
phone. His slurred speech resolved within 10 minutes, but his
mother urged him to go to the ED. He does say that he had a few
episodes of slurred speech within the past few days, but he
cannot tell me how many.
With regards to his seizure history, he is vague but describes
confusion and slurred speech in ___ prompting initiation of
Dilantin. He may have had another episode during his sleep, but
is not clear on this. He has since transitioned to Keppra. He
denies ever having a generalized seizure.
Of note, there were no recent illnesses. He did run out of
insulin the day prior to presentation.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty comprehending
speech. Denies loss of vision, blurred vision, diplopia,
vertigo,
tinnitus, hearing difficulty, or dysphagia. Denies focal muscle
weakness, numbness, parasthesia. Denies loss of sensation.
Denies
bowel or bladder incontinence or retention. Denies difficulty
with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria. Denies
myalgias, arthralgias, or rash.
Past Medical History:
IDDM
Hyperlipidemia
Seizures (since ___, never with GTC, unclear semiology)
Depression - followed by psychiatrist regularly
Social History:
___
Family History:
No family history of seizures, strokes.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 98.4 HR: 100 BP: 130/75 RR: 18 SaO2: 97% RA
General: Obese man, disheveled, NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, distant heart sounds
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Obese, NT/ND
Extremities: Warm, no edema, there are multiple excoriations of
elbows and hands. Hypertrophic plaque at bilateral elbows
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place, and
partially to time. Attentive, but has difficulty with ___
backwards. Recalls a coherent history, although required much
questioning. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Content of speech
demonstrates intact naming (high and low frequency). Only one
phonemic paraphasia during our interview. Normal prosody. No
dysarthria. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry (although prominent
facial hair). Hearing intact to finger rub bilaterally. Palate
elevation symmetric. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
- Motor - Normal bulk and tone. No drift. Fine intention tremor
on FHF. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 1 1 0 0
R 2 1 1 0 0
Plantar response flexor bilaterally.
- Coordination - Intention tremor on FNF bilaterally. Slowed
RAM bilaterally.
- Gait - Normal initiation. Narrow base. Normal stride length
and arm swing. Stable without sway. Positive Romberg.
** Swallow examination performed in ED by neuro resident and
patient passed **
DISCHARGE EXAM: Only change is negative rhomberg
Pertinent Results:
ADMISSION LABS:
___ 09:07PM BLOOD WBC-10.2 RBC-4.64 Hgb-13.9*# Hct-39.5*#
MCV-85 MCH-30.0 MCHC-35.2* RDW-14.5 Plt ___
___ 09:07PM BLOOD Neuts-72.9* ___ Monos-5.4 Eos-2.7
Baso-0.3
___ 09:07PM BLOOD ___ PTT-28.8 ___
___ 09:07PM BLOOD Glucose-241* UreaN-16 Creat-0.6 Na-137
K-4.6 Cl-103 HCO3-21* AnGap-18
___ 09:07PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
URINE:
___ 11:53PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:53PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 11:53PM URINE RBC-4* WBC-29* Bacteri-FEW Yeast-NONE
Epi-3
___ 11:53PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
=========================================================
IMAGING:
CXR ___: A and lateral views of the chest were obtained. Heart
is normal
in size, and cardiomediastinal silhouette is stable. Lungs are
clear. There
is no pleural effusion or pneumothorax.
CTA Head/Neck ___: (please note this read is not supported by
further imaging reads)***
Evolving subacute left temporal parietal infarct, grossly
unchanged in comparison with the prior MRI dated ___
from an outside institution. There is no evidence of
intracranial hemorrhage or mass effect. CTA of the head and neck
appears grossly unremarkable with no evidence of flow stenotic
lesions or aneurysms.
NCHCT ___: ***** This read is opposite read from above*****
Unchanged hypodense region in the left parietal lobe. Given its
stability over 3 days and comparison with outside MRI, this is
unlikely to represent an infarction. A malignancy such as a
glioma is far more likely.
MR SPECT ___: Marked elevation of choline to NAA ratios within
the left parietal lobe lesion
compatible with malignant glioma, grade 3 or grade 4.
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.There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The estimated
cardiac index is normal (>=2.5L/min/m2). 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
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: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved regional and global
biventricular systolic function. No definite structural cardiac
source of embolism identified.
Brief Hospital Course:
Mr. ___ is a ___ year-old right-handed man with a history
of IDDM, HLD, and seizures who had one episode of slurred speech
on ___ lasting 2 hours. He was initially admitted to an
outside hospital and transferred to ___ given his MRI
findings.
# NEUROLOGY:
He was admitted to the stroke neurology service from ___
to ___. Ultimately, his presenting symptoms were thought to be
partial complex seizures as they were similar to prior partial
complex seizures with semiology of slurred speech. His Keppra
dose was not adjusted and his prior home phenytoin was not
restarted. He did not have further episodes of slurred speech
while in the hospital.
With regards to the MRI findings from the OSH, the initial
MRI showed a T2 hyperdense parietal lesion concerning for late
subacute infarct versus mass. Since initially there was concern
that this lesion represented a stroke, his stroke risk factors
were assessed: LDL was 177 and his statin was optimized to
atorvastatin 80. A1c was 12.5%. TTE with bubble was
unremarkable. CTA Head and neck showed patent vessels. He
continued Aspirin 325.
However, subsequent ___ and MR spect supported that this
lesion is a mass, most likely a glioma. The patient was seen by
neurooncologist, Dr. ___ will see the patient in
outpatient brain tumor clinic.
# CARDIOPULMONARY: His LDL was 177 and his statin was changed as
described above. He continued his home colesevelam. ECHO was
unremarkable. Cardiac enzymes were negative x1.
# INFECTIOUS DISEASE: Initial urinalysis was suggestive of UTI,
however patient was asymptomatic and urine culture revealed
mixed flora, so no antibiotic therapy given.
# ENDOCRINE: He has longstanding IDDM, on Humulin ___ 45 units
in the morning and Levemir 80units in the evening. A1c was
12.5%. Given that his home regimen provided good control of his
FSGs we did not alter his home insulin regimen. He was
counseled on the need for insulin compliance, diet and exercise
as he is morbidly obese with a metabolic syndrome. His
metformin was held while inpatient and restarted on discharge.
# PSYCHIATRY: longstanding depression. He continued his home
sertraline 200mg daily and buspirone 15mg BID. He is regularly
seen by a psychiatrist when outpatient.
TRANSITIONAL ISSUES:
1) Outpatient MRI brain w/ and w/o contrast was arranged in 1
month to allow us to reeval lesion
2) Neurology and neuroonc follow-up
3) PCP, ___, was updated prior to patient's discharge.
4) Patient needs intensive counseling on medication compliance,
diet, exercise.
====================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes
4. LDL documented (required for all patients)? (x) Yes (LDL
=177)
5. Intensive statin therapy administered? (x) Yes
6. Smoking cessation counseling given? (x) No - n/a: patient is
a former smoker
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes
9. Discharged on statin therapy? (x) Yes
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) No - (x) N/A
===================================================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BusPIRone 15 mg PO BID
2. LeVETiracetam 2250 mg PO BID
3. MetFORMIN (Glucophage) 500 mg PO BID
4. colesevelam 1875 mg oral BID
5. Simvastatin 20 mg PO DAILY
6. Sertraline 200 mg PO DAILY
7. albuterol sulfate ___ puffs inhalation q4H prn sob
8. Aspirin 325 mg PO DAILY
9. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN pain
10. insulin detemir 80 units SC QPM
11. HumuLIN ___ (insulin NPH and regular human) 45 units
subcutaneous QAM
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. BusPIRone 15 mg PO BID
3. LeVETiracetam 2250 mg PO BID
4. Sertraline 200 mg PO DAILY
5. Atorvastatin 80 mg PO HS
RX *atorvastatin 80 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
6. albuterol sulfate ___ puffs inhalation q4H prn sob
7. colesevelam 1875 mg oral BID
8. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q8H:PRN pain
9. insulin detemir 80 units SC QPM
10. MetFORMIN (Glucophage) 500 mg PO BID
11. NovoLIN ___ (insulin NPH and regular human) 45 units
subcutaneous before breakfast
Discharge Disposition:
Home
Discharge Diagnosis:
1) Stroke versus brain mass
2) Seizure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you while you were admitted to
___. You were hospitalized
because of an episode of slurred speech. You had multiple
images of your brain which showed a lesion on the left side of
your brain. We had to do multiple scans while you were here to
better characterize this. You will receive these results at
your next visit with our Neuro oncologist, Dr. ___.
Please see your medication list below.
Followup Instructions:
___
|
19777058-DS-21
| 19,777,058 | 27,920,106 |
DS
| 21 |
2144-06-08 00:00:00
|
2144-06-08 14:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
erythromycin base
Attending: ___
Chief Complaint:
Right sided flank pain.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F history of dementia, A&Ox1 at baseline, DNR/DNI status
post fall.
Transferred from ___ for multiple rib fractures. Is
from an assisted living facility and got up to go to the
bathroom last night with help from her home health aide, but she
went limp and fell.
Past Medical History:
PMH: COPD, Dementia (AOx1 at baseline; will go 24hrs without
opening eyes or moving sometimes), HTN
PSH:
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Temp: 97.6 HR: 70 BP: 165/80 Resp: 16 O(2)Sat: 96 Normal
Constitutional: Constitutional: No fever, no
chills
Head / Eyes: No diplopia
ENT: no earache
Resp: No cough
Cards: No chest pain
Abd: No abdominal pain
Flank: No dysuria
Skin: No rash
Ext: No back pain
Neuro: No headache
Psych: No depression
Discharge Physical Exam:
Pertinent Results:
___ 06:35AM BLOOD WBC-7.8 RBC-4.15 Hgb-10.6* Hct-34.4
MCV-83 MCH-25.5* MCHC-30.8* RDW-15.6* RDWSD-47.1* Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-106* UreaN-11 Creat-0.8 Na-136
K-3.9 Cl-96 HCO3-28 AnGap-16
___ CXR:
Re- demonstration of displaced right fifth through ninth
posterior rib
fractures. No pneumothorax.
___ CT Head:
Marked cerebral atrophy and chronic small vessel ischemic
disease without
evidence of acute intracranial hemorrhage. Please note that MRI
is more
sensitive for detection of acute infarction.
___ CT C-Spine:
1. No fractures.
2. Moderate cervical spondylosis with mild to moderate bilateral
neural
foraminal narrowing, worse at C4-5. Mild anterolisthesis of C3
on C4 and C4 on C5, most likely degenerative in etiology.
___ Xray Right Humerus:
No acute fracture
___ Xray Right Shoulder:
No acute fracture
Brief Hospital Course:
Ms. ___ is an ___ yo F admitted to the Acute Care Trauma
Surgery service on ___ after an assisted fall. She had
imaging that revealed right sided rib fractures ___. CT head and
C-spine were negative for acute injuries. She was admitted to
the floor for pain control and oxygenation monitoring.
On HD1 tertiary exam was completed and revealed no new injuries.
Her pain was well controlled on oral medications. Mental status
remained at baseline. She remained stable from a cardiopulmonary
standpoint, vital signs were routinely monitored. She tolerated
a regular diet without difficulty. She was incontinent of urine
which is her baseline status. Physical therapy evaluated her and
recommended discharge back to assisted living and family agreed
with plan.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet
and pain was well controlled. The patient received discharge
teaching and follow-up instructions. Written instructions were
given to the assisted living facility.
Medications on Admission:
Citalopram 20 mg PO DAILY
Docusate Sodium 100 mg PO BID
Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
Metoprolol Tartrate 50 mg PO DAILY
Omeprazole 20 mg PO
Advair 100/50
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Do not exceed 4 grams in 24 hours.
2. TraMADol ___ mg PO Q6H:PRN pain
Take lowest effective dose.
3. Citalopram 20 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
6. Metoprolol Tartrate 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right rib fractures ___
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery on ___ after an
assisted fall. You had xray imaging that showed right sided rib
fractures ___. You were admitted to the hospital for pain
control and close respiratory monitoring. You remained stable
and are now ready to be discharged to home to continue your
recovery.
Please note the following discharge instructions:
* Your injury caused right sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
19777098-DS-10
| 19,777,098 | 28,088,647 |
DS
| 10 |
2129-10-03 00:00:00
|
2129-10-03 15:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / Keflex
Attending: ___.
Chief Complaint:
Generalized tonic clonic seizure
Major Surgical or Invasive Procedure:
Intubation at ___
Extubation at ___
History of Present Illness:
HPI:
Mr. ___ is a ___ who presents as a tranfer from ___ with several seizures followed by intubated in the
setting of recent nausea/vomiting and persistent headache on a
background of epilepsy.
Information is obtained from the transfer records and from his
family. The patient is intubated on arrival and cannot
participate in history gathering process.
He was last seen in our department in ___ at which time he was
transfered to our hospital intubated for concerns regarding
status epilepticus (repeat GTCs, perhaps 3, with prolonged
post-ictal period). He was sent to the ICU and was monitored
with
EEG and MRI brain which were unrevealing. He was extubated and
shortly thereafter discharged without AED. It was assumed at
that
time that his seizures were triggered by overusing tramadol for
back pain. He did not follow up with his neurology appointment
at
___ and we have no records of his subsequent history.
His wife informs me that since discharge he has been followed by
a neurologist ___ and has unfortunately had perhaps 3
seizure cluster episodes and everytime has been transferred to
___ and (as far as she can remember) has been intubated
every time. The trigger for these clusters has not always been
so
clear, however on one occasion he had a skin infection on his
arm
(cellulitis).
He has been tried on several AED including Depakote (she cannot
remember the others), but has had varied side effects such as
calf pain and eventually settled on topamax roughly ___ year ago.
The dose is listed as 25mg BID, which his wife was told was a
very small dose but he has not had any seizures in about ___ year
and she feels that the dose has been adequate. She monitors his
medications and makes sure that he takes the topamax twice every
day. He has not missed any doses.
Last week, he had perhaps 2 days of nausea/vomiting with
diarrhea
that was "going around". 5 other people in his house had the
same
symptoms and recovered well. The patient himself did not have a
fever during the episode (but perhaps some chills) and recovered
well over the next few days and was able to eat, drink and take
his medication. He did, however continue to have a headache that
was bifrontal. He may have taken an extra percocet for the pain.
His wife denies any report of neck stiffness, altered behavior,
Over the past 2 nights, his wife noted that he had two episodes,
one each night, of loud grunting that she thinks may have
represented a small seizure. She checked on him (they sleep in
separate beds) but he was able to respond thereafter.
At roughly 5am this morning, he again had another episode of
grunting. She went to check in on his and he looked okay
however
perhasp 10minutes later he had a "full blown seizure" with whole
body shaking which lasted 5 minutes. He had a second episode 5
minutes later and his wife called EMS. He had another episode as
they arrived and a fourth in the ambulance on the way. Between
episodes he was not interactive. His ___ at the scene was
173mg/dl.
On arrival to ___, he was given 2 mg ativan and quickly
intubated and placed on propofol. His BP decreased into ___
systolic, he was given fluids. Labs at ___ showed
leukocytosis and lactic acid 15, bicarb 5. He underwent NCHCT
which did not show abnormality. he was tranferred to ___.
On arrival, sedation was switched to fentanyl/Midaz and neuro
was
consulted. EEG was ordered. He was then given 1g phenytoin and
transferred to the neuro ICU.
Past Medical History:
Past Medical History:
Epilepsy: he was admitted to our hospital in ___ after several
new onset seizure episodes that were followed by intubated and
ICU monitoring. He underwent MRI and EEG which were unrevealing.
He was discharged but did not follow up with ___ neurology. He
was not discharged on any AEDs at that time. Based on his
admission medication list, he is taking lyrica and topamax but
at
small doses for pain.
Chronic Back pain- Patient has been mostly followed by a
___ physician for this problem. ___ years ago
he fell while at work on the ___ and fell down 14 feet
injuring
his back. His family wasn't sure the total of extent of his
injury but think he had L4/L5 vertebral disc protrusion and
stenosis of the canal. His images are at ___.
He has a history of taking many pain medications and taking them
NOT as precribed. For pain, he is currently on lyrica 50mg QID,
topamax 25 bID, flexeril 10mg, ibuprofen and percocet QID
Heel Fracture- sustained during above mentioned fall
?Syncope- He has two known syncopal events apart from the
seizures described above. One was ___ years ago where he
reported
feeling lightheaded and fell forward and hit his head suffereing
a laceration of his forehead. The second was ___ year ago where
he
fainted while in the bathroom.
Hemorrhoids- He has been followed by a surgeon who has
recommended surgical intervention in the past.
Social History:
___
Family History:
Family History:
FH: He was one of 6 brother and several of them have prostate
cancer. Both of his parents lived to their ___. His
mother had a stroke in her ___. There is no family history of
seizure.
Physical Exam:
Admission Physical exam:
99.3 68 99/64 18 100%
GEN: intubated sedated on fentanyl.midaz
HEENT: supple, good range of motion
CV: RRR s1s2
Lungs: CTA in frontal fields
Abd: soft, nd +ns
Ext: warm, wp, 2+ pulses, no edema
GU foley in place
skin: no significant lesions
Neurological exam:
MS: intubated sedated
CN: +doll's eyes, + ptosis on the right (previously reported in
___, face symmetric during grimace, + gag,
Motor: no clear asymmetries, tone is normal to slightly flaccid
in all extremities without asymmetry, no adventitious movements
Reflexes: 1+ and symmetric in the uppers, 1+ symmetric in the
lowers, absent ankle jerks,
Sensory: did not withdraw to painful stimuli in any limb
coordination/gait: untested
DISCHARGE EXAM:
General: WDWN
HEENT: Right eyelid without swelling or erythema
CV: RRR, no murmurs
Abd: S/NT/ND
Extremities: WWP
MS: A&Ox3, ___ backwards without difficulty, speech fluent,
follows commands
CN: PERRL, EOMI, face symmetric, tongue midline, no dysarthria
Motor: Normal bulk and tone, intact strength throughout
Reflexes: 2+ throughout
Sensation: Intact to light touch
Gait: Intact
Pertinent Results:
Labs:
133 ___ AGap=13
4.1 15 0.9
Ca: 8.0 Mg: 2.1 P: 2.7
ALT: 31 AP: 65 Tbili: 0.3 Alb: 3.5
AST: 33 LDH: Dbili: TProt:
___: Lip: 37
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
WBC 18.8 ___
Hgl 12.7
Plt 340
HCT 37.5
Blood culture ___ from ___): alphan hemolytic strep ___
bottles)
Blood cultures (___): no growth
Urine culture (___): no growth
MRI brain: Unremarkable brain MRI without evidence of
hemorrhage, infarct or abnormal enhancement.
MRI C-spine: No evidence of cord compression. Cervical
spondylosis as described above, worst at C5-C6, where there is
moderate canal narrowing.
CT sinus: Right preseptal cellulitis without post-septal
extension.
Brief Hospital Course:
ICU COURSE: ___ year old man diagnosed with epilepsy in ___
(here) of unknown etiology. An extensive work-up was negative
and the only trigger found was tramadol use. He had presented
with status and was intubated. Since discharge, he has had 3
other episodes of GTC status epilepticus for which he has been
intubated at ___. Numerous AEDs have been tried
and reactions of variable severity and legitimacy resulted in
the patient being maintained on topiramate 25 BID. His last
seizure was in the setting of cellulitis treated with Keflex ___
year ago. His only semiology is GTC.
He had a gastroenteritis which resolved a week ago with a
subsequent severe, question bifrontal headache since. He has not
been obviously febrile, but his wife does describe rigors. He
has only taken Percocet for analgesia and has not head any head
trauma. Over the past 2 mornings prior to admission, he had had
periods of grunting in the early morning. On the morning of
admission, his early morning grunting was followed by a GTC
within 10 minutes. He subsequently had 3 (one prior to EMS
arrival, one on EMS arrival, one at ___ with no return
to baseline between them. He was given 2mg Ativan, intubated,
and sent here after nl NCHCT and CXR.
Here, serum and urine tox screens were negative. He was given
1gm PHT and started on 100 fosPHT TID. He was diagnosed with
right pre-septal orbital cellulitis, started on clindamycin with
vancomycin added when found that GPCs were growing in pairs and
chains from an OSH blood culture. He was extubated overnight and
has done well.
FLOOR Course:
Patient was admitted in stable condition. He was continued on
Phenytoin 100mg TID without further seizures. He was continued
on Vancomycin for preseptal cellulitis and positive blood
culture, and Clindamycin was discontinued. ID was consulted
given OSH blood culture grew strep viridans in one of 4 tubes.
They recommended TTE to rule out any vegetations or endocarditis
which was normal. He was discharged on Vancomycin 1000mg IV q12h
to complete a 7 day course since first negative blood culture
(___). PICC line was placed in right arm and
placement confirmed prior to discharge. ___ services arranged to
administer Vancomycin at home. Patient switched to Phenytoin ER
300mg po daily for convenience on discharge. Patient to see
Neurologist in one week at which time Phenytoin level will be
checked. Level from ___ was 9.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H
2. Multivitamins 1 TAB PO DAILY
3. Garlipure (garlic extract) 600 mg oral QD
4. Topiramate (Topamax) 25 mg PO BID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Ibuprofen 400 mg PO Q8H:PRN pain
7. Pregabalin 50 mg PO QID
8. Cyclobenzaprine 5 mg PO TID:PRN pain
9. Magnesium Oxide 400 mg PO DAILY
10. Zinc Sulfate 220 mg PO DAILY
Discharge Medications:
1. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q6H
2. Cyclobenzaprine 5 mg PO TID:PRN pain
3. Garlipure (garlic extract) 600 mg oral QD
4. Ibuprofen 400 mg PO Q8H:PRN pain
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Magnesium Oxide 400 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Pregabalin 50 mg PO QID
9. Zinc Sulfate 220 mg PO DAILY
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral QD
RX *calcium carbonate-vitamin D3 [Calcium 600 + D(3)] 600 mg
calcium (1,500 mg)-400 unit 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*5
11. Vancomycin 1000 mg IV Q 12H
To continue Vancomycin 1000mg IV q12h until ___, last dose
in the evening.
RX *vancomycin 1 gram 1 g IV every twelve (12) hours Disp #*4
Vial Refills:*0
12. Phenytoin Sodium Extended 300 mg PO DAILY
RX *phenytoin sodium extended 300 mg 1 capsule(s) by mouth daily
Disp #*30 Capsule Refills:*5
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Seizure
Pre-septal cellulitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were transferred to our ___ from ___ after you
had three seizures. Your seizure medications were changed from
Topamax to Phenytoin extended release 300mg PO daily. We hope
that your seizures will be better controlled on this medication.
We also started you on calcium and vitamin D that you should
take while you are taking phenytoin. You were treated with
Vancomycin for cellulitis of your right eyelid and a positive
blood culture. You were sent home on Vancomycin to complete a 7
day course, which will be completed on ___. You will have
your PICC line removed by ___ services on ___ after your
last Vancomycin dose.
Please contact your doctor or go to the nearest Emergency Room
if you experience any of the below listed Danger Signs.
It was a pleasure caring for you on this hospitalization.
Followup Instructions:
___
|
19777350-DS-13
| 19,777,350 | 24,671,669 |
DS
| 13 |
2169-05-02 00:00:00
|
2169-05-02 12:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Demerol
Attending: ___.
Chief Complaint:
Left Subdural Hematoma
Major Surgical or Invasive Procedure:
___ Left mini-craniotomy for subdural hematoma evacuation
History of Present Illness:
___ is a ___ right handed male with history of afib on
coumadin who presents to ___ with 3 weeks of gait
instability and 2 days of word finding difficulty. The patient
reports the he had no trauma. He reports mild headache,
intermittent, wholocephalic, with intensity range from ___.
Denies nausea or vomiting, denies vision changes. He reports
that the last 3 weeks he feels "clumsy", "unsure" about his step
and he was to watch his step when he walks. He also reports that
the last 2 days has difficulty with his speech. Mostly
difficulty finding the correct word to use, and it takes him
more time than usual. Initially it was thought that he has a
stroke so an MRI
was obtained at ___ which demonstrated a large chronic SDH
with some acute area. His INR was reversed with KCentra and
vitamin K and was transferred to ___ on ___ for
further management.
Past Medical History:
Afib on coumadin
Asthma
HTN
Social History:
___
Family History:
Non-contributory
Physical Exam:
Upon arrival:
-------------
General: appearance well
GCS 15
opens eyes spontaneously, follows commands, speech slow,
scanning, paraphasic errors, comprehension intact
AOx3
Pupils equal and reactive, EOMI, visual acuity intact
V1-V3 sensation intact
Face Symmetric
Palate elevates
Shrugs shoulders
Tongue protrudes midline
NO Pronator Drift
Motor:
Trap DeltoidBicepsTriceps WF WE Grip
Right5 4+/5 4+/5 4+/5 4+/5 4+/5 4+/5
Left5 ___ 5 5 5
IP QuadHamATEHLGastroc
Right5 4+/5 4+/5 4+/5 4+/5 4+/5
Left5 5 5 5 5 5
Sensation:
intact to light touch
Cerebellar:
No dysmetria, no dysdiachodokinesia
Upon discharge:
---------------
Pertinent Results:
Please see OMR for all pertinent results
Brief Hospital Course:
___ right handed M, afib on coumadin with large left chronic
SDH with some acute areas, presenting with dysphasia and gait
instability. His INR was reversed at the outside hosptial with
KCentra and vitamin K and he was transferred to ___
on ___ for further management.
#L subdural hematoma
He was admitted to the ___ where he was placed on the OR
schedule for evacuation of the hematoma on ___. He was started
on keppra 500mg bid for seizure prophylaxis. He underwent left
mini-craniotomy for subdural hematoma evacuation on ___.
Please see operative report by Dr. ___ full details. A
postop head CT showed interval SDH evacuation with substantially
decreased midline shift now measuring 7 mm. Subdural drain was
placed intraoperatively and removed on POD#2 without
complication. He was made floor status and evaluated by physical
and occupational therapy, who recommended that he was safe for
home with no services. He was discharged home on ___.
#Atrial fibrillation
Mr ___ was on ___ outpatient for his atrial fibrillation
prior to hospitalization. At the OSH he was reversed with
KCentra and he received three days of Vitamin K+ po. He should
hold Coumadin at least 2 weeks postop.
Medications on Admission:
FLOVENT HFA 220 MCG INHALE 1 PUFF BY MOUTH TWICE A DAY,
LOSARTAN POTASSIUM 100 MG TAB TAKE 1 TABLET BY MOUTH ONCE A DAY,
METOPROLOL SUCC ER 50 MG TAB TAKE 1 TABLET BY MOUTH EVERY DAY,
PANTOPRAZOLE TAB 40MG,
TAMSULOSIN CAP 0.4MG,
WARFARIN SODIUM 5 MG TABLET - TAKE 1 & ___ TABLETS BY MOUTH
EVERY DAY ALTERNATING WITH 2 TABLETS DAILY (HOLD)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
3. LevETIRAcetam 500 mg PO BID Duration: 5 Days
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*10 Tablet Refills:*0
4. Senna 17.2 mg PO HS
5. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*12 Tablet Refills:*0
6. Losartan Potassium 100 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Left acute on chronic subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Hemorrhage with Surgery
Surgery
· You underwent a surgery called a craniotomy to have blood
removed from your brain.
· Please keep your sutures along your incision dry until they
are removed.
· It is best to keep your incision open to air but it is ok to
cover it when outside.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· ***Please do NOT take any blood thinning medication
(Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the
neurosurgeon. You were previously on Coumadin. Please do not
start retaking for 2 weeks from surgery ___ you may
resume).
· ***You have been discharged on Keppra (Levetiracetam).
This medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instructions (for 7
days after surgery). It is important that you take this
medication consistently and on time.
· You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating, and
remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
· You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
· Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
· Headache is one of the most common symptoms after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the incision
site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason
Followup Instructions:
___
|
19777630-DS-3
| 19,777,630 | 25,657,916 |
DS
| 3 |
2167-12-14 00:00:00
|
2167-12-16 18:52:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Deep Venous Thrombosis
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ y/o woman with h/o CVA in ___ with
residual R-sided hemiplegia and expressive aphasia, R-sided DVT
s/p IVC filter placement, who p/w increased right leg swelling.
Pt was evaluated and treated for stroke in ___ at ___ in
___, though details are unclear without their records.
She was initially transferred to a rehabilitation facility in
___, then moved to a facility in ___ because her
daughter lives in the area. Per outside records, while at rehab
pt was initially diagnosed with DVT in late ___, with IVC
filter placement ___. Since that time, she has had chronic
edema in the RLE, but over the past ___ days has had acute
worsening with increased swelling and achiness. She was
transferred from her nursing facility out of concern for
compartment syndrome.
On presentation to the ED, she was afebrile with normal vitals.
Labs were significant for H/H: 9.6/29.6. She underwent NCHCT
which showed no active bleeding, as well as LENIs notable for
DVT in the RLE involving the right common femoral vein, proximal
SFV, distal SFV, right popliteal and right peroneal veins. In
the LLE, partially occlusive thrombus seen at the common femoral
vein/greater saphenous vein junction w/o evidence of DVT in the
distal LLE. Vascular surgery was consulted in the ED and
recommended against surgical intervention. Neurology also saw
her in the ED and recommended obtaining records from prior
stroke eval/tx with formal consult this morning regarding risks
and benefits of anticoagulation. Pt was admitted to the floor
for further management.
This morning, she reports that her leg looks about the same as
last night. She is not currently in any pain. She denies any
numbness or tingling, though notes that at baseline she has
decreased sensation in the right leg below the knee. At baseline
she has no movement in the right arm or leg.
Past Medical History:
- Embolic/Hemorrhagic CVA ___, resulting right hemiparesis
and aphasia)
- DVT (no no anticoagulation ___ CVA, has IVC filter)
- Asthma/COPD from Second hand smoke
- Benign HYpertension
- Hyperlipidemia
Social History:
___
Family History:
Mother: Multiple TIAs/CVA (died of CVA in her ___
No clotting disorders in the family
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
Vitals- 98.1 - 120/57 - 72 - 16 - 100% RA
General- Alert, sitting comfortably in bed, NAD. Pt has
expressive aphasia but able to communicate.
HEENT- Sclerae anicteric, MMM, oropharynx clear.
Neck- no carotid bruits
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- RLE markedly swollen and tense, tender to palpation but not
painful at rest. Cord not palpable. Sensation intact to light
touch above the knee but not below, which pt reports is
baseline. LLE without edema or tenderness, WWP. Measured just
above the knee, circumference in RLE is 48cm, LLE is 44cm. No
edema in the upper extremities.
Neuro- R eyelid droop, attenuation of R NLF but activates
symmetrically on smiling, complete plegia of R arm and leg.
Left-sided motor function grossly intact. Pt has expressive
aphasia with difficult finding words, circuitous speech, and
yes/no confusion. Comprehension intact.
========================
DISCHARGE PHYSICAL EXAM
========================
Vitals- 98.0/afebrile - 114/46 - 74 - 18 - 99% RA
Fingersticks- 117-195
Exam unchanged other than noted pertinents:
Ext- RLE markedly swollen and tense, similar to yesterday.
Tender to palpation. Circumference is stable from yesterday at
53cm around, elevated from 48cm on admission. LLE circumference
unchanged at 44cm. No upper extremity edema.
Pertinent Results:
=================
ADMISSION LABS:
=================
___ 05:55PM BLOOD WBC-5.1 RBC-3.26* Hgb-9.6* Hct-29.6*
MCV-91 MCH-29.3 MCHC-32.3 RDW-13.7 Plt ___
___ 05:55PM BLOOD Neuts-63.1 ___ Monos-5.7 Eos-3.3
Baso-0.3
___ 05:55PM BLOOD Glucose-136* UreaN-11 Creat-1.0 Na-140
K-3.8 Cl-102 HCO3-26 AnGap-16
___ 07:15AM BLOOD Calcium-9.6 Phos-4.2 Mg-2.0
___ 07:15AM BLOOD ___ PTT-28.4 ___
=================
DISCHARGE LABS:
=================
___ 06:43AM BLOOD WBC-4.7 RBC-3.28* Hgb-9.5* Hct-30.4*
MCV-93 MCH-28.9 MCHC-31.2 RDW-13.9 Plt ___
___ 06:43AM BLOOD Glucose-118* UreaN-10 Creat-0.9 Na-144
K-4.3 Cl-107 HCO3-27 AnGap-14
========
IMAGING
========
BILAT LOWER EXT VEINS Study Date of ___ 6:00 ___
Preliminary Report
IMPRESSION:
Deep venous thrombosis involving the right common femoral vein,
proximal SFV, distal SFV, right popliteal and right peroneal
veins.
Partially occlusive thrombus seen in the left leg at the common
femoral vein/greater saphenous vein junction. There is no
evidence of DVT in the distal portion of the left lower
extremity.
CT HEAD W/O CONTRAST Study Date of ___ 10:05 ___
IMPRESSION:
No acute intracranial abnormality. Old left frontal infarction
as above.
MR HEAD W & W/O CONTRAST; MRA BRAIN W/O CONTRAST Study Date of
___ 10:20 AM
Preliminary Report
IMPRESSION:
Exam limited by motion artifact. An old left frontal infarct is
unchanged. No acute intracranial abnormality or focus of
enhancement.
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with h/o CVA in ___ with
residual R-sided hemiplegia and expressive aphasia, R-sided DVT
s/p IVC filter placement, who presented with increased right leg
swelling, found on ___ to have marked clot burden in the RLE
with associated swelling and pain.
==================
ACTIVE ISSUES
==================
# Deep Venous Thrombosis: Patient presented with extreme
swelling of the right lower extremity, found to have very large
clot burden in RLE. Unclear if this is simply
clot-begetting-more-clot or patient has a hypercoaguable state.
She is essentially unmoving on the right side, so is at high
risk in general for clotting. She protected currently by IVC
filter from large emboli. Neurology was consulted regarding the
risks of anticoagulation given her prior hemorrhagic stroke, and
felt that the risk of rebleeding was too high for this to be a
safe option. Vascular surgery was also consulted to evaluate for
alternative treatment options. Local TPA also not a safe option
given high risk for systemic effects. Thrombectomy was thought
to have little utility because without systemic anticoagulation
post-operatively she is at high risk for rapid reaccummulation
of clot. She was treated conservatively with compression wraps,
elevation and pain control with standing tylenol and tramadol
prn.
# Prior Stroke with Late Effects: Hemorrhagic stroke occurred in
___, resulting in R-sided hemiplegia and expressive aphasia.
Per neurology, the location of her bleed (left, lobar) is more
typical of a amyloid bleed than a hypertensive bleed, but
outside records were unable to clarify the etiology. During her
hospitalization, she underwent a head CT and MRI/MRA with
contrast, both of which demonstrated stability of the previous
left frontal infarct without any acute abnormality. Patient
already getting stroke rehab as an outpatient, but ___ and OT
teams were consulted while inpatient to help address and reduce
contractures (considerable sources of pain) and fine-tune her
outpatient plan. Regarding risk factors, pt has h/o HTN and HLD.
She was continued on her home statin.
================
CHRONIC ISSUES
================
# Benign Hypertension: Patient was continued on her home
labatelol and furosemide, with good control of blood pressures
while hospitalized.
# Hyperlipdiemia: Patient was continued on her home
atorvastatin.
# COPD: Patient was continued on her home albuterol and advair.
====================
TRANSITIONAL ISSUES
====================
Transitional issues:
# Please consider possible utility of long-term prophylactic
heparin SQ or prophylactic dosed enoxaparin to prevent new DVTs
forming in UE or elsewhere. Neuro at ___ reports it has been
used short term by some providers but little evidence for
utility/safety long term. This should be discussed in depth by
outpatient neurologist.
# Pt. discharged with prescriptions for tramadol and oxycodone.
Pt. would like to try tramadol first, but if this is
insufficient she will transition to oxycodone.
# Please keep right leg elevated with compression ACE wrap to
hip as much as tolerated.
# There have been rare reports of serotonin syndrome when using
tramadol and mirtazapine simultaneously. Please monitor pt. for
this.
# FSG elevated during this admission. Please consider sending
HbA1c, following FSG, and possible initiation of oral
antihyperglycemic as needed.
# Code: FULL
# Contact: Daughter ___, also HCP,
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. Milk of Magnesia 30 mL PO DAILY:PRN constipation
5. Bisacodyl 10 mg PR HS:PRN constipation
6. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN Gi
irritation
7. Atorvastatin 20 mg PO DAILY
8. Labetalol 200 mg PO BID
9. Cyanocobalamin 1000 mcg IM/SC MONTHLY ON THE ___
10. Mirtazapine 15 mg PO HS
11. Ferrous Sulfate 325 mg PO DAILY
12. Furosemide 40 mg PO DAILY
13. Potassium Chloride 10 mEq PO DAILY
14. Tizanidine 2 mg PO TID:PRN muscle spasm
15. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
Do not exceed 3gm/day.
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
3. Atorvastatin 20 mg PO DAILY
4. Bisacodyl 10 mg PR HS:PRN constipation
5. Ferrous Sulfate 325 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Labetalol 200 mg PO BID
8. Mirtazapine 15 mg PO HS
9. Pantoprazole 40 mg PO Q24H
10. Tizanidine 2 mg PO TID:PRN muscle spasm
11. Docusate Sodium 100 mg PO DAILY:PRN constipation
12. Senna 8.6 mg PO BID:PRN constipation
13. TraMADOL (Ultram) 50 mg PO Q4-6H:PRN pain
Do not exceed 400mg/day.
RX *tramadol 50 mg 1 tablet(s) by mouth every 4 to 6 hours Disp
#*30 Tablet Refills:*0
14. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
Gi irritation
15. Cyanocobalamin 1000 mcg IM/SC MONTHLY ON THE ___
16. Furosemide 40 mg PO DAILY
17. Milk of Magnesia 30 mL PO DAILY:PRN constipation
18. Potassium Chloride 10 mEq PO DAILY
19. OxycoDONE (Immediate Release) 5 mg PO Q4-6H:PRN pain
For use in place of tramadol if needed.
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Right lower extremity deep vein thrombosis
Secondary diagnosis:
Status post stroke
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 ___ due to pain in the right leg. You
were found to have a significant amount of clot in the veins of
your right leg. This causes fluid to collect in the leg and
results in swelling and pain. You have a filter in your
inferior vena cava (the main vein returning blood to the heart
from your lower body) that should protect you from clots
traveling to the lungs. You were evaluated very carefully by
the neurologists and vascular surgeons. Unfortunately, given the
nature of your stroke, you are very high risk for rebleeding and
so could not be started on systemic anticoagulation (blood
thinners). This included local medications to dissolve the
clot. The surgeons also felt that surgically removing the clot
would be high risk and that it would be very likely for it
reform. We therefore recommend that you continue with leg wraps
to the thigh, elevation (above the heart if possible), and pain
control as needed. You should continue working to stay as
mobile as possible.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your medicine team at ___
Followup Instructions:
___
|
19777832-DS-16
| 19,777,832 | 28,022,225 |
DS
| 16 |
2118-06-06 00:00:00
|
2118-06-06 16:21:00
|
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 pain
Major Surgical or Invasive Procedure:
Lap cholecystectomy
History of Present Illness:
Ms. ___ is a ___ female with no past medical history
presenting with acute onset abdominal pain two days ago. She
went to urgent care where she had her labs checked. They were
abnormal and thus she was referred to ___. She was then referred
to the ___. The patient does not report n/v. She has had a
similar pain intermittently for the past ___ years. The time in
between her pain episodes then was so infrequent that she did
not connect the instances. The pain that she had on the day of
presentation to the OSH was different from the pain she had had
before because it was so long in duration and so intense
radiating from her back to the stomach and it would take her
breath away. No fevers or chills or change in her bowel habits.
Pain associated with reflux and increased gas. Her pain was not
related to food intake. She went to the hospital and was found
to have elevated bilirubin and transaminitis with multiple
stones in her gallbladder concerning for cholecystitis. Surgery
was consulted who recommended ERCP prior to cholecystectomy at
___. She has not had weight loss or weight gain. Transferred
from ___ for ERCP per ___ surgery
there and confirmed by ACS here. . ROS: Pertinent positives and
negatives as noted in the HPI. All other systems were reviewed
and are negative.
PAST MEDICAL/SURGICAL HISTORY:
No PMH/PSH
Anxiety attack x 1.
SOCIAL HISTORY: ___
FAMILY HISTORY: No family history of gallstones. Grandmother
with ulcers in her
stomach.
Past Medical History:
See HPI
Social History:
___
Family History:
See HPI
Physical Exam:
ADMISSION:
=========
EXAM(8)
98.2 PO ___ 18 99 RA
Currently she has ___ pain in the epigastrum but it is not
worsened with palpation.
VITALS: Afebrile and vital signs stable (see eFlowsheet)
___: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE:
=========
Vitals: 24 HR Data (last updated ___ @ 2346)
Temp: 98.9 (Tm 98.9), BP: 108/73 (106-123/73-78), HR: 78
(74-85), RR: 18 (___), O2 sat: 97% (97-100), O2 delivery: Ra
Fluid Balance (last updated ___ @ ___)
Last 8 hours Total cumulative -950ml
IN: Total 0ml
OUT: Total 950ml, Urine Amt 950ml
Last 24 hours Total cumulative -635ml
IN: Total 1520ml, PO Amt 120ml, IV Amt Infused 1400ml
OUT: Total 2155ml, Urine Amt 2150ml, EBL 5ml
Physical exam:
GEN: A&O, NAD
CV: RRR
PULM: not in respiratory distress, breathing comfortably
ABD: Soft, nondistended, minimal tenderness epigastric, no
rebound or guarding, incisions c/d/i
Wound: incision c/d/i
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
===========================
___ 01:40AM BLOOD WBC-8.0 RBC-4.39 Hgb-10.5* Hct-35.1
MCV-80* MCH-23.9* MCHC-29.9* RDW-16.0* RDWSD-45.8 Plt ___
___ 01:40AM BLOOD Glucose-97 UreaN-8 Creat-0.7 Na-135 K-5.0
Cl-107 HCO3-18* AnGap-10
___ 01:40AM BLOOD ALT-345* AST-233* AlkPhos-190*
TotBili-1.2 DirBili-0.5* IndBili-0.7
MICRO:
=====
none
IMAGING/OTHER STUDIES:
======================
ABDOMINAL US:
Gallbladder is filled with stones. No wall thickening. There is
no sonographic ___ sign. No biliary ductal dilatation. CBD
measures 3 mm.
MRCP ___. Moderately motion degraded study.
2. Cholelithiasis without acute cholecystitis, biliary ductal
dilatation, or choledocholithiasis.
___ 05:30AM BLOOD WBC-7.2 RBC-4.26 Hgb-10.3* Hct-32.6*
MCV-77* MCH-24.2* MCHC-31.6* RDW-16.1* RDWSD-44.4 Plt ___
___ 05:30AM BLOOD Glucose-75 UreaN-7 Creat-0.6 Na-141 K-4.6
Cl-109* HCO3-21* AnGap-11
___ 05:30AM BLOOD ___ PTT-30.1 ___
___ 05:30AM BLOOD ALT-198* AST-60* AlkPhos-161* TotBili-0.5
___ 05:30AM BLOOD Lipase-26
___ 05:30AM BLOOD Mg-2.1
Brief Hospital Course:
Ms. ___ is a ___ female with the past medical history
and findings noted above who presents with RUQ pain, found to
have symptomatic cholelithiasis.
# SYMPTOMATIC CHOLELITHIASIS:
Patient presented to OSH following acute right-sided abdominal
pain with obstructive LFT pattern and gallstones observed on
RUQ. Patient transferred given concern for choledocholithiasis
requiring ERCP. Upon arrival, pain had resolved, LFTs
downtrending, and repeat RUQ with persistence of gallstones but
no CBD dilation, overall consistent with passed stone. Per
surgery team request, MRCP obtained and confirmed no persistent
choledocholithiasis. On ___, she was taken to the OR and
underwent a laparoscopic cholecystectomy. For details of the
procedure please see the surgeon's operative report.
Following a brief uneventful recovery in the PACU the patient
was transferred to the surgical floor. Her diet was advanced to
a regular diet which was well tolerated. Her pain was well
controlled with oral pain medication.
Prior to discharge the patient was tolerating a regular diet,
her pain was well controlled with oral pain medication. She
voided without issue, and was ambulating independently. She was
afebrile and hemodynamically normal, she was deemed medically
appropriate for discharge home with close follow up in the
surgery clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 150 mg PO DAILY
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr prn Disp #*7 Tablet
Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
Please hold for diarrhea or loose stool.
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
Please hold for diarrhea or loose stool.
4. BuPROPion XL (Once Daily) 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
symptomatic cholelithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted with abdominal pain due to
gallstones. You underwent surgical removal of your gallbladder
to prevent recurrent episodes of pain.
Please take all medications as prescribed and follow up with all
appointments as detailed below.
ACTIVITY: -Do not drive until you have stopped taking pain
medicine and feel you could respond in an emergency. -You may
climb stairs. -You may go outside, but avoid traveling long
distances until you see your surgeon at your next visit. -Don't
lift more than ___ lbs for 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. -You may start some
light exercise when you feel comfortable. -You will need to stay
out of bathtubs or swimming pools for a time while your incision
is healing. Ask your doctor when you can resume tub baths or
swimming. HOW YOU MAY FEEL: -You may feel weak or "washed out"
for a couple of weeks. You might want to nap often. Simple tasks
may exhaust you. -You may have a sore throat because of a tube
that was in your throat during surgery. -You might have trouble
concentrating or difficulty sleeping. You might feel somewhat
depressed. -You could have a poor appetite for a while. Food may
seem unappealing. -All of these feelings and reactions are
normal and should go away in a short time. If they do not, tell
your surgeon.
YOUR INCISION: -Tomorrow you may shower and remove the gauzes
over your incisions. Under these dressing you may 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).
If your incisions are closed with dermabond (surgical glue),
this will fall off on it's own in ___ days. -Your incisions may
be slightly red. This is normal. -You may gently wash away dried
material around your incision. -Avoid direct sun exposure to the
incision area. -Do not use any ointments on the incision unless
you were told otherwise. -You may see a small amount of clear or
light red fluid staining your dressing or clothes. If the
staining is severe, please call your surgeon. -You may shower.
As noted above, ask your doctor when you may resume tub baths or
swimming.
YOUR BOWELS: -Constipation is a common side effect of narcotic
pain 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. -If you go 48 hours without a
bowel movement, or have pain moving the bowels, call your
surgeon.
PAIN MANAGEMENT: -It is normal to feel some discomfort/pain
following abdominal surgery. This pain is often described as
"soreness". -Your pain should get better day by day. If you find
the pain is getting worse instead of better, please contact your
surgeon. -You will receive a prescription for pain medicine to
take by mouth. It is important to take this medicine as
directed. o Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed. -Your pain
medicine will work better if you take it before your pain gets
too severe. -Talk with your surgeon about how long you will need
to take prescription pain medicine. Please don't take any other
pain medicine, including non-prescription pain medicine, unless
your surgeon has said its okay. -If you are experiencing no
pain, it is okay to skip a dose of pain medicine. -Remember to
use your "cough pillow" for splinting when you cough or when you
are doing your deep breathing exercises. If you experience any
of the following, please contact your surgeon: - sharp pain or
any severe pain that lasts several hours - pain that is getting
worse over time - pain accompanied by fever of more than 101 - a
drastic change in nature or quality of your pain
MEDICATIONS: Take all the medicines you were on before the
operation just as you did before, unless you have been told
differently. If you have any questions about what medicine to
take or not to take, please call your surgeon.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19777866-DS-14
| 19,777,866 | 26,641,186 |
DS
| 14 |
2151-02-24 00:00:00
|
2151-02-28 14:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Motrin / Tylenol
Attending: ___.
Chief Complaint:
Shock
Major Surgical or Invasive Procedure:
CVL placement ___
History of Present Illness:
Mr. ___ is a ___ w/ PMH of HTN and prostate cancer s/p radical
prostatectomy who presents with vomiting, diarrhea, fever, and
hypotension.
The patient had a planned colonoscopy to evaluate possible
invasion of prostate cancer into colon (see below). Last night
he
started prepping. However, after the second bottle of Mg citrate
he had multiple episodes of nonbloody emesis and well as several
nonbloody loose stools. After several hours his wife noted that
he looked very unwell, was curled up on the bed in the fetal
position, shaking, and appeared confused. He endorses chills. At
that time she called EMS.
When EMS arrived, they found the patient to be tachycardic to
130s and hypotensive with SBP ___. He was given IVF and
transported to the ED.
Of note, the patient denies headache, vision changes, stiff
neck,
chest pain, SOB, cough, abdominal pain, sick contacts, recent
travel. He does endorse about 2 weeks of diarrhea, aka ~3 loose
nonbloody stools daily. He has also felt a little more weak than
usual for the past week. Otherwise he denies any new symptoms
before last night.
Past Medical History:
- Prostate cancer: s/p radical prostatectomy ___, staging at
that time: pathologic T2c, N0, M0, but had rising PSA after
surgery. Was seen here in ___ at which time radiation and ADT
were recommended, but pt declined treatment and was lost to
follow-up. Re-presented in ___ to ___ at which time PSA 136
and he was started on abiraterone and Lupron injections at that
time. He received 1 Lupron injection so far in ___. PET scan
___ showing large (12cm) soft tissue mass in pelvis c/w
recurrent disease, w/o e/o metastases. There was apparently
concern for invasion into colon vs. other colon mass, thus he
was
planned for colonoscopy for further evaluation.
- HTN
- Bilateral hernia repair in ___
- Severe LAD coronary artery calcification noted on PET scan
___
Social History:
___
Family History:
Father - colon cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 98.6 HR 64 BP 157/139 RR 17 SaO2 95% on RA
GEN: cachectic, in no acute distress, mildly somnolent, lying in
bed
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, nares patent, OP
clear
CV: RRR, nl S1/S2, no m/g/r
RESP: CTAB, no wheezing, crackles, or other adventitious breath
sounds
GI: NABS, nondistended, nontender, firm in bilateral lower
quadrants, no rebound/guarding
SKIN: no notable lesions, R IJ with dressing c/d/i
NEURO: A/Ox3 although mildly somnolent, moves all extremities
PSYCH: normal affect
DISCHARGE EXAM
***
Pertinent Results:
ADMISSION LABS:
===============
___ 09:10AM BLOOD WBC-11.9* RBC-3.26* Hgb-8.7* Hct-25.9*
MCV-79* MCH-26.7 MCHC-33.6 RDW-14.7 RDWSD-43.0 Plt ___
___ 09:10AM BLOOD Neuts-92.4* Lymphs-5.9* Monos-0.9*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-11.04* AbsLymp-0.70*
AbsMono-0.11* AbsEos-0.01* AbsBaso-0.02
___ 09:10AM BLOOD ___ PTT-27.4 ___
___ 09:10AM BLOOD Plt ___
___ 09:10AM BLOOD Glucose-75 UreaN-9 Creat-1.1 Na-143
K-2.4* Cl-109* HCO3-19* AnGap-15
___ 09:10AM BLOOD ALT-11 AST-19 AlkPhos-83 TotBili-0.6
___ 09:10AM BLOOD Albumin-2.4* Calcium-8.3* Phos-2.5*
Mg-2.0
___ 04:35PM BLOOD Calcium-7.6* Phos-2.1* Mg-1.8
___ 09:37AM BLOOD Lactate-4.2* K-2.4*
___ 11:51PM BLOOD Lactate-0.8 Creat-1.1 K-3.5
___ 11:51PM BLOOD freeCa-1.13
IMAGING:
=========
___ Imaging CHEST (PORTABLE AP)
Subtle linear opacities projecting over the right lower lung
field may be
secondary to overlap of vascular structures, rather than
consolidation.
If/when patient able, dedicated PA and lateral views would be
helpful for
further assessment.
___BD & PELVIS WITH CO
IMPRESSION:
1. Redemonstration of a large confluent lobulated pelvic mass
measuring 11.4 x 9.7 cm involving the sigmoid colon with an
intraluminal component. No evidence of obstruction.
2. Lack of intra-abdominal and subcutaneous fat limits exam,
however,
retroperitoneal and mesenteric fat appears a more radiodense
than expected, which may represent a small amount of mesenteric
ascites.
___ Imaging DX CHEST PORT LINE/TUBE
IMPRESSION:
The tip of a right internal jugular central venous catheter
projects over the distal SVC. No pneumothorax.
Discharge labs:
___ 06:40AM BLOOD WBC-6.1 RBC-3.06* Hgb-8.3* Hct-24.4*
MCV-80* MCH-27.1 MCHC-34.0 RDW-15.9* RDWSD-45.8 Plt ___
___ 03:15PM BLOOD Glucose-95 UreaN-5* Creat-0.8 Na-141
K-3.1* Cl-111* HCO3-23 AnGap-7*
___ 05:44AM BLOOD ALT-13 AST-25 AlkPhos-79 TotBili-0.3
___ 03:15PM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0
___ 11:24PM BLOOD calTIBC-160* Ferritn-129 TRF-123*
___ 11:24PM BLOOD 25VitD-6*
Brief Hospital Course:
HOSPITAL COURSE
================
___ with hx recurrent prostate cancer and HTN, who presents
with vomiting and diarrhea in the setting of colonoscopy prep,
found to be hypotensive with elevated lactate and fever
concerning for shock secondary to hypovolemia and sepsis.
___ w/ CAD (noted on PET scan), and prostate cancer s/p radical
prostatectomy with recurrence and known large pelvic mass with
possible colonic extension, currently receiving Lupron and
abiraterone who was admitted to the ICU with septic shock with
probable GI source, now improved and transferred to the floor.
ACUTE ISSUES
=======================
# Shock, hypovolemic vs. septic
# Fever
# Leukocytosis
# Vomiting/diarrhea
# Lactic acidosis - RESOLVED
Pt presents with acute on subacute diarrhea and vomiting as well
as fevers/chills and found to be in shock, responsive to fluids
but still requiring pressors in the ED. Likely etiology is both
hypovolemia in the setting of ongoing diarrhea and acute
vomiting due to prep, as well as possible sepsis given fever,
chills, leukocytosis, with possible GI source given invasion of
prostate cancer into bowel, but other less likely possible
sources include urine and lung. He was admitted to the ICU for
NE pressor support. He was given significant IVF and weaned off
pressors on ___ and transferred to the floor and completed a
week of IV antibiotics. All blood cultures remained negative.
He was hemodynamically stable throughout his stay on the general
medical floor.
#Prostate Cancer
#Pelvic Mass - malignant
Per e-mail exchange with outpatient oncology team at ___,
initially considered inpatient prep + inpatient colonoscopy
given difficulties preparing for it as outpatient, however in
discussion with GI and outpatient team, percutaneous ___ biopsy
was initially pursued, but it was very difficult to properly
position the patient. He ultimately had a sigmoidoscopy and
pathology shows adenocarcinoma and high grade villous adenoma.
His outpatient oncologist and PCP were emailed of these results,
and patient has f/u with them this week.
# ___
Baseline Cr 0.6 in ___. High of 1.3. Likely pre-renal from
hypovolemia and hypotension. He received IVF and his Cr improved
back to baseline.
# Subacute diarrhea - resolved
Pt endorses 2 weeks of nonbloody diarrhea (several loose stools
daily), with acute worsening in the setting of taking prep.
Infectious work up negative for C diff, campy, salmonella,
shigella.
# Hypokalemia
Seems to be chronic, possibly ___ HCTZ although this was
discontinued months ago. ___ be contribution of GI losses from
weeks of diarrhea. Unlikely to be nutritional component as pt
endorses good diet, although also has hypophosphatemia and low
albumin so may be malnutrition component. Takes daily potassium
supplementation outpatient. He was ultimately discharged on
supplemental potassium 60 mEQ and his outpatient providers were
emailed and asked to recheck this as an outpatient. Given
improvement in his diarrhea, and the fact that this is long
standing, it is suggestive of K wasting in the urine.
Outpatient providers can ___ further.
# Malnutrition
# Hypophosphatemia
Pt cachectic with hypoalbuminemia and electrolyte abnormalities
which may be ___ diarrhea/prep but also possible nutritional
component. His po intake improved substantially over the
course of his hospital stay.
CHRONIC ISSUES
=======================
# Prostate cancer
Continued home abiraterone. His outpatient oncologist was
notified and involved with inpatient management as above
Greater than ___ hour spent on care on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Potassium Chloride 10 mEq PO DAILY
2. abiraterone 1000 mg oral DAILY
3. Sildenafil 100 mg PO ASDIR
Discharge Disposition:
Home
Discharge Diagnosis:
1. Sigmoid mass
2. Anemia (stable)
3. Sepsis (resoved)
4. Low potassium
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital for low blood pressure and signs of
infection while preparing for colonoscopy at home.
You were treated in the intensive care unit with fluids through
the vein, antibiotics and special medicines to keep your blood
pressure in a safe range.
You had a sigmoidoscopy on ___ and biopsies were done of the
mass. You will get the results either from us or from Dr ___
___ you see her in followup.
Your potassium levels remains quite low - please take the higher
dose of potassium that we are prescribing to you and have your
potassium level rechecked. Your vitamin D levels are also low,
please take the vitamin D tablet once a week. I was unable to
send your prescriptions to ___ Electronically so
our RN is giving you prescriptions.
Followup Instructions:
___
|
19777866-DS-15
| 19,777,866 | 24,734,414 |
DS
| 15 |
2151-03-18 00:00:00
|
2151-03-18 15:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Motrin / Tylenol
Attending: ___
___ Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with the past medical
history of HTN, iron deficiency, prostate cancer s/p radical
prostatectomy with recurrence currently on Lupron and
abiraterone
and reportedly in remission; large pelvic mass (found in ___
with colonic extension, biopsy ___ showing new adenocarcinoma
and high grade villous adenoma, undergoing evaluation for XRT
presents to the ER with diarrhea. He was admitted ___ -
___
for shock from GI source and required an ICU stay. He had a
biopsy of the pelvic mass which later confirmed a concurrent
secondary malignancy for which he is undergoing evaluation with
medical and radiation oncology.
He has been having non-bloody diarrhea for the past 2 weeks, ___
times/day, associated with mild left-sided abdominal cramping,
and moderate to severe. He was seen by radonc today to discuss
treatment plan and found to be febrile and tachycardic and was
sent to the ER. He denies any fevers at home, chest pain,
nausea,
vomiting, shortness of breath, cough,
dysuria/hematuria/frequency, recent antibiotic use, but does
note
30 lb weight loss.
Vitals in the ER:
Yest 13:13 102.2 103 117/72 18 100% RA
Today 10:02 98 73 97/59 16 97% RA
There, the patient received:
___ 17:55 PO Acetaminophen 1000 mg
___ 17:55 PO Potassium Chloride 40 mEq
___ 18:43 IVF 40 mEq Potassium Chloride / NS
___ 21:02 IV Ciprofloxacin 400 mg
___ 22:23 IVF 40 mEq Potassium Chloride / NS
___ 22:23 IV MetroNIDAZOLE 500 mg
___ 23:07 PO Potassium Chloride 40 mEq
___ 23:07 IVF 40 mEq Potassium Chloride / NS
___ 02:14 IVF NS 1000 mL
___ 02:14 IVF 40 mEq Potassium Chloride / NS
___ 08:06 PO/NG Vancomycin Oral Liquid ___ mg
___ 08:06 PO Potassium Chloride 40 mEq
___ 09:52 IV MetroNIDAZOLE 500 mg
___ 09:58 IV Ciprofloxacin (400 mg ordered)
___ 10:42 IVF 40 mEq Potassium Chloride / NS
___ 10:50 IV Magnesium Sulfate (4 gm ordered)
Past Medical History:
- Prostate cancer: s/p radical prostatectomy ___, staging at
that time: pathologic T2c, N0, M0, but had rising PSA after
surgery. Was seen here in ___ at which time radiation and ADT
were recommended, but pt declined treatment and was lost to
follow-up. Re-presented in ___ to ___ at which time PSA 136
and he was started on abiraterone and Lupron injections at that
time. He received 1 Lupron injection so far in ___. PET scan
___ showing large (12cm) soft tissue mass in pelvis c/w
recurrent disease, w/o e/o metastases. There was apparently
concern for invasion into colon vs. other colon mass, thus he
was
planned for colonoscopy for further evaluation.
- HTN
- Bilateral hernia repair in ___
- Severe LAD coronary artery calcification noted on PET scan
___
Social History:
___
Family History:
Father - colon cancer
Physical Exam:
ADMISSION EXAM:
VITALS: T 98 79 104/62 18 95% RA
GENERAL: Alert and in no apparent distress; cachectic
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate, dry
CV: Heart regular rate; normal perfusion, no appreciable JVD
RESP: Symmetric breathing pattern with no stridor. Breathing is
non-labored
GI: Abdomen soft, non-distended, mass palpable in abdomen, no
hepatosplenomegaly appreciated.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, normal muscle tone, low bulk
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: normal thought content, logical thought process,
appropriate affect
===========================
DISCHARGE EXAM:
___ 0737 Temp: 97.6 PO BP: 115/72 HR: 68 RR: 18 O2 sat:
100% O2 delivery: Ra
GENERAL: Alert and in no apparent distress, appears comfortable,
cachectic appearance, conversant
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Moist
mucus membranes.
CV: RRR, no murmur, no S3, no S4. 2+ radial pulses bilaterally.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored on room air.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No Foley
MSK: Moves all extremities, no edema or swelling
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: Pleasant, appropriate affect
Pertinent Results:
LABS ON ADMISSION:
___ 03:20PM BLOOD WBC-10.1* RBC-3.49* Hgb-9.5* Hct-27.8*
MCV-80* MCH-27.2 MCHC-34.2 RDW-16.8* RDWSD-48.2* Plt ___
___ 03:20PM BLOOD Neuts-74.6* Lymphs-17.6* Monos-6.4
Eos-0.4* Baso-0.3 Im ___ AbsNeut-7.52* AbsLymp-1.77
AbsMono-0.64 AbsEos-0.04 AbsBaso-0.03
___ 04:55PM BLOOD ___ PTT-29.2 ___
___ 03:20PM BLOOD Glucose-102* UreaN-10 Creat-0.9 Na-135
K-2.5* Cl-102 HCO3-21* AnGap-12
___ 03:20PM BLOOD Calcium-8.3* Phos-3.4 Mg-1.6
___ 03:42PM BLOOD Lactate-2.2*
___ 10:50PM BLOOD Glucose-90 Lactate-1.1 K-2.5*
___ 06:10PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 06:10PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM*
___ 06:10PM URINE RBC-2 WBC-8* Bacteri-FEW* Yeast-NONE
Epi-1
___ 06:10PM URINE CastHy-1*
___ 06:10PM URINE Mucous-RARE*
========================
LABS ON DISCHARGE:
___ 11:17AM BLOOD WBC-6.9 RBC-2.73* Hgb-7.5* Hct-22.1*
MCV-81* MCH-27.5 MCHC-33.9 RDW-17.0* RDWSD-49.8* Plt ___
___ 11:17AM BLOOD Glucose-77 UreaN-7 Creat-0.8 Na-137
K-3.3* Cl-107 HCO3-21* AnGap-9*
___ 11:17AM BLOOD Calcium-7.9* Phos-3.2 Mg-1.7
___ 09:53PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 09:53PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD*
___ 09:53PM URINE RBC-14* WBC-16* Bacteri-NONE Yeast-NONE
Epi-<1
___ 09:53PM URINE CastHy-2*
___ 09:53PM URINE Mucous-RARE*
========================
MICROBIOLOGY:
Blood cultures x2 ___: PENDING - NGTD
Urine culture ___: >100,000 CFU/mL E. coli
C. difficile ___: Positive
========================
CXR ___:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
Mr. ___ is a ___ male with HTN, iron deficiency,
prostate cancer s/p radical prostatectomy with recurrence
currently on Lupron and abiraterone and reportedly in remission;
large pelvic mass (found in ___ with colonic
extension, biopsy ___ showing new adenocarcinoma and high
grade villous adenoma, undergoing evaluation for XRT. He was
sent to ED from radiation oncology after he was found to have
fever and tachycardia and had 2 weeks of diarrhea and was found
to have C. difficile.
#Severe sepsis - Initially he was febrile, tachycardic,
hypotensive and found to have C. difficile infection. Sepsis
resolved quickly. Lactate was elevated to 2.2.
#C. difficile infection/diarrhea: He was having frequent loose,
non-bloody stool. He got IV fluids with KCl. He was started on
oral Vancomycin 125mg PO QID on ___ and will finish on
___. He was tolerating oral intake and only having ___
bowel movements per day that were becoming formed.
#Hypokalemia, hypomagnesemia, hypophosphatemia: These were
secondary to GI losses and resolved with repletion, except for K
was 3.3 prior to discharge (given 40meq KCl prior to leaving).
He will continue his prior to admission KCl daily and should
have labs rechecked on/around ___.
#E. coli bacteriuria: Initial UA was not concerning for
infection but urine culture was sent and grew >100,000 CFU/ml E.
coli. He denied urinary symptoms and fever and sepsis were
likely due to C. difficile infection. Since he was having
diarrhea, he could have had some contamination since E. coli in
urine. Repeat UA was not consistent with infection. He was not
started on treatment for UTI since asymptomatic.
#Prostate Cancer - Continue Lupron, abiraterone, and prednisone.
He needs ___ medical oncology follow up upon discharge.
#Colon adenocarcinoma- Pelvic Mass found to be adenocarcinoma
and high grade villous adenoma (malignant): Per patient, he is
working with his medical oncologist. Plan is to do XRT to
shrink the mass and then possible surgical removal. Will need
outpatient medical and radiation oncology follow up. Dr. ___
is his radiation oncologist.
#Severe protein calorie malnutrition - Weight loss of 57.8 to
52.3 kg over past 1 month, in setting of two malignancies. Added
Ensure to regular diet and nutrition was consulted. Weight was
53.25kg on discharge.
#Iron deficiency anemia: Hb was 9.5 on admission and down to 7.5
on ___, but likely reflects some degree of hemoconcentration in
setting of diarrhea and then got IV fluids. Baseline Hb is
around 8.0 over past 1 month and was stable at 7.5 on discharge.
Stool does not appear bloody. He was continued on home iron.
TRANSITION OF CARE ISSUES:
- Repeat BMP, Mg, Phos, CBC on/around ___
- Follow up with PCP, medical and radiation oncology
- Complete total of 10 days of oral vancomycin - to finish on
___
Check if applies: [ X ] Mr. ___ is clinically stable for
discharge today. The total time spent today on discharge
planning, counseling and coordination of care today was greater
than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Vitamin D ___ UNIT PO 1X/WEEK (MO)
3. Sildenafil 100 mg PO DAILY:PRN sex
4. abiraterone 500 mg oral BID
5. Potassium Chloride 60 mEq PO DAILY
6. PredniSONE 5 mg PO DAILY
7. Hydrocortisone Cream 1% 1 Appl TP BID:PRN hemorrhoids
8. omeprazole-sodium bicarbonate ___ mg-gram oral DAILY
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*10 Tablet Refills:*0
2. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin [Firvanq] 25 mg/mL 5 ml by mouth four times a day
Disp ___ Milliliter Refills:*0
3. abiraterone 500 mg oral BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Hydrocortisone Cream 1% 1 Appl TP BID:PRN hemorrhoids
6. omeprazole-sodium bicarbonate ___ mg-gram oral DAILY
7. Potassium Chloride 60 mEq PO DAILY
8. PredniSONE 5 mg PO DAILY
9. Vitamin D ___ UNIT PO 1X/WEEK (MO)
10. HELD- Sildenafil 100 mg PO DAILY:PRN sex This medication
was held. Do not restart Sildenafil until you discuss with your
primary doctor, as this can lower your blood pressure, which we
want to avoid while recovering from infection
Discharge Disposition:
Home
Discharge Diagnosis:
C. difficile infection
Hypokalemia
Hypomagnesemia
Hypophosphatemia
Sepsis
E. coli bacteriuria
Iron deficiency anemia
Severe malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were hospitalized with fever, low blood pressure and fast
heart rate and found to have an infection called C. difficile
infection. You had diarrhea that led to fluid losses and this
led to hydration. You were started on antibiotics that you will
continue at home. Drink plenty of water and stay well hydrated.
Please see your primary doctor early this upcoming week and have
potassium level checked, as this can be low if you have ongoing
diarrhea.
Followup Instructions:
___
|
19777874-DS-5
| 19,777,874 | 25,401,731 |
DS
| 5 |
2110-09-20 00:00:00
|
2110-09-22 22:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Polysubstance withdrawal
Major Surgical or Invasive Procedure:
Insertion of right basilic ___ peripherally inserted
central catheter
History of Present Illness:
___ year old male with history of polysubstance abuse presents
from jail for nausea, vomiting and diarrhea. Patient reports
last using multiple drugs 3 days ago including Oyxocodone,
Methadone, Klonopin, Cocaine, and EtOH. Yesterday he developed
nausea, vomiting, diarrhea, tremors, diaphoresis and visual
hallucinations. He was sent to ___. He was given 3L NS,
valium 5mg x2, ativan 1mg x1, clonidine 0.5mg x1. He was noted
to have leukocytosis of 26.8, HCT 55, Cl 89, HCO3 31, BUN/Cr
109/5.7. An EKG demonstrated QTc of 574ms.
He was then transferred to ___ for further care.
Initial vitals on arrival: 100.1F 90 140/83 18 97% on room air
In the ED he received an additional 3L of NS, 2mg Ativan x2,
40meq KCl. He was given Vancomycin and Cefepime,
thiamine/folate. Repeat laboratory testing includes:
___ Ca: 8.8 Mg: 3.2 P: 5.2
2.9/___/3.3
Lactate 2.3
ALT 47, AST 29, AP 55, TBili 1.2, Alb 4.2, Lip 85
STox: Negative
UTox: Negative
BCx: NGTD on ___
Past Medical History:
IVDA
Polysubstance abuse
Social History:
___
Family History:
___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- T:99.3 BP:134/62 P:89 R: 16 O2:98% RA
GENERAL: Sleepy, awakes to verbal stimuli
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, ___, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: warm, dry. No ___ lesions ___ nodes.
NEURO: ___, pupils 4->3 bilaterally, +tremor
DISCHARGE PHYSICAL EXAM:
Tx vitals: 98.5 144/64 75 20 98RA
GENERAL: NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, ___, bowel sounds present, no rebound
tenderness or guarding, no organomegaly. Tender to palpation,
but not with palpation using stethoscope.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: warm, dry
NEURO: A&Ox3, pupils 4->3 bilaterally, +tremor
Pertinent Results:
ADMISSION LABS:
___ 10:30PM BLOOD ___
___ Plt ___
___ 10:30PM BLOOD ___
___
___ 02:37AM BLOOD ___ ___
___ 10:30PM BLOOD ___
___
___ 10:30PM BLOOD ___
___ 10:30PM BLOOD ___
___ 10:57PM BLOOD ___
PERTINENT LABS THROUGHOUT HOSPITAL STAY:
___ 05:11PM BLOOD ___
___
___ 02:37AM BLOOD ___ cTropnT-<0.01
___ 02:37AM BLOOD ___
___ 06:30AM BLOOD ___
___ 02:37AM BLOOD ___
___
___ 06:30AM BLOOD ___
___
___ 06:30AM BLOOD ___ ___
___ 02:37AM BLOOD ___
___ Plt ___
___ 06:30AM BLOOD ___
___ Plt ___
DISCHARGE LABS:
XXXXXXXXXXXXXXXXXXXXXXXX
IMAGING STUDIES:
Transthoracic Echocardiography (___):
No echocardiographic evidence of endocarditis. Normal regional
and global biventricular systolic function. If clinically
indicated, a transesophageal echocardiogram may better assess
for valvular vegetations.
CXR (___):
Heart size is within normal. There is no focal consolidation,
pneumothoraces or pleural effusion. There is minimal
atelectasis at the left lung base.
CT CHEST W/O CONTRAST (___):
IMPRESSION:
1. Nodular opacities in the left lower lobe in ___
distribution,
suggestive of infection, inflammation or aspiration. No focal
consolidation or pleural effusion.
2. Abdominal findings are reported separately
CT ABD AND PELVIS W/O CONTRAST (___)
1. Limited assessment due to lack of intravenous contrast.
Within this
limitation, no acute CT findings to account for patient's
clinical
presentation.
2. Small hiatal hernia.
CXR (___):
There has been placement of a ___ PICC line with distal
lead tip at the cavoatrial junction. The heart size is within
normal limits. Lungs are clear. There are no pneumothoraces.
MICROBIOLOGY:
Blood Cultures (___): Pending
Blood Cultures (___): Pending
Urine Culture (___): NGTD
Brief Hospital Course:
___ year old male with history of polysubstance abuse presenting
with signs of withdrawal and prolonged QTc to 620 ___s
___, hypokalemia and hypernatremia.
# MICU Course
Patient was placed on telemetry throughout MICU stay. All
medications known to prolong QTc (methadone, zofran) were
discontinued and serial EKGs were performed. QTc on the second
day of admission was 455 and it had normalized to 429 by the
third day. He was also given potassium repletion and D5W to
correct his hypernatremia of 153. CIWA scale was initially in
place due to concern over alcohol withdrawal, however this was
discontinued due to concern for malingering in addition to the
long half life of the valium he had already received.
Blood cultures were drawn at admission but remain NGTD. A
transthoracic echo revealed no sonographic evidence of
endocarditis. A CT abdomen and pelvis was unremarkable except
for a small hiatal hernia. CT chest revealed some evidence of
aspiration/infection, however given lack of fever, cough and
downtrending ___ count it was felt that this was reactive rather
an infectious process and antibiotics were discontinued.
The patient continued to experience nausea and vomiting
throughout his stay in the MICU which responded to IV zofran and
intravenous fluids. He was subsequently transferred to the floor
for further care.
# Polysubstance abuse- reported multiple drugs use 3 days ago
including Oxycodone, Klonopin, Methadone, Heroin, Cocaine, and
EtOh. Symptoms of with drawl (pain and nausea) are delayed
onset. No seizure activity. QTc normalized in ___ of ___: 455.
He was initially on CIWA while in the ICU, this was discontinued
as he had no clinical evidence of alcohol withdrawal.
# Leukocytosis- unclear etiology. Initial concern for
endocarditis given IVDU. No NEW of back pain/neuro sx's,
bone/joint pain to suggest osteo or epidural abscess, however
endorses baseline pain so we continued to reassess as patient is
at high risk. No skin abscess on exam. Vanc/Cefepime given in
ED. No major Dukes criteria met in absence of murmur or
bacteremia. Transthoracic eco was normal. Leukocytosis improved
off antibiotics and cultures were no growth at time of
discharge.
# ___- Hypernatremia with Cr to 2.5. Patient has no known
underlying renal disease, Cr up to 2.5 on presentation. Cr
normalized to 0.9.
# Hypernatremia: Na to 153 ___ with improvement in
UOP.
#Hypokalemia - Potassium and magnesium were repleted and close
to normal at time of discharge. He should continue potassium
supplementation as outpatient to replete his total body stores.
# QT prolongation- initially 574 at ___, now improved to
455 on repeat. Possibly due to methadone overuse. This should
improve with further holding of methadone.
On the morning of discharge, Pt had multiple syncopal episodes
this AM wherein he became unresponsive for ___ minutes. Officers
in the room reported that Mr. ___ claimed "something doesn't
feel right" and then became unresponsive. The team responded and
found Mr. ___ lying supine in bed unresponsive to verbal
stimuli. Upon trying to open his eyes, he resisted, something a
truely unconscious person is unable to do. He became fully
interactive after 3 minutes with no postical state. No tonic
clonic movements, loss of bowel or bladder, or vital sign
abnormalities occured. According to Mr. ___, "it felt like
pins and needles rushing up through my body...and it was like it
just exploded out of my face." These episodes were felt to be
consistent with psychogenic syncope. Psychiatry was consulted to
see patient, no change in management recommended.
# Transitional Issues
- The patient's methadone was held while in patient in
accordance with recommendations from Toxicology. Additionally,
they recommended that he be considered for buprenorphine therapy
instead of methadone if a ___ opioid is to be
reinitiated.
- Please place patient on prison clonidine withdrawal protocol
- Please check full electrolyte panel (including K and P) on ___
to assess if electrolyte repletion is still required or if
additional doses are needed
- Upon release from jail, please communicate disposition with
PCP
- ___ PO intake
- Suggest repeating EKG on ___ to ensure QTc trending down,
especially if receiving zofran (discharge QTc 450)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. DiCYCLOmine Dose is Unknown PO Frequency is Unknown
2. CloniDINE Dose is Unknown PO Frequency is Unknown
3. Prochlorperazine Dose is Unknown PO Frequency is Unknown
4. Chlordiazepoxide HCl Dose is Unknown PO Frequency is Unknown
5. Ibuprofen Dose is Unknown PO Frequency is Unknown
6. Ondansetron Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
2. ___ Hydrox.-Simethicone ___ mL PO QID:PRN Gi
upset
3. Potassium Chloride 40 mEq PO DAILY Duration: 3 Days
Hold for K >4.5
RX *potassium chloride [___] 20 mEq 1 tablet(s) by mouth daily
Disp #*3 Tablet Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting
5. Phosphorus 500 mg PO BID
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Polysubstance abuse
Opioid Withdrawal
Hypokalemia
Dehydration
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were transferred to us from an outside hospital in what our
toxicoligists determined, was opioid withdrawal. You had changes
in your electrolytes, kidney function, and white blood count,
all of which were treated and have now normalized. The symptoms
you are now experiencing (diarrhea, muscle aches, stomach
cramps) are the result of heroin and methadone withdrawal. These
symptoms will slowly resolve with time. From a medical
standpoint, you are in stable condition and we recommend a drug
rehabilitation program for your longterm health.
We have stopped your methadone as it caused toxicity to your
heart. Your outpatient providers can determine if you require
additional opiate replacement such as suboxone.
We have discharged you on potassium and phosphate replacement as
your levels were low.
Followup Instructions:
___
|
19777911-DS-12
| 19,777,911 | 21,390,181 |
DS
| 12 |
2168-06-13 00:00:00
|
2168-06-14 09:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right-sided weakness
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
The patient is a ___ year-old right-handed ___ woman with
MDS/AML s/p cord blood transplant, prior left MCA stroke (in
___
while plts >700), who presents to the ED with right-sided
weakness for the past 3 days. History is obtained via
translation from the patient's daughters.
For the past week, the patient had a cold with a cough
productive
of creamy white-yellow phlegm, fever to ___, and general
malaise. The patient had decreased po intake as well. She had
no trouble moving her body until ___ morning when she awoke
unable to move the right arm and leg because of weakness. She
was not able to hold objects in the right hand and the righ leg
weakness prohibited walking or even lifting the leg off the bed.
Since she was sick and in bed most of the week, medical
attention
was not sought until today.
Of not the patient did have a left MCA stroke in ___ in the
setting of thrombocytosis to 700. Per her daughter, her symptoms
at that time were of confusion and calling her family members
the
wrong name and saying some incorrect words. Beyond that the
details are unclear at this time. It is clear, however, that
there was no weakness at that time or at other times in her
past.
While, right hemianopia was noted at subsequent Neuro-Onc
evaluations (by Dr. ___ in ___ this was not endorsed by
the
patient in history of this stroke.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies focal numbness, parasthesia. Denies loss of
sensation. Denies bowel or bladder incontinence or retention. No
rigors, night sweats, or noticeable weight loss. Denies chest
pain, palpitations. Denies nausea, vomiting, diarrhea,
constipation, or abdominal pain. No recent change in bowel or
bladder habits. Denies dysuria or hematuria. Denies myalgias,
arthralgias, or rash.
Past Medical History:
1. MDS/AML, s/p induction chemo w/ 7+3, and cord blood
transplant
2. Stroke, LMCA (in the setting of thrombocytosis) ___
3. Peptic ulcer disease
4. Depression
5. Central retinal vein occlusion, right
6. Pars plana vitrectomy, lens removal, left
7. s/p Appendectomy
8. Thalassemia trait
9. Chronic back pain
Social History:
___
Family History:
She has two healthy daughters. Her only sister died at age ___.
Her mother died at ___ and her father died in his ___ with
unknown
circumstances
Physical Exam:
Vitals: 99.4 79 132/62 18 99%
General: appears older than stated age, frequent coughing, NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: Basilar crackles and rhonchi, with crackles ___ way
up
lung field on left.
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: 1+ pitting edema to knees bilaterally
Neurologic Examination:
Awake, alert, oriented x 3. Able to relate history without
difficulty. Attentive. Speech is fluent with full sentences,
intact repetition, and intact verbal comprehension. Naming
intact
(knuckles, thumb, elbow, glasses). Per daughter, there is no
dysarthria or paraphasias and prosody is normal. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
- Cranial Nerves - PERRL 3->2 brisk. ? Right upper
quadrantanopsia, although VF exam is made difficult by
translation. EOMI, no nystagmus. V1-V3 without deficits to
light
touch bilaterally. Right nasolabial fold flattening, but
symmetric activation. Hearing intact to finger rub bilaterally.
Palate elevation symmetric. Weak shoulder shrug on the right.
Tongue midline.
- Motor - Normal bulk. Slightly decreased tone on the right
arm.
Normal tone elsewhere. Right arm drifts downward and hits bed.
No tremor or asterixis.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ 5 5 4 5 5 5 5 5
R 2+ 4 3+ ___ 2 4 2 3+ 4 2
- Sensory - No deficits to light touch, pin bilaterally. No
exinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 tr 1
Plantar response upgoing on right, flexor on left. No clonus
- Coordination - No dysmetria with finger to nose testing on
left. Weakness on right limits testing. Weakness also limits
coordination testing on right and.
- Gait - deferred
On discharge the patient's exam is signficant for the above with
the following changes
CN: visual fields are full to confrontation
Motor:
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ 5 5 4+ 5 5 5 5 5
R 4 ___- 5 4 4 5 4+ 4+ 5 4+
Sensory: mild decrease to LT and pin on the right hemi-body
Pertinent Results:
___ 06:00AM BLOOD WBC-11.2* RBC-3.41* Hgb-11.9* Hct-33.8*
MCV-99* MCH-34.7* MCHC-35.1* RDW-12.7 Plt ___
___ 07:05PM BLOOD Neuts-66.8 ___ Monos-7.3 Eos-1.8
Baso-0.3
___ 06:00AM BLOOD ___ PTT-37.4* ___
___ 07:05PM BLOOD Glucose-102* UreaN-17 Creat-1.1 Na-146*
K-4.0 Cl-108 HCO3-22 AnGap-20
___ 07:05PM BLOOD ALT-46* AST-40 AlkPhos-96 TotBili-0.4
___ 07:05PM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 06:00AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.1
___ 06:15AM BLOOD %HbA1c-5.5 eAG-111
___ 06:15AM BLOOD Triglyc-162* HDL-35 CHOL/HD-4.7
LDLcalc-98
___ 06:15AM BLOOD TSH-0.77
___ 07:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:05PM URINE RBC-1 WBC-9* Bacteri-FEW Yeast-NONE Epi-0
___ 07:05PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ CT/CTA
1. No evidence of acute intracranial abnormalities. MRI would
be more
sensitive for an acute infarction, if clinically warranted.
2. Chronic left middle cerebral artery territory infarct
involving the left parietal lobes, as seen on prior studies.
Progression of global cerebral volume loss since ___.
3. Focal high-grade stenoses of the proximal inferior division
of the left middle cerebral artery and proximal P2 segment of
the right posterior cerebral artery. Irregularity and mild
narrowing of the proximal A2 segment of the left posterior
cerebral artery. Allowing for differences in technique, these
stenoses appear to have been present on contrast enhanced MPRAGE
sequences from MRIs dated ___ and ___.
Their chronicity is consistent with sequela of atherosclerotic
disease.
4. New opacification of the paranasal sinuses compared to CT
from ___. Please correlate with symptoms.
5. Mildly enlarged 1.9 cm right level IIA lymph node. Mildly
enlarged 1.3 cm precarinal lymph node and several prominent 9 mm
right paratracheal lymph nodes. Please correlate clinically.
6. 2 cm calcified left thyroid nodule. While ultrasound will
demonstrate extensive shadowing due to the calcification within
this nodule, it it could be attempted to evaluate for any
potential noncalcified soft tissue components.
___ MRI
1. A new focus of slow diffusion measuring 5 x 12 mm with
corresponding high signal on T2 and FLAIR in the posterior limb
of the left internal capsule is consistent with a subacute
infarct.
2. Diffuse extensive opacification of the paranasal sinuses
including an
air-fluid level in the right maxillary sinus is new compared to
the prior
study of ___ and is likely inflammatory.
3. Stable appearance of chronic infarcts and ventriculomegaly.
___ ECHO
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thicknesses and
cavity size are normal. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Doppler parameters are indeterminate for left
ventricular diastolic function. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve is
bicuspid. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity size and regional/global systolic function. Normal
diastolic function. Mild mitral regurgitation. Mild aortic
regurgitation. No evidence of intracardiac shunting.
Brief Hospital Course:
Mrs ___ is a ___ year-old right-handed woman with AML s/p cord
blood transplant now in remission and a prior left MCA stroke,
who presented to the ED with 3 days of right-sided weakness in
the setting of an upper respiratory illness and fevers.
Neurological examination reveals right NLFF but normal facial
activation, weakness of the right arm and leg in an upper motor
neuron pattern, right upgoing toe. MRI shows an acute
thalamocasular ischemic stroke on the left, which correlates
well with her symptoms. ECHO was unchanged from prior. CTA did
show multiple areas of intracranial vascular disease. The
patient was started on high intensity statin and plavix.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented (required for all patients)? (x) Yes (LDL =
98) - () No
5. Intensive statin therapy administered? (x) Yes - () No [if
LDL >= 100, reason not given: ____ ]
(intensive statin therapy = simvastatin 80mg, simvastatin
80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin
20mg or 40mg, for LDL >= 100)
6. Smoking cessation counseling given? () Yes - (x) No [if no,
reason: (x) non-smoker - () unable to participate]
7. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100
or on a statin prior to hospitalization, reason not discharged
on statin: ____ ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No [if no, reason not
discharge on anticoagulation: ____ ] - (x) N/A
Medications on Admission:
1. Acyclovir 400 mg PO Q8H
2. FoLIC Acid 1 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO TID
4. Multivitamins 1 TAB PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Acyclovir 400 mg PO Q8H
3. FoLIC Acid 1 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO TID
5. Multivitamins 1 TAB PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Clopidogrel 75 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ACUTE ISCHEMIC STROKE
UTI
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 ___ were hospitalized due to symptoms of right sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition in which a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed ___ for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- history of cancer
We are changing your medications as follows:
- started plavix
- stop aspirin
- start atorvastatin
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If ___ experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
___
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- 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 ___ with care during this
hospitalization.
Followup Instructions:
___
|
19778133-DS-7
| 19,778,133 | 20,287,154 |
DS
| 7 |
2154-12-11 00:00:00
|
2154-12-14 16:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ woman with a history of h/o lupus,
multiple vascular risk factors, and headaches who presents to
the ED for a second evaluation of a persistent headache. She has
had this headache for 3 weeks. It is different than her typical
headaches and it is severe.
She has had headaches since age ___. Her typical headaches are
bilateral non-throbbing headaches in the front and back of her
head. They are not associated with nausea, vomiting, or
photophobis. She gets these weekly and is on nortriptyline for
ppx, though this is not helping much. She previously tried
topiramate for ppx but did not have much success with this
either.
For the past three weeks she has been getting daily headaches.
The headache is unilateral in the right temple and throbbing. It
comes and goes. It is worse whenever she stands up and walks
around - "10+" out of 10. It is relieved some by sitting and
lying down to ___. When asked if the headaches are waking her
from sleep, she endorses this. She has never had a headache like
this before. This morning she had associated nausea and vomiting
as well.
She also reports an episode of vision loss today. She was at
work, sitting on the toilet (though not straining) and had
transient loss of vision where "everything looked dark for one
minute." She thinks it was just in her right eye (though didn't
cover one eye to confirm). She had difficulty remembering
details and said it may have been her entire vision w/both eyes.
She had concurrent nausea.
She also reports right eye burning pain and 20 pound weight loss
in the past month. She had some tinnitus last week but none more
recently.
Past Medical History:
Hypertension
Depression
Obesity
Positive PPD, treated
Hypercholesteremia
GERD (gastroesophageal reflux disease)
Vitamin D deficiency
nephropathy
Type 2 diabetes mellitus
Hypothyroidism
migraine without aura
SLE (systemic lupus erythematosus)
Genital Herpes
Social History:
___
Family History:
- father with HTN, DM
- grandfather with stroke
- mother with migraine
Physical Exam:
On admission:
General: tearful, appears uncomfortable
HEENT: +photophobia, especially in right eye
Neck: no meningismus. negative kernig and brudzinski
Pulmonary: breathing comfortably on RA
Abdomen: obese
Extremities: no edema, warm
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Alert, oriented. Able to relate history without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. Pt. was able to name high
frequency items (chair, watch, thumb) but not low frequency
items (watch face, watch band, feather, hammock, cactus). She
called watch band a "brace." Described the cookie jar picture
with very little detail. Attentive, able to name ___ backward
without difficulty. There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 6 to 4mm bilaterally (in dim room). VFF to
confrontation with finger wiggling tested in each eye
separately; without extinction to DSS visually. Funduscopic exam
revealed no papilledema.
III, IV, VI: EOMI without nystagmus. No ptosis.
V: Facial sensation intact to light touch and temp in all
distributions, decreased to pinprick in all distributions.
VII: No facial droop with symmetric upper and lower facial
musculature bilaterally
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XI: full strength in trapezii bilaterally.
XII: Tongue protrudes in midline with full ROM right and left
-Motor: ?BLE spasticity (vs. pt not relaxing). No pronator drift
bilaterally. No tremor noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 3+ 2
R 2+ 2+ 2+ 3 2
- Toes were mute bilaterally.
- Crossed adductors were present and pec jerks were absent bilat
-Sensory: Has decreased pinprick sensation on face (50%),
anterior chest, arms (30%) and legs compared to upper paraspinal
region. No pinprick level on back, but endorses increase in PP
sensation lower on her back. Temperature sensation is intact on
her face, but decreased in her arms and legs bilaterally.
Position and vibration sense is intact in all extremities.
-Coordination: No dysmetria on FNF bilaterally. Rapid
alternating movements with normal and symmetric cadence and
speed.
-Gait: Good initiation. Narrow-based, normal stride. Able to
walk in tandem and on toes and heels without difficulty. Romberg
absent.
On discharge: exam unchanged from admission exam
Pertinent Results:
___ 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:00PM NEUTS-67.5 ___ MONOS-6.7 EOS-1.1
BASOS-0.4 IM ___ AbsNeut-5.69# AbsLymp-2.03 AbsMono-0.56
AbsEos-0.09 AbsBaso-0.03
___ 08:00PM WBC-8.4# RBC-4.48 HGB-13.7 HCT-40.2 MCV-90
MCH-30.6 MCHC-34.1 RDW-12.2 RDWSD-39.4
___ 08:00PM URINE UCG-NEGATIVE
___ 08:00PM GLUCOSE-75 UREA N-18 CREAT-1.3* SODIUM-137
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-26 ANION GAP-15
___ 06:14AM TRIGLYCER-66 HDL CHOL-56 CHOL/HDL-3.4
LDL(CALC)-120
___ 06:14AM %HbA1c-5.4 eAG-108
___ 06:14AM TSH-___*
MRI/MRA brain:
1. Multiple small white matter lesions, predominantly in the
frontal lobes,
likely secondary to patient's known lupus. No acute infarct.
2. A 2 mm anteriorly oriented outpouching off of the right
inferior M2 branch,
which is likely an infundibulum. The possibility of a small
aneurysm cannot
be excluded. . Otherwise, normal MRA of the brain.
3. Normal MRA of the neck.
Brief Hospital Course:
___ is a ___ woman with a history of lupus and chronic
headaches, who presented to the ED with a severe HA that has
been present for the past 3 weeks and is different in quality to
her typical headaches. Headache is right sided, lasts ___ min
each time, can occur up to 6 ___ in a day. Associated with
sharp stabbing pain in right temple with associated right eye
tearing and the right side of her face feeling hot. Denies runny
nose. Also has baseline migraine headache for which she is on
nortriptyline. She was diagnosed with SUNCT headache and started
on verapamil and indomethacin. Indomethacin greatly relieved her
right sided headaches. She was discharged later in the day once
the headaches improved. Her blood pressure medications were
adjusted as she was started on verapamil to prevent hypotension.
She was counseled extensively on not using a lot of indomethacin
as it can cause renal problems.
Transitional issues:
1. F/u with PCP to titrate BP medications. Home amlodipine was
stopped and labetalol was halved to 100mg po BID. Started on
verapamil SR.
2. Have PCP ___ FT4 level as her TSH was 75. She may require
more levothyroxine
3. Have PCP draw antiphospholipid antibodies (lupus
anticoagulant) to evaluate for stroke risk
4. Will likely need a new prophylactic migraine agent as
nortriptyline does not seem to be working (still having 1
migraine/week at baseline)
5. Refer to neurologist
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Hydroxychloroquine Sulfate 400 mg PO DAILY
2. MetFORMIN (Glucophage) 850 mg PO BID
3. Amlodipine 5 mg PO DAILY
4. Labetalol 200 mg PO BID
5. Nortriptyline 150 mg PO QHS
6. Simvastatin 10 mg PO QPM
7. Omeprazole 20 mg PO DAILY
8. Levothyroxine Sodium 175 mcg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. PredniSONE 10 mg PO DAILY
11. Ferrous GLUCONATE 324 mg PO DAILY
Discharge Medications:
1. Ferrous GLUCONATE 324 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Hydroxychloroquine Sulfate 400 mg PO DAILY
4. Labetalol 100 mg PO BID
5. Levothyroxine Sodium 175 mcg PO DAILY
6. MetFORMIN (Glucophage) 850 mg PO BID
7. Nortriptyline 150 mg PO QHS
8. Omeprazole 20 mg PO DAILY
9. PredniSONE 10 mg PO DAILY
10. Acetaminophen 650 mg PO Q6H:PRN headache
11. Verapamil SR 120 mg PO Q24H
RX *verapamil 120 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
12. Simvastatin 10 mg PO QPM
13. Indomethacin 25 mg PO TID:PRN headache
RX *indomethacin 25 mg 1 capsule(s) by mouth three times a day
Disp #*42 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
SUNCT headaches, migraine headaches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro: non-focal
Discharge Instructions:
Dear Ms. ___,
You were admitted for a new headache called a short-lasting
unilateral neuralgiform headache (aka SUNCT) in addition to
migraines. You have had an underlying migraine, and the SUNCT
headaches (the episodes that last for ___ minutes and are
sharp and stabbing in the right side of your temple associated
with facial flushing and your eye feeling hot/teary) are
additional headaches. The SUNCT headaches have responded nicely
to indomethacin. This is a medication you can use to stop the
SUNCT headaches. Please do not take more than 3 times per day as
they can injure your kidneys.
You were also started on verapamil, which is a blood pressure
medication, to help prevent these headaches. Please decrease
your dose of labetalol to 100mg from 200mg to prevent your blood
pressure from going too low. Please also stop amlodipine.
Please follow up with your primary care physician, who will
refer you to a neurologist to get better control of your
headaches. Do not take ibuprofen for your headaches as this can
cause kidney injury given that you currently have lupus. You can
take Tylenol as needed, but do not take more than 4000mg per day
and do not take this more than 3 days in 1 week or you will get
additional headaches called medication overuse headaches.
It was a pleasure taking care of you, and we wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19778204-DS-20
| 19,778,204 | 21,542,859 |
DS
| 20 |
2128-03-25 00:00:00
|
2128-03-29 16:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right upper quadrant pain
Major Surgical or Invasive Procedure:
Diagnostic laparoscopy with peritoneal biopsy
History of Present Illness:
HPI:
Reports onset of RUQ at 10pm last night. Reports similar
occurrence in ___ and ___, each time after meals. Feels
like someone is shoving a fist into his abdomen. Reports that
he
was sweating, that he tried to vomit to relieve the pain but
that
nothing seemed to help. pain was constant and unremitting.
Took
ibuprofen which had minimal effect. Has also had bilateral
shoulder pain. Pain was somewhat relieved by recumbent position
and exacerbated by walking.
Past Medical History:
1. HIV diagnosed ___ years ago, reportedly last count was normal,
followed at ___.
2. HTN
Social History:
___
Family History:
Positive for heart disease and diabetes, mother passed away in
early ___ with heart disease. One sister and 3 brothers, one
brother with early heart attack at age ___.
Physical Exam:
Physical examination upon admission: ___
PE: 98.6 86 150/100 14 100%
Gen: AOx3 NAD
Cor: RRR without MRG
Res: CTAB normal WOB
Abd: Mildly obese, diffusely TTP, positive ___ sign
Ext: WWP without edema
Neuro: Without focal deficit
Psych: Normal mood, appropriate affect
Physical examination upon discharge: ___:
vital signs: t=98.4, hr=88, bp=154/99,, rr=18
General: resting comfortably, NAD
CV: Ns1, s2, -s3, -s4
LUNGS: diminished BS right side
ABDOMEN: soft, distended, hypoactive BS, mild erythema umbilcal
port, port sites clean and dry
EXT: + dp bil., no pedal edema bil., no calf tenderness bil.
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 05:38AM BLOOD WBC-15.3* RBC-3.65* Hgb-11.9* Hct-35.0*
MCV-96 MCH-32.6* MCHC-34.1 RDW-12.3 Plt ___
___ 05:40AM BLOOD WBC-15.2* RBC-3.48* Hgb-11.6* Hct-33.8*
MCV-97 MCH-33.3* MCHC-34.3 RDW-12.4 Plt ___
___ 09:45PM BLOOD WBC-16.9* RBC-4.60 Hgb-15.6 Hct-45.0
MCV-98 MCH-33.8* MCHC-34.6 RDW-12.2 Plt ___
___ 11:10AM BLOOD WBC-17.5*# RBC-4.97 Hgb-16.5 Hct-48.3
MCV-97 MCH-33.1* MCHC-34.1 RDW-12.1 Plt ___
___ 09:45PM BLOOD Neuts-90.6* Lymphs-5.1* Monos-3.8 Eos-0.4
Baso-0.1
___ 11:10AM BLOOD Neuts-92.7* Lymphs-3.3* Monos-3.6 Eos-0.1
Baso-0.2
___ 05:38AM BLOOD Plt ___
___ 07:05AM BLOOD ___ PTT-28.5 ___
___ 09:45PM BLOOD WBC-16.9* Lymph-5.1* Abs ___ CD3%-55
Abs CD3-471* CD4%-28 Abs CD4-243* CD8%-26 Abs CD8-224
CD4/CD8-1.1
___ 05:40AM BLOOD Glucose-93 UreaN-10 Creat-0.8 Na-138
K-3.4 Cl-100 HCO3-25 AnGap-16
___ 05:40AM BLOOD Glucose-102* UreaN-12 Creat-0.7 Na-141
K-3.4 Cl-105 HCO3-25 AnGap-14
___ 11:10AM BLOOD Glucose-216* UreaN-21* Creat-1.1 Na-138
K-4.7 Cl-102 HCO3-19* AnGap-22
___ 05:38AM BLOOD ALT-45* AST-41* AlkPhos-130 Amylase-75
TotBili-0.4
___ 05:40AM BLOOD ALT-49* AST-49* AlkPhos-137* TotBili-0.5
___ 09:45PM BLOOD ALT-70* AST-43* LD(LDH)-281* AlkPhos-72
Amylase-737* TotBili-0.9
___ 11:10AM BLOOD ALT-90* AST-43* AlkPhos-91 TotBili-0.7
___ 05:38AM BLOOD Lipase-64*
___ 05:40AM BLOOD Lipase-47
___ 05:51AM BLOOD Lipase-143*
___ 05:40AM BLOOD Lipase-711*
___ 09:45PM BLOOD Lipase-1110*
___: chest x-ray:
Mild bilateral lower lobe atelectasis. Otherwise no acute
cardiopulmonary
abnormality
___: liver/gallbladder ultrasound:
IMPRESSION: Cholelithiasis with at least one stone impacted in
the
gallbladder neck, with associated gallbladder distention and
positive
sonographic ___ sign. Findings are concerning for acute
cholecystitis in the correct clinical setting.
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. Evidence of pancreatitis with surrounding inflammatory
changes and fluid.
The fluid is somewhat high-density, likely due to slight
hemorrhagic
component. There is hypoperfusion of the pancreatic parenchyma
in the body.
There is no evidence of a pseudocyst, splenic vein thrombosis,
or
pseudoaneurysm.
2. Cecal bascule without evidence of volvulus.
3. Cholelithiasis without definite evidence of cholecystitis.
4. Bilateral small pleural effusions with associated
atelectasis.
___: MRCP abdomen:
IMPRESSION:
1. Acute hemorrhagic pancreatitis with small focus of necrosis
within the
pancreatic neck. Hemorrhagic fluid collection noted within the
lesser sac as well as hemorrhagic fluid seen extending
inferiorly from the pancreas, as described above.
2. Cholelithiasis. No evidence of acute cholecystitis or
choledocholithiasis.
3. Small bilateral pleural effusions with bibasilar atelectasis.
SPECIMEN SUBMITTED: peritoneal biopsy.
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
Previous biopsies: ___ ANAL BIOPSY AT 9 O'CLOCK (1
JAR).
DIAGNOSIS:
Peritoneum, biopsy (A): Fibroadipose tissue with fat necrosis.
Clinical: Gallstone pancreatitis.
Brief Hospital Course:
___ year old gentleman admitted with right upper quadrant pain.
Upon admission, he was made NPO, given intravenous fluids and
underwent imaging. Initial blood work showed an elevated white
blood cell count and lipase, signs concerning for cholecystitis.
He underwent an ultrasound of the abdomen which showed
cholelithiasis with at least one stone impacted in the
gallbladder neck. His blood work and liver enzymes were closely
monitored as well as serial abdominal examinations. On HD # 2,
he reported to have increased abdominal pain and he underwent a
cat scan of the abdomen which showed pancreatitis involving the
head and neck with surrounding inflammatory changes and fluid.
His liver enzymes were closely monitored.
After his liver enzymes decreased, he was taken to the
operating room. A cholecystectomy was planned, but due to the
severe peritoneal inflammation related to the pancreatitis, he
underwent a diagnostic laparoscopy with peritoneal biopsy. The
biopsy showed fibroadipose tissue with fat necrosis. The
operative course was stable with minimal blood loss. He was
extubated after the procedure and monitored in the recovery
room. His post-operative vital signs were stable with a
borderline high diastolic blood pressure despite resumtion of
home blood pressure medication.
On POD #1, he was started on clear liquids with transition to a
low fat diet. Instruction was provided on foods included in a
low fat diet. He reported minimal pain and abdominal distention
with food but noted that it subsided with the passage of flatus.
His white blood cell count stabilized at 15 and his lipase has
trended up to 64 and stabilized at discharge to 62. His
vital signs have remained stable and he has been afebrile.
On HD # 9, he was discharged home with instructions to follow-up
with the acute care service with an abdominal cat scan prior to
the visit. Discussion for interval cholecystectomy will be
addressed.
OF note: The patient was instructed to address blood pressure
management with primary care provider at upcoming visit.
Medications on Admission:
Atripla daily (given efavirenz and truvada here)
Multivitamin
Lisinopril 30mg
Discharge Medications:
1. Efavirenz 600 mg PO DAILY
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Lisinopril 30 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
hold for loose stool
5. Acetaminophen 650 mg PO Q6H:PRN pain
6. Senna 1 TAB PO BID:PRN constipation
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
avoid driving while on this medication, may cause drowsiness
Discharge Disposition:
Home
Discharge Diagnosis:
cholilithiasis
gallbladder pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You
underwent an ultrasound which showed gallstones. Because your
pain was increasing, you underwent a cat scan of the abdomen and
an MRI which showed the gallstones and pancreatitis. You were
placed on bowel rest and given intravenos fluids. Once your
liver studies improved, you were taken to the operating room to
have your gallbladder removed. They were unable to remove your
gallbladder because of the bowel inflammation related to the
pancreatitis. Your abdomen was explored and a biopsy was taken.
Since this procedure, your vital signs have been stable and you
are preparing for discharge home with the following
instructions. You will need to return in 6 weeks to have your
gallbladder removed.
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Your incision may be slightly red aroudn the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
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).
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing r clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
After some operations, diarrhea can occur. If you get diarrhea,
don't take anti-diarrhea medicines. Drink plenty of fluitds and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription from your surgeon for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
IF you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, 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.
In some cases you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19778376-DS-10
| 19,778,376 | 23,902,689 |
DS
| 10 |
2129-09-27 00:00:00
|
2129-09-29 21:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Simvastatin / pantoprazole
Attending: ___.
Chief Complaint:
shortness of breath + anemia (called into ED by PCP after found
to have hct 17)
Major Surgical or Invasive Procedure:
___ - Bone Marrow Biopsy
History of Present Illness:
Ms. ___ is a ___ F who developed abdominal pain in
___ followed by jaundice, dark urine, and pale stools.
On ___, she self-presented to ___ for jaundice and malaise
and was admitted. Imaging did not reveal any evidence of
obstruction and serologies were normal. Based on the results of
a liver biopsy done on ___, together with her clinical
presentation, Ms. ___ was diagnosed with probable herbal
supplement-induced liver injury. She was discharged on ___
with outpatient hepatology follow-up.
Ms. ___ saw Dr. ___ Hepatology on ___ and was
started on prednisone 40mg/day in the context of ongoing
increases in bilirubin (22.7* on ___ and 25.4* on ___.
On ___, she was also started on furosemide for mild ___
edema.
There was no significant change in her symptoms until the day
prior to admission, when Ms. ___ began to feel dizzy,
lightheaded, and short of breath, especially when active but
even when at rest. Her blood was drawn on ___ in preparation
for her outpatient appointment with Dr. ___ for
___. Following the blood draw, she received a call from her
PCP telling her to come into the ___ ED given her extremely
low hemoglobin (6.4*) and hematocrit (19.3*).
As per the ED admission note, Ms. ___ initially reported
that "her current jaundice is a whiter, 'pastier' yellow than
her former orange-yellow with higher bilirubin. Her urine
production has remained dark, and she has not noticed decreased
urinary production. The patient endorses nausea and dizziness,
SOB, fatigue and low-grade fever. She denies bleeding, no
dysuria, no rashes, no melena.
___ ED Review of Systems:
- Positive for Dyspnea, Edema and Fever/chills.
- No Black stool, Chest pain, Diplopia, Dysuria/freq, Headache,
Hives, Rash, ST or Tinnitus.
- Constitutional: +Fatigue
- GI / Abdominal: +Nausea and dizziness
- Psych: Normal
Reports allergy to pantoprazole."
Past Medical History:
- patent foramen ovale
- s/p embolic stroke (paradoxical) in ___ - not on
anticoagulation
- hypothyroidism
- ocular migraines
- osteopenia
- recent herbal supplement-induced liver injury (probable dx)
Social History:
___
Family History:
- Father: lung cancer, history of exposure as ___;
never smoker
- Mother: persistent "yellowing of skin" with unknown diagnosis,
osteoporosis died of vascular dementia
- Sister: osteoporosis, prediabetes
- Father's extended family: breast cancer (PGM and paternal
aunt), multiple sclerosis, epilepsy
- Mother's extended family: type 1 DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3 | 97/44 | 79 | 18 | 99%RA
General: Alert and oriented
HEENT: EOMI, icteric sclerae, conjunctival pallor, clear
oropharynx
Neck: supple, no LAD, no JVD
CV: RRR, II/VI systolic ejection murmur, no rubs or gallops
Lungs: CTAB no wheezes, ronchi or crackles
Abdomen: Non distended, normal BS, soft, non-tender to deep and
superficial palpation. No hepato-splenomegaly.
GU: No CVAT
Ext: WWP, varicosities, trace pitting edema bilaterally
Neuro: AOx3, CN II-XII preserved, moves all 4 extremities
purposefully
Skin: Dry, moist, jaundiced
DISCHARGE PHYSICAL EXAM:
Unchanged from above
Pertinent Results:
ADMISSION LABS
==============
___ 09:46PM ___ PTT-25.4 ___
___ 09:33PM HGB-6.2* calcHCT-19
___ 09:30PM GLUCOSE-156* UREA N-19 CREAT-0.7 SODIUM-139
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
___ 09:30PM ALT(SGPT)-122* AST(SGOT)-82* ALK PHOS-171*
TOT BILI-9.8*
___ 09:30PM LIPASE-47
___ 09:30PM ALBUMIN-3.8 IRON-248*
___ 09:30PM calTIBC-369 FERRITIN-1339* TRF-284
___ 09:30PM WBC-25.4* RBC-2.07* HGB-6.3* HCT-17.9* MCV-86
MCH-30.4 MCHC-35.2* RDW-17.3*
___ 09:30PM NEUTS-74* BANDS-3 LYMPHS-12* MONOS-6 EOS-0
BASOS-0 ___ METAS-4* MYELOS-1* NUC RBCS-2*
___ 09:30PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+
___ 11:13AM UREA N-15 CREAT-0.7 SODIUM-138 POTASSIUM-4.6
CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
___ 11:13AM ALT(SGPT)-119* AST(SGOT)-69* ALK PHOS-179*
TOT BILI-9.9*
___ 11:13AM ALBUMIN-3.7
___ 11:13AM WBC-24.7*# RBC-2.21*# HGB-6.4*# HCT-19.3*#
MCV-87 MCH-29.1 MCHC-33.4 RDW-15.8*
___ 11:13AM NEUTS-73* BANDS-4 LYMPHS-15* MONOS-5 EOS-0
BASOS-0 ___ METAS-1* MYELOS-2* NUC RBCS-1*
___ 11:13AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-OCCASIONAL MICROCYT-2+ POLYCHROM-NORMAL
___ 11:13AM ___
PERTINENT LABS
==============
___ 02:31AM BLOOD ___ 05:20AM BLOOD Parst S-NEGATIVE
___ 11:15AM BLOOD QG6PD-14.8*
___ 05:20AM BLOOD Ret Aut-8.0*
___ 05:05AM BLOOD Ret Aut-4.5*
___ 05:20AM BLOOD Heinz-NEGATIVE Ret Aut-2.5
___ 11:15AM BLOOD Ret Aut-1.3
___ 02:31AM BLOOD Ret Aut-1.5
___ 09:30PM BLOOD Albumin-3.8 Iron-248*
___ 05:20AM BLOOD Hapto-<5*
___ 02:31AM BLOOD VitB12-1081* Hapto-<5*
___ 09:30PM BLOOD calTIBC-369 Ferritn-1339* TRF-284
___ 02:31AM BLOOD TSH-1.9
___ 01:48PM URINE Hemosid-NEGATIVE
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Parvovirus B19 DNA, QL Real-Time PCR
Parvovirus B19 DNA, Qn PCR Not Detected Not
Detected
Test Result Reference
Range/Units
SOURCE Whole Blood
EBV DNA, QN PCR <200 <200 copies/mL
Test Result Reference
Range/Units
CERULOPLASMIN 42 ___ mg/dL
MICROBIOLOGY
============
___ 5:20 am Blood (Malaria)
Malaria Antigen Test (Final ___:
Negative for Plasmodium antigen.
RADIOLOGY
=========
___ 2:___BD & PELVIS W/O CONTRAST
1. No evidence of retroperitoneal or pelvic hematoma.
2. No splenomegaly.
3. Pancreatic body cystic lesion most likely represents a side
branch IPMN. Follow up MRI in six months is recommended as per
MRCP report ___.
DISCHARGE LABS
==============
___ 05:20AM BLOOD WBC-6.6 RBC-2.70* Hgb-8.3* Hct-24.0*
MCV-89 MCH-30.6 MCHC-34.4 RDW-23.4* Plt ___
___ 05:20AM BLOOD Neuts-59.3 ___ Monos-5.5 Eos-0.8
Baso-0.5
___ 05:20AM BLOOD Glucose-87 UreaN-16 Creat-0.6 Na-139
K-3.9 Cl-107 HCO3-22 AnGap-14
___ 05:20AM BLOOD ALT-92* AST-58* LD(LDH)-578* AlkPhos-133*
TotBili-6.3*
___ 05:20AM BLOOD Calcium-8.7 Phos-5.0* Mg-2.3
Brief Hospital Course:
Ms. ___ is a ___ year old female with hypothyroidism and
history of a recent episode of likely herbal supplement-induced
liver injury who presented with severe anemia and progressive
shortness of breath.
ACTIVE ISSUES
# Anemia
The etiology of the patient's anemia was unclear. Her initial
low reticulocyte pointed to an inappropriate bone marrow
response and underproduction. However, given the degree and
acute drop of her anemia and low reticulocyte count, hemolysis
and/or blood loss were likely explanations. For her work up, a
CT of the abdomen did not show any retroperitoneal bleeds. The
patient had no clinical signs or symptoms to suggest other
bleeding sources. Her blood smear was unremarkable. She had a
negative Heinz body prep and G6PD testing. Her direct Coombs
test was negative. A parasite smear and testing for malaria were
negative as well. Hematology was consulted for this case, and a
bone marrow biopsy was pursued. At the time of discharge, the
patient had the bone marrow biopsy pathology, PNH genetic
testing, and EBV/CMV/parvovirus titers pending. Given that
___ Disease could potentially cause hemolytic anemia, her
previous liver biopsy was sent for copper staining, and
ceruloplasmin and urinary copper excretion tests were sent as
well. During admission, the patient was transfused total 3U
pRBCs, and she was stable with a HCT of ~24. Her reticulocyte
count steadily increased during admission from 0.2 to 8.0.
Follow up was arranged with Hematology/Oncology as outpatient to
review bone marrow biopsy. Last, given the concern for
furosemide causing hemolysis, it was discontinued.
# Hepatitis
The etiology of her hepatitis was thought to be likely
drug-induced liver injury. Her LFTs improved during the
hospitalization from prior, and her prednisone was tapered to 20
mg daily during admission. Given the improvements, ursodiol was
discontinued.
INACTIVE ISSUES
# Hypothyroidism: Per prior notes, thought to be secondary to
___'s. Continue home dose of levothyroxine in-house.
TRANSITIONAL ISSUES
# Repeat MRI in 6 month to f/u possible IPMN in pancreas.
# Pt to have o/p CBC with DIFF and LFTs drawn and faxed to Dr.
___ within 5 days of discharge.
# Pt to have o/p f/u with heme/onc physician to review findings
from bone marrow biopsy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 40 mg PO DAILY
2. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
3. Ursodiol 300 mg PO BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. PredniSONE 20 mg PO DAILY
RX *prednisone 10 mg 2 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*1
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
4. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Anemia
Secondary: Drug-Induced Hepatitis
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 ___ after being found to be severely
anemic on laboratory testing. We gave you a total of 3 units of
blood, and you had stable blood count after that. We performed a
lot of different laboratory tests, a lot of which are still
pending. Nothing has come up positive yet.
Please keep your follow up appointments with Dr. ___ will
review new data with you as they come in. Please take your
medications as outlined below. It was a pleasure to take care of
you. Please do not hestitate to contact us with any questions.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
19778536-DS-20
| 19,778,536 | 27,605,620 |
DS
| 20 |
2173-01-10 00:00:00
|
2173-01-10 16:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangiopancreatography
Magnetic resonance elastography
History of Present Illness:
___ with localized unresectable neuroendocrine tumor encasing
the mesentery who developed nausea yesterday evening and was
transferred with a diagnosis of SBO from OSH. The patient has
had upset stomach off and on with gas sounds for the past few
weeks, but there was a change with nausea developing yesterday.
This morning he couldn't eat cereal because of nausea and
vomiting which was not controlled by Compazine and Zofran. He
felt weak and also couldn't tolerate oral nutritional
supplement, so wife called ambulance who took him to a local
hospital. There he had CT scan that showed SBO with dilated
proximal small bowel loops with air-fluid levels and a
transition at the level of the
ileum. NGT was placed but how much was suctioned up was not
documented.
He was transferred to ___ for surgical eval. Here surgery saw
patient and he had KUB that confirmed NGT location and signs of
SBO. Vitals 98.6 80 119/65. Surgery recommended ___
medical management.
Past Medical History:
#localized unresectable neuroendocrine tumor encasing the
mesentery
--followed by Dr. ___ with octreotide every 28d, last on ___
#Ascites requiring weekly paracentesis
#Malnutrition, weight loss
No longer requires medication for HTN, HL
Social History:
___
Family History:
Esophageal cancer and alcoholism in his father
MI in his mother
Physical ___:
ADMISSION:
___ 1127 Temp: 98.0 PO BP: 131/78 R Lying HR: 93 RR: 16 O2
sat: 94% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score: ___
thin male with some temporal wasting
non toxic, aox3 fluent speech
NGT in place, capped
CTAB
RRR NMRG
soft abdomen, trace bulging flanks, hypoactive bowel sounds, no
tenderness to palpation, percussion, no appreciable organomegaly
no suprapubic tenderness
no peripheral edema
no confusion
no signs of bleeding
no asterexis
DISCHARGE
98.0 PO 125/75 78 16 95% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, mildly distended, non-tender to palpation.
Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION
___ 03:56AM BLOOD WBC-10.9*# RBC-4.73 Hgb-13.1* Hct-40.4
MCV-85 MCH-27.7 MCHC-32.4 RDW-14.3 RDWSD-44.4 Plt ___
___ 03:56AM BLOOD Neuts-87.9* Lymphs-4.1* Monos-6.3
Eos-0.2* Baso-0.5 Im ___ AbsNeut-9.59*# AbsLymp-0.45*
AbsMono-0.69 AbsEos-0.02* AbsBaso-0.05
___ 03:56AM BLOOD Glucose-130* UreaN-25* Creat-1.1 Na-130*
K-7.2* Cl-95* HCO3-24 AnGap-11
___ 05:33AM BLOOD Albumin-2.7* Calcium-8.5 Phos-4.8* Mg-2.1
DISCHARGE
___ 06:50AM BLOOD WBC-5.6 RBC-4.45* Hgb-12.1* Hct-38.9*
MCV-87 MCH-27.2 MCHC-31.1* RDW-14.3 RDWSD-45.7 Plt ___
___ 06:50AM BLOOD Glucose-84 UreaN-16 Creat-0.9 Na-140
K-4.4 Cl-100 HCO3-25 AnGap-15
___ 06:50AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
CT abdomen/pelvis performed ___ at ___
moderate bilateral pleural effusions slight decrease in
mod-significant ascites stable lobulated mass lesion near root
of mesentery, 8.5x5.3x5.5cm, unchanged since ___ proximal
small bowel loops with air-fluid levels and a transition at the
level of the ileum
KUB ___
Small-bowel obstruction, likely distal
Upper endoscopy
Normal mucosa in esophagus, stomach and duodenum
MRE
IMPRESSION:
1. Evidence of unchanged distal small-bowel obstruction
secondary to the
central mesenteric mass as described above.
2. Unchanged edema and mucosal hypoenhancement of the most
distal dilated
small bowel loops proximal to the transition point concerning
for vascular
compromise. Evidence of marked luminal narrowing of the SMV and
SMA.
3. Moderate amount pleural effusions and large amount of
intra-abdominal
ascites.
4. Unchanged central mesenteric mass biopsy-proven
neuroendocrine tumor with associated mesenteric adenopathy.
5. 8 mm hypoenhancing right hepatic lobe lesion, incompletely
evaluated and remains indeterminate. This can be followed on
subsequent imaging.
Brief Hospital Course:
#Small bowel obstruction
#Pancreatic neuroendocrine tumor
The patient initially presented with nausea and was found to
have a small bowel obstruction secondary to his known pancreatic
neuroendocrine tumor. He was initially treated with an NG tube,
kept NPO, treated with fluids and Zofran for nausea. However, by
the second day of his admission, his symptoms were markedly
improved, his NGT was removed and his diet was advanced.
Endoscopy showed normal mucosa in esophagus, stomach and
duodenum. MRE showed evidence of unchanged distal small-bowel
obstruction secondary to the central mesenteric mass. Based on
these findings, the patient's clinical improvement, and his
ongoing ascites, surgery decided to hold off on a bypass at this
time and see him in follow up as an outpatient.
# Ascites
Per hepatology evaluation, ascites seems to be multifactorial
due to portal hypertension due to the obliteration of his portal
vein and encasement of his SMA/SMV by his tumor, as well as
obstruction of his lymph system contributing to chylous nature
of the ascites. The liver is unlikely cirrhotic given normal
LFTs,
synthetic function and non-cirrhotic appearance on OSH CT scan.
For the concern for chylous ascites (based on patient's
description) as well as overall malnutrition, he was seen by
nutrition, who recommended a low fat, sodium restricted diet
with ensure enlive supplements mixed with beneprotein and 15 mL
medium chain triglycerides oil. A triene/tetraene ratio was also
checked with results pending on discharge; if> 0.4 and s/sx of
deficiency consider parenteral fat emulsion. He had a
paracentesis on the day of discharge, both therapeutic on
schedule for his weekly tap and also diagnostic to evaluate for
chylous ascites. Also continued home Lasix 10 mg daily while
inpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 10 mg PO DAILY
2. Creon 12 1 CAP PO TID W/MEALS
3. Pantoprazole 40 mg PO Q24H
4. Vitamin D ___ UNIT PO 1X/WEEK (FR)
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Pancreatic neuroendocrine tumor
Ascites
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with nausea/vomiting and found
to have a small bowel obstruction due to your pancreatic
neuroendocrine tumor. In addition to your primary medicine team,
the surgery, hepatology and gastroenterology teams also
evaluated you.
For the small bowel obstruction, your symptoms improved, and
surgery decided based on the imaging and your symptoms that it
is reasonable to wait to do a bypass. Please go to the follow up
appointment with them.
For your ascites, the hepatology team evaluated and felt that it
was unlikely due to underlying cirrhosis and more likely due to
portal hypertension as well as lymph node system obstruction. We
did a paracentesis and will notify you of the results.
In addition to your surgery follow up appointment, we also
scheduled a follow up appointment with your oncologist and
primary care doctor.
It was a pleasure taking care of you!
Sincerely,
Your ___ team
Followup Instructions:
___
|
19779079-DS-19
| 19,779,079 | 21,487,198 |
DS
| 19 |
2163-12-08 00:00:00
|
2163-12-09 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:
Dyspnea, Fever, Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with pmhx of prostatitis, hep c, IVDA on suboxone who
presents with ILI for one week. Pt reports he developed fever 4
days ago and was doing well with ___ meds but had to return
early from work today because he was out of breath and drowsy.
He also had cough these past ___ days. Pt had not been able to
eat or keep fluid down since afternoon. Multiple family members
reported to be ill with similar complaints.
Pt presented to PCP today with complaints of increased dyspnea
and was found to be hypoxic to 86% on RA as well as febrile to
102. He was started on 2L O2 NC with no improvement of his SpO2.
Pt was referred to the ED. In the ED pt admitted to injecting
his suboxone.
In the ED, initial vitals: 100.8 118 146/70 26 95% NC
-Exam was significant for pinpoint pupils. Pt was noted to be
somnolent although mental status improved during ED stay
-Labs were significant for FluAPCR: Positive, h/h 12.8/39.2,
platelets 89, Mg: 1.2 P: 1.3, Lactate:1.0
-Imaging was significant for CXR notable for multifocal
pneumonia possible AP window lymphadenopathy.
-Pt was given IV Ketorolac 30 mg, 3L NS, Piperacillin-Tazobactam
4.5 g, IV Acetaminophen IV 1000 mg, IV Vancomycin 1000 mg,
Tamiflu
On transfer, vitals were: 97 136/55 32 98% Non-Rebreather ->
weaned to high flow with SpO2 96%.
On arrival to the MICU, patient reports he feels better. He is
very sleepy but arousable and answers questions appropriately.
He reports that his breathing is improved from earlier with the
breathing mask.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
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:
hepatitis C since ___
Polysubsubstance abuse, on Suboxone
anxiety/ mood disorder
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION:
Vitals: T: AF BP: 117/57 P: 95 R: 18 O2: 92% on 100% FiO2 high
flow
GENERAL: very sleepy but arousable, oriented
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: decreased breath sounds throughout, bronchial breath
sounds over the L side of chest anteriorly.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, mildly tender to palpation over epigastric area and
RUQ, non-distended, bowel sounds present, no rebound tenderness
or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes, no identifiable track marks or erythematous
skin lesions
NEURO: EOMI, PERLLA, sleepy but oriented. Can obey commands.
DISCHARGE:
T 97.9 BP 100/41-109/49 HR 56-60 RR 18 96 2 L
I/O: ~1800/4000
Gen: Answers questions appropriately
HEENT: no LAD, MMM
Cor: regular, normal s1s2, no S3,
Pulm: speaking in full clear sentences. B/L crackles noted on
posterior and axilla with rhonchi
Abd: soft, ntnd, tattoos notable
Neuro: AAOX3, moving all extremeities
MSK: no ___ edema, wwp
Psych: appropriate
Skin: numerous tattoos over arms and torso; over fingernails
wioth flashlight no signs of emboli. No peripheral edema.
Pertinent Results:
ADMISSION/IMPORTANT LABS:
========================
___ 07:18PM BLOOD WBC-6.2 RBC-4.50* Hgb-12.8* Hct-39.2*
MCV-87 MCH-28.4 MCHC-32.7 RDW-12.7 RDWSD-40.3 Plt Ct-89*
___ 07:18PM BLOOD Neuts-83.9* Lymphs-9.0* Monos-6.6
Eos-0.0* Baso-0.2 Im ___ AbsNeut-5.23 AbsLymp-0.56*
AbsMono-0.41 AbsEos-0.00* AbsBaso-0.01
___ 07:18PM BLOOD Glucose-120* UreaN-13 Creat-1.0 Na-134
K-3.5 Cl-98 HCO3-28 AnGap-12
LABS AT DISCHARGE:
=================
___ 07:15AM BLOOD WBC-6.6 RBC-4.27* Hgb-12.0* Hct-38.0*
MCV-89 MCH-28.1 MCHC-31.6* RDW-13.2 RDWSD-42.3 Plt ___
___ 07:15AM BLOOD Plt ___
MICRO:
=====
___ 9:42 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
__________________________________________________________
___ 9:18 am IMMUNOLOGY
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
98,000 IU/mL.
Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0
Test.
Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08
IU/mL.
Limit of detection: 1.50E+01 IU/mL.
__________________________________________________________
___ 1:45 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 9:37 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
__________________________________________________________
___ 6:07 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 7:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
========
CXR ___
Multifocal pneumonia possible AP window lymphadenopathy.
Recommend followup to resolution.
RUQUS
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with HCV, new thrombocytopenia, new
HCAP/flu //
r/o nodularity of liver, r/o splenomegaly, r/o ascites
TECHNIQUE: Grey scale and color Doppler ultrasound images of
the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the
liver is smooth. There is 2 hyperechoic liver nodules, the first
in segment 8
measuring 6 x 4 x 4 mm, the second in segment ___ measuring 1.5
x 1.1 x 1.1
cm. These are consistent with hemangiomas, however given the
underlying liver
disease close attention on follow-up is recommended. This could
be performed
in 3 months time. Alternatively, further characterization with
MRI could be
performed. No other concerning liver lesions identified.. The
main portal
vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 4 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: Imaged portion of the pancreas appears within normal
limits, without
masses or pancreatic ductal dilation, with portions of the
pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 16.1 cm.
KIDNEYS: The right kidney measures 12.7 cm. The left kidney
measures 12.8 cm.
Normal cortical echogenicity and corticomedullary
differentiation is seen
bilaterally. There is no evidence of masses, stones, or
hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
IMPRESSION:
2 hyperechoic liver lesions measuring 6 x 4 x 4 mm and 1.5 x 1.1
x 1.1 cm in
segments 8 and ___ respectively, as detailed above. Although
these are likely
hemangiomas, either close 3 month follow-up or further
characterization with
MRI is recommended given the underlying liver disease.
Moderate splenomegaly with the spleen measuring 16.1 cm.
RECOMMENDATION(S): Close interval left 3 month follow-up with
ultrasound or
further characterization with MRI as described above.
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old man with hx iv drug use, hcap/flu, on
vanc/cefepime,
persistent o2 requirement, admitting to recent K2/spice use, got
8 L IVF in
ICU // r/o HSP vs pulmonary edema vs multilobar pneumonia
TECHNIQUE: Multi detector helical scanning of the chest was
coordinated with
intravenous infusion of nonionic iodinated contrast agent and
reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and
parasagittal, and 8 mm MIP
axial images. All images were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 36.0 cm; CTDIvol = 22.6 mGy
(Body) DLP = 814.2
mGy-cm.
Total DLP (Body) = 814 mGy-cm.
COMPARISON:
There are no prior chest CT scans available for review. Study
is read in
conjunction with chest radiograph ___.
FINDINGS:
Supraclavicular and axillary lymph nodes are not not enlarged.
There is no
soft tissue abnormality in the chest wall suspicious for
malignancy or
infection. This study is not appropriate for subdiaphragmatic
diagnosis.
Thyroid is unremarkable. Thymus is edematous and mildly
enlarged, but not
mass like.
Atherosclerotic calcification is not apparent head neck or
coronary arteries.
Mediastinal and hilar lymph nodes are numerous, but not
pathologically
enlarged, presumably reactive. Aorta is normal size, but
biventricular
cardiomegaly and dilated pulmonary arteries are best evaluated
with dedicated
cardiac imaging. No filling defects are seen in the central
pulmonary
arteries.
Small nonhemorrhagic right pleural effusion is mostly fissural.
Left pleural
effusion is minimal. There is no pericardial effusion.
Widespread pulmonary consolidation is severe. The right lower
lobe is almost
entirely airless ; the left lower lobe is heterogeneously
consolidated in the
superior segment and the basal segments are nearly airless. The
attenuation
of both lower lobes, 25 ___, is lower than that generally seen
with atelectasis
and suggests pneumonia except that this is a young patient whose
hypoxic vaso
constriction may decrease pulmonary blood flow more efficient
with only see in
older patients. Nevertheless there is sufficient the
consolidation in the
upper lobes to suggest widespread pneumonia.
Peribronchovascular ground-glass opacification also prominent in
the upper
lobes suggests a different process, sensitivity or toxicity.
There no bone lesions in the chest cage suggesting infection or
malignancy.
IMPRESSION:
Severe nearly global bibasilar consolidation could be pneumonia
or pneumonia
with substantial atelectasis. Multi focal pneumonia elsewhere,
predominantly
dependent upper lobes.
Widespread peribronchovascular edema or pneumonitis could be due
to diffuse
alveolar damage from widespread pneumonia or toxic inhalation.
This is less
likely pulmonary hemorrhage alone because of its symmetric
distribution.
Small nonhemorrhagic pleural effusions, not concerning for
infection.
Biventricular cardiomegaly and probable pulmonary arterial
hypertension.
Echocardiography recommended.
Mild reactive central adenopathy.
RECOMMENDATION(S): Echocardiography.
ECHO ___
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF = 65%). Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. There is mild posterior leaflet mitral
valve prolapse. There is no pericardial effusion.
IMPRESSION: no vegetations seen
Brief Hospital Course:
___ hx IVDU p/w fevers, hypoxemic respiratory failure.
Attributed to influenza A and multifocal bacterial PNA. Admitted
to MICU for hypoxia, and had prolonged course notable for
hypoxia ___ severe pneumonia and atelectasis. Patient admitted
while in hospital to injecting ground suboxone tablets and
inhaling K2. Patient had CT chest showing severe pneumonia and
negative TTE. Patient discharged on levofloxacin abx regimen to
end ___, and finished 5 day azithromycin and oseltamivir
courses in house.
Of note, patient was discharged late ___ as he insisted he had
to make a meeting the following morning. We emphasized risks of
leaving to patient, as medical team determined patient should
stay in house one more day to see response to oral antibiotics.
Medical team implored to patient to return if he had worsening
SOB, fevers, or any other symptoms that concerned him.
# Influenza with superimposed bacterial pneumonia: FluA + with
CXR showing multifocal pneumonia. Caused hypoxemic respiratory
failure, still on 3L O2 NC by time to transfer to floor.
Persistent hypoxia was thought to be volume overload positive 7
L after 24 hr ICU stay versus possible K2 use (patient reports
using K2/spice - synthetic marijuana equivalent which he
inhaled). Ct chest ___ concerning for GGO's, but alveolar
hemorrhage lower on differential as patient has decreasing
hemoptysis and stable hgb. Pulm was consulted who felt likely
etiology was severe multilobar pneumonia. Patient was kept on
nebs, incentive spirometry, and was encourage to ambulate and
was satting 96 % on RA by ___, and his Vanc/cefepime was switch
to po levaquin to end on ___. We advised patient to stay one
more day (patient had just been switch to po antibiotics), but
he insisted on making early am ___ meeting.
# Hypoxia: DDx included fluid overload, HCAP above, or possible
HSP ___ K/2 spice use. Patient admitted to using K2 last week.
CT chest showed possible alveolar filling process on top of
multilobar pneumonia - was thought to be pulmonary edema versus
alveolar hemorrhage vs another etiology. TTE showed no
vegetations ruling out septic emboli. Pulmonary consulted and
felt likely severe atelectasis in setting of major pneumonia.
Patient s/p Lasix 20mg IV on ___ and ___ and ___, and had
improvement in O2 to satting 96 % on RA by d/c.
# Hx IVDU: patient presented with fevers, respiratory symptoms.
fevers have abated with treatment, making HCAP likely diagnosis.
However given patient's story of injecting suboxone with tap
water, got TTE which showed no vegetations. HIV negative, Hep B
negative, HCV viral load: 98,000 IU. Patient to continue
suboxone on d/c.
# HCV infection: Chronic condition, last viral load 1 million in
___. Felt may be contributing to thrombocytopenia on
admission ___ cirrhosis and splenic sequestration. RUQ US showed
moderate splenomegaly, viral load 98,000 IU.
# 2 hyperechoic liver lesions: Noted on RUQUS obtained to eval
for thrombocytopenia below. ___ be hemangioma. Formal read was
"2 hyperechoic liver lesions measuring 6 x 4 x 4 mm and 1.5 x
1.1 x 1.1 cm in segments 8 and ___ respectively, as detailed
above. Although these are likely hemangiomas, either close 3
month follow-up or further characterization with MRI is
recommended given the underlying liver disease." Spoke with
patient that he will require followup U/S in 3 months concerning
these lesions.
# Thrombocytopenia: Plt 80 on admission. Likely ___ illict drug
effect vs splenic sequestration. Last plt count in ___ was
140. RUQ US showed mod splenic enlargement which may have
explained initial thrombocytopenia versus illicit drug effect
from K2/spice above. Platelets uptrended to 238 by discharge.
# Anxiety: patient has long history of "failed" medications for
anxiety; unclear if he has a psych provider. Continued home
gabapentin
TRANSITIONAL ISSUES
==================================
-Patient discharged on po levaquin antibiotics to end on ___
-Patient left late on ___, day prior to planned discharge
(medical team wanted to stabilize patient on 24 hrs of levaquin
and ensure patient had been weaned off oxygen, but patient had
to make very early meeting on ___. Medical team emphasized
need for patient to follow up with PCP and to return to ED if he
had any symptoms that concerned him.
-Please arrange liver follow up for patient regarding Hep C
infection above; viral load currently downtredning
-RUQ U/S in house showed two possible hemangiomas; please
arrange follow up U/S in 3 months.
-Please perform follow CXR in ___ weeks to ensure improvement in
PNA above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 900 mg PO TID
2. CloniDINE 0.3 mg PO QHS
3. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
4. Wellbutrin (unknown dose).
Discharge Medications:
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
2. Gabapentin 900 mg PO TID
3. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin [Adult Tussin Chest Congestion] 100 mg/5 mL ___
ml by mouth every 6 hours Refills:*0
4. Ibuprofen 600 mg PO Q6H:PRN headache, pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
5. CloniDINE 0.3 mg PO QHS
6. Levofloxacin 750 mg PO DAILY
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth daily
Disp #*7 Tablet Refills:*0
7. Acetaminophen 325-650 mg PO Q8H:PRN pain, fever
RX *acetaminophen 325 mg ___ tablet(s) by mouth up to three
times a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
IVDU
K2 Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you felt short of breath. At
___ ___ determined you had a pneumonia and the flu.
It was felt your infection became very serious because of both
your injection of pills into your veins and prior inhalation of
possible contaminated drugs. As a result, we ask that you
continue with your suboxone program as directed, and abstain
from smoking. We ask that you follow up as directed below. Of
note, we desired to keep you in the hospital for at least one
more day to see your response to oral antibiotics, but you had
an important meeting tomorrow morning. We ask you that if you
feel more short of breath, have fevers or chills, to please come
back to hospital.
We wish you all the best!
-Your ___ Care Team
Followup Instructions:
___
|
19779220-DS-17
| 19,779,220 | 21,027,927 |
DS
| 17 |
2164-07-26 00:00:00
|
2164-07-29 21:13:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Iodine / atorvastatin
Attending: ___.
Chief Complaint:
High grade small bowel obstruction
Major Surgical or Invasive Procedure:
___: Enterolysis
History of Present Illness:
___ presents with 1 day of diffuse abdominal pain and
distention. Subsequently, she developed 2x dark emesis which was
found to be guaiac positive in the ED. Her last bowel movement
was this morning but of note, was hard in texture and small
volume compared to her baseline. Of note, she c/o nausea x 2
weeks and has not passed gas since before yesterday. She denies
hematochezia and any other symptoms.
Past Medical History:
Past Medical History:
cholelithiasis
gastric polyp concerning for ?GIST ___ years ago)
HTN
HLD
RBBB
CHF with preserved EF
Polyvalvular disease: ___ MR, 1+ AR, mild AS (TTE ___.
anxiety
GERD
urinary incontinence
constipation
OA
glaucoma
Past Surgical History:
tah
appendectomy
squamous cell CA nose
cataract surgery L eye
Social History:
___
Family History:
Father died of cardiac disease, age ___. He also
had a history of hypertension. Her mother died at a young age
during childbirth.
Physical Exam:
Admission Physical Exam:
Vitals: 97.6 80 184/72 18 99% RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist.
CV: RRR, ___ holosystolic murmur at left ___ intercostal space.
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended, tender in RLQ voluntary guarding.
Hyperactive bowel sounds. Hypertypanitic to palpation.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 01:26PM GLUCOSE-161* UREA N-14 CREAT-0.8 SODIUM-140
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
___ 01:26PM CALCIUM-9.1 PHOSPHATE-4.6* MAGNESIUM-1.8
___ 01:26PM WBC-21.0*# RBC-4.49 HGB-13.6 HCT-41.2 MCV-92
MCH-30.3 MCHC-33.0 RDW-14.7 RDWSD-49.6*
___ 01:26PM PLT COUNT-242
___ 06:44AM GLUCOSE-182* UREA N-14 CREAT-0.9 SODIUM-136
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-23 ANION GAP-20
___ 06:44AM CALCIUM-8.7 PHOSPHATE-4.0 MAGNESIUM-1.9
___ 06:44AM WBC-10.9* HCT-43.8
___ 08:49PM LACTATE-1.5
___ 08:46PM GLUCOSE-137* UREA N-15 CREAT-0.9 SODIUM-138
POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-29 ANION GAP-20
___ 08:46PM ALT(SGPT)-19 AST(SGOT)-34 ALK PHOS-115* TOT
BILI-0.7 DIR BILI-0.2 INDIR BIL-0.5
___ 08:46PM LIPASE-23
___ 08:46PM ALBUMIN-4.2 CALCIUM-10.2 PHOSPHATE-3.8
MAGNESIUM-2.2
___ 08:46PM WBC-13.4*# RBC-5.00 HGB-14.9 HCT-44.7 MCV-89
MCH-29.8 MCHC-33.3 RDW-14.6 RDWSD-47.6*
___ 08:46PM NEUTS-89.2* LYMPHS-6.6* MONOS-3.4* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-11.93* AbsLymp-0.88* AbsMono-0.45
AbsEos-0.01* AbsBaso-0.04
___ 08:46PM PLT COUNT-277
___ 08:46PM ___ PTT-29.5 ___
___ 07:06PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 07:06PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-MOD
___ 07:06PM URINE RBC-2 WBC-24* BACTERIA-FEW YEAST-NONE
EPI-2
___ 07:06PM URINE AMORPH-OCC
___ 07:06PM URINE MUCOUS-RARE
___: Gallbladder US:
1. Extensive cholelithiasis without definite acute
cholecystitis.
2. Equivocal millimetric echogenic focus within the main
pancreatic duct is of uncertain etiology, question small focus
of fat or calcification, but doubtful clinical significance.
___: CT Abd&Pel:
1. Uncomplicated small bowel obstruction with a transition point
in the right lower quadrant.
2. Cholelithiasis and gallbladder wall calcification without
evidence of
cholecystitis.
3. Stable prominence of the intra and extrahepatic biliary tree.
4. Moderate hiatal hernia.
___:
No definite free intraperitoneal air is evident, but the
appearance of
partially layering small pleural effusions suggests that the
radiograph was performed in a semi upright rather than fully
upright position. With this in mind, if there remains strong
clinical suspicion for free intraperitoneal air, a left lateral
decubitus view of the abdomen or a fully upright chest
radiograph would be recommended. Exam is otherwise remarkable
for worsening bibasilar atelectasis.
___: CT Abd&Pel:
1. No bowel obstruction or evidence of ischemia. Postoperative
changes are seen without acute findings.
2. Bilateral small to moderate pleural effusions with associated
atelectasis are worse compared to prior.
Brief Hospital Course:
Ms. ___ is a ___ year-old female who presented to ___ on
___ with complaints of abdominal pain. CT abdomen&pelvis
revealed a high-grade small bowel obstruction with a transition
point in the right lower quadrant. The patient was admitted to
the Acute Care Surgery service and, given the findings, was
taken to the Operating Room where she underwent Enterolysis.
There were no acute events in the Operating Room (reader, please
see Operative report for details). The patient was transferred
to the PACU and, once stable, was transferred to the surgical
floor for further monitoring.
On POD1, the patient self d/c'd her NGT. She was started on IV
lopressor for elevated systolic blood pressure. On POD2, her
foley catheter was removed and a urinalysis was sent for
complaints of dysuria. No urinary tract infection was apparent
on UA or from the urine culture and she remained afebrile and
her dysuria resolved.
On POD3, the patient was triggered for systolic blood pressure
greater than 200 and she was Enaliprat and hydralazine was
increased. On POD4, the patient reported increased abdominal
pain and a chest x-ray and CT abd&pelvis were ordered. Findings
revealed no bowel obstruction or evidence of ischemia but did
show b/l small to moderate pleural effusions associated with
atelectasis. The patient was encouraged to use her incentive
spirometer and ambulate.
On POD5, the patient was started on sips which were
well-tolerated. Losartan and home aspirin were started. She was
administered a fleets and soap suds enema and was disimpacted
with good effect. As the patient reported low abdominal pain, a
UA and UCx were ordered which showed no apparent infection. The
patient reported this pain greatly improved after having a bowel
movement.
On POD6, the patient was advanced to a regular diet which was
well-tolerated. All IV blood pressure medications were
discontinued and her home carvedilol was started. Blood
pressures were well-controlled. On POD7, the patient was started
on her home Isosorbide. The patient's systolic blood pressure
decreased to the ___ and 110s which she initially tolerated, but
then became acutely symptomatic with complaints of dizziness. a
1L LR bolus was administered with good effect and her systolic
blood pressure increased to the 130s. The patient was kept in
the hospital for an additional day for further monitoring. The
patient and her daughter were instructed to hold the patient's
isosorbide until her follow-up appointment with her PCP. She
was also instructed to check her blood pressure at home and to
seek medical attention if her hypertension was not controlled.
The patient was alert and oriented throughout hospitalization;
pain was initially managed with IV pain medication and then
transitioned to oral pain medication once tolerating a diet.
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. The patient's intake and output were closely
monitored. The patient's fever curves were closely watched for
signs of infection, of which there were none.
The patient's blood counts were closely watched for signs of
bleeding, of which there were none. The patient received
subcutaneous heparin and ___ dyne boots were used during this
stay and was encouraged to get up and ambulate as early as
possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. She was having soft, formed bowel movements. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. Follow-up appointments were scheduled with the patient's
primary care provider as well as with the Acute Care Surgery
clinic.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Diltiazem 180 mg PO BID
2. Ethacrynic Acid 25 mg PO DAILY
3. Carvedilol 25 mg PO BID
4. Losartan Potassium 50 mg PO BID
5. Pravastatin 10 mg PO QPM
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carvedilol 25 mg PO BID
3. Diltiazem 180 mg PO BID
4. Losartan Potassium 50 mg PO BID
5. Pravastatin 10 mg PO QPM
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
7. TraMADOL (Ultram) 12.5 mg PO Q6H:PRN pain
do NOT drink alcohol or drive while taking this medication
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*30 Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
please hold for loose stool
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*30 Capsule Refills:*0
9. Senna 8.6 mg PO BID:PRN constipation
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Rolling Walker
Dx: small bowel obstruction
Prognosis: good
Duration: 13 (thirteen) months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small Bowel Obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on
___ and were found to have a small bowel obstruction. You
were admitted to the Acute Care Surgery service for further
medical care. You were taken to the Operating Room and
underwent an exploratory laparotomy with lysis of adhesions. You
tolerated this procedure well and were transferred to the
surgical floor for pain control and to await return of your
bowel function.
You are now tolerating a regular diet, your pain is better
controlled and you have worked with the Physical Therapists.
You are now medically cleared to be discharged home to continue
your recovery.
Please note the following discharge instructions:
Please monitor your bowel function closely. If you notice that
you are passing bright red blood with bowel movements or having
loose stool without improvement please call the office or go to
the emergency room if the symptoms are severe. If you are taking
narcotic pain medications there is a risk that you will have
some constipation. Please take an over the counter stool
softener such as Colace, and if the symptoms do not improve call
the office. If you have any of the following symptoms please
call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery.
You will be prescribed a small amount of the pain medication.
Please take this medication exactly as prescribed. You may take
Tylenol as recommended for pain. Please do not take more than
4000mg of Tylenol daily. Do not drink alcohol while taking
narcotic pain medication or Tylenol. Please do not drive a car
while taking narcotic pain medication.
Followup Instructions:
___
|
19779355-DS-8
| 19,779,355 | 23,617,018 |
DS
| 8 |
2164-06-07 00:00:00
|
2164-06-07 20:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ Afib on Pradaxa, ___, s/p fall two days ago now with R
gluteal hematoma. He reportedly ambulates with a walker at
baseline. Two days ago while at his home, he was found on the
ground next to his stairs which are two steps high. He did not
reportedly have LOC, however no one witnessed fall. He was not
brought to the hospital at that point, but the next morning
could not get out of bed due to right leg pain.
The patient is unable to give a good history due to his history
of a stroke in ___, and communication is difficult due to him
being hard of hearing. However, at this time the patient denies
pain, per the son, and has not had fevers/chills. Notably, he
was recently admitted and discharged 10 days ago from ___ for
bloody bowel movements and a diagnosis of sigmoid colitis,
thought to be ischemic vs. infectious. He completed a course of
Cipro/Flagyl for this.
Past Medical History:
- a fib, previously on coumadin, 2 weeks ago INR was 13, so
coumadin was stopped given fall risk and he was placed on ASA 81
1 week ago
- R sided heart failure per ICI he has severe TR, moderate AR,
dilated RV with high RA pressure, possible PFO. Most recent Echo
was ___ and showed an EF of 65%. Very non compliant with
his
lasix, his cardiologist recently recommended hospital admission
to adjust volume status and the patient refused.
- HTN
- colonic polyps, due for colonoscopy this year
- allergic rhinitis
Social History:
___
Family History:
Adopted. Daughter has ___ Syndrome.
Physical Exam:
TRANSFER TO MEDICINE PHYSICAL EXAM:
Vitals: T: 98.8 BP 110/41 HR 67 RR 18 ___
General: sleeping comfortably and awakens to voice, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, edentulous
Neck: supple, JVP elevated to mid neck at 45 degrees, no LAD
Lungs: Crackles at bases bilaterally
CV: irregularly irregular, systolic murmur heard throughout
percordium
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 1+ pitting edema ___ bilaterally
Neuro: following some commands. face symmetric, PEERL, tongue
midline
DISCHARGE PHYSICAL EXAM:
Vitals: Tc 97.8, P84, BP 116/96, RR 18
General: Awake, calm, making eye contact
HEENT: Sclera anicteric, MMM, oropharynx clear, edentulous
Lungs: CTAB
CV: irregularly irregular, systolic murmur heard throughout
percordium
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 1+ pitting edema ___ bilaterally
Neuro: following some commands. face symmetric, PEERL, tongue
midline; aphasic
Pertinent Results:
ADMISSION LABS:
___ 01:10PM BLOOD WBC-9.7# RBC-3.34* Hgb-9.8* Hct-30.5*
MCV-91 MCH-29.3 MCHC-32.1 RDW-13.9 RDWSD-46.2 Plt ___
___ 01:10PM BLOOD Neuts-75.8* Lymphs-10.3* Monos-12.6
Eos-0.6* Baso-0.3 Im ___ AbsNeut-7.36* AbsLymp-1.00*
AbsMono-1.22* AbsEos-0.06 AbsBaso-0.03
___ 01:10PM BLOOD ___ PTT-34.0 ___
___ 01:10PM BLOOD Glucose-144* UreaN-7 Creat-0.7 Na-136
K-3.0* Cl-101 HCO3-28 AnGap-10
___ 05:15PM BLOOD Lactate-1.4
DISCHARGE LABS:
___ 05:20AM BLOOD WBC-6.1 RBC-2.98* Hgb-8.7* Hct-27.7*
MCV-93 MCH-29.2 MCHC-31.4* RDW-14.5 RDWSD-49.1* Plt ___
___ 05:20AM BLOOD Glucose-100 UreaN-10 Creat-0.6 Na-141
K-3.8 Cl-104 HCO3-31 AnGap-10
IMAGING:
___ Bilateral hip Xrays:
No acute fracture or dislocation seen.
CT chest/A/P with contrast:
1. Right gluteal region 10 x 6 cm hematoma. No evidence of
active extravasation. Otherwise, no acute sequelae of trauma.
2. Ascending thoracic aortic aneurysm, measuring 5.3 cm.
3. Main pulmonary artery dilation to 4.5 cm.
4. Severe global cardiomegaly.
5. Fusiform infrarenal abdominal aortic aneurysm/ectasia
measuring up to 2.5cm.
6. Trace bilateral simple layering pleural effusions.
CT head noncon:
1. No acute intracranial process.
2. Foci of encephalomalacia in the left frontoparietal lobe and
left occipital lobe, sequelae of prior infarct, better seen on
MRI from ___.
3. Chronic findings including white matter small vessel ischemic
changes, age-related global involutional change, and changes
related to chronic sinusitis.
CT Cspine:
1. No acute fracture or malalignment.
2. Stable appearance of multilevel degenerative changes.
ECHO ___:
IMPRESSION: Mild ___ ventricular cavity dilation with normal
regional/global systolic function. Moderate right ventricular
cavity dilation with preserved free wall motion. Moderate
pulmonary artery hypertension. Moderate to severe tricuspid
regurgition. Moderate aortic regurgitation. Mild-moderate mitral
regurgitation. Moderately dilated ascending aorta.
Compared with the prior report (images not available for review)
of ___, the severity of mitral regurgitation, tricuspid
regurgitation and aortic regurgitation are now increased,
pulmonary artery systolic hypertension is now present, and there
is now biventricular cavity dilation. The aortic measurements
are similar.
MICRO:
___ Urine culture:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
___ (___) with PMHx afib (on Pradaxa), CVA (___)
with residual aphasia, dCHF, recent hospitilization for ischemic
colitis presenting after a fall 2 days prior to admission with
difficulty walking found to have a right gluteal hematoma.
ACUTE ISSUES:
# R gluteal hematoma: Due to fall prior to admission. Found on
CT to be 10cm x 6cm. Initially admitted to surgery, ACS deemed
this hematoma nonoperative. His Hgb was 9.8 on admission, down
from 12.5 on discharge. Trended down to 8.6 and was remained
stable for the rest of the admission. Pradaxa was held on
admission and then restarted once Hgb was stable, with stable
counts once restarted.
# Fall: Given the history of falling down steps while not using
his cane, it seems most likely that this was mechanical. He had
no events on telemetry other than his baseline afib. He had an
echo done here which showed moderate tricuspid regurgitation,
but nothing that would likely contribute to the fall. Patient
walks well with cane/assistence but still has some residual
weakness from stroke. Patient's family believes that patient
will need to go to nursing facility indefinitely due to
inability to get enough care at home. Given that patient will be
well monitored at nursing facility, risk of fall is much less
than at home, decision was made with family's input to continue
pradaxa for afib despite the fall risk. He was seen by physical
therapy who recommended discharge to rehab given his gait
instability.
CHRONIC ISSUES:
# Atrial fibrillation: CHADS2 score 5, Given prior CVA.
anticoagulation management as above.
# dCHF: Continued home lasix and metoprolol
# BPH: Continued home finasteride and tamsulosin
TRANSITIONAL ISSUES:
# CODE: full
# CONTACT: ___ (daughter in ___) ___
or Daughter ___ (in ___ ___
# R gluteal hematoma- please evaluate for any worsening.
Currently back on Pradaxa to reduce stroke risk.
# Discharged to ___ considering persistent fall risk
# New echocardiogram showed increased MR, TR, and AR, new
pulmonary artery hypertension, and biventricular cavity
dilation. These findings are not likely to be the reason for
fall, but may warrant cardiology follow up.
# Due to prior CVA, started on Atorvastatin 40 mg qPM.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Dabigatran Etexilate 150 mg PO BID
2. Finasteride 5 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO BID
5. Tamsulosin 0.4 mg PO BID
6. Vitamin D ___ UNIT PO DAILY
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob or wheeze
8. Atorvastatin Dose is Unknown PO QPM
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob or wheeze
2. Atorvastatin 40 mg PO QPM
3. Dabigatran Etexilate 150 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Metoprolol Tartrate 12.5 mg PO BID
7. Tamsulosin 0.4 mg PO BID
8. Vitamin D ___ UNIT PO DAILY
9. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6h prn
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
S/p Fall
Secondary:
Ischemic colitis
Chronic diastolic heart failure
atrial fibrillation
benign prostatic hypertrophy
Prior CVA with residual deficits
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay. You were
admitted after a fall. You had multiple imaging studies that did
not reveal any head bleed or fractures. You were found to have a
large hematoma on your right hip. Your anticoagulation was
stopped and your blood counts were monitored for several days.
They were stable, so after discussion with your family, the
anticoagulation was restarted. You were seen by physical therapy
who recommended discharge to rehab. We wish you the best!
Your ___ care team
Followup Instructions:
___
|
19779485-DS-11
| 19,779,485 | 25,107,093 |
DS
| 11 |
2120-08-02 00:00:00
|
2120-08-03 15:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
neutropenic fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with a history of high-grade B-cell
lymphoma, C4D7 of R-CHOP, who presents with worsening cough and
temperature to 100 at home. He denies chest pain, nausea,
vomiting, or diarrhea, and has no other symptoms.
In the ED, patient was hemodynamically stable with a Tm 101.5.
His physical exam was unremarkable. ANC was 900. CXR showed
evidence of possible RLL pneumonia. He was given 1 L NS,
cefepime, and 1g acetaminophen with defervescence. He was
admitted for neutropenic fever.
On arrival to the floor, he feels okay. He still has a cough and
shortness of breath. He feels chest congestion, but no pain. He
has not had any diarrhea or GI symptoms. No rashes or mouth
sores. He has had no sick contacts & does not smoke.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- Diagnosed high-grade B-cell lymphoma on ___
- ___ PET scan- FDG avid lymphadenopathy involving the left
supraclavicular, leftaxilla, pre vascular, retroperitoneal,
mesenteric stations and spleen consistent with known lymphoma.
___ 5.
Treatment History:
C1D1 R-CHOP: ___- unable to complete rituxan
C1D8 Rituxan: ___
C2D1 R-CHOP: ___
___ PET scan after 2 cycles: Marked interval improvement
with no residual FDG avid disease. ___ 1.
C3D1 R-CHOP: ___
C4D1 R-CHOP: ___
PAST MEDICAL HISTORY:
- Bladder cancer, low grade, Now followed by Dr. ___ at
___ in ___
- HYPOGONADISM
- H/O ANABOLIC STERIOD USE
- H/O NECROTIZING FASCIITIS LUE
- Hepatitis B
Social History:
___
Family History:
- No history of lymphoma
Physical Exam:
ADMISSION PHYSICAL EXAM:
==================
Vitals: 98.3 PO 114 / 66 81 18 100 Ra
GENERAL: well appearing man, NAD
HEENT: no scleral icterus, mmm with no OP lesions
NECK: no LAD
LUNGS: normal work of breathing on room air, expiratory
wheezes
in all lung fields with no crackles
CV: rrr, no m/r/g
ABD: soft, NT/ND, normal bowel sounds
EXT: warm, no edema
SKIN: no rashes
NEURO: alert, mentating well, moving all 4 extremities, no
gross CN deficits
ACCESS: PIV
DISCHARGE PHYSICAL EXAM:
==================
Vitals: 98.1 121/65 70 18/ 94% RA
GENERAL: well appearing man, NAD, A/Ox3
HEENT: no scleral icterus, MMM with vesicle on right upper
lip,
no oropharyngeal ulcerations, EOMI
NECK: no LAD
LUNGS: unlabored respirations, rhonchi bilaterally and minimal
expiratory wheezes bilaterally
CV: RRR, no murmurs, rubs, or gallops
ABD: soft, NT/ND, normoactive bowel sounds, no rebound or
guarding
EXT: warm, no edema, no ulcers or erythema b/l on ___
SKIN: no rashes
NEURO: alert, mentating well, moving all 4 extremities, no
gross CN deficits
ACCESS: PIV
Pertinent Results:
ADMISSION LABS
===========
___ 11:30AM BLOOD WBC-1.7* RBC-3.73* Hgb-11.1* Hct-33.0*
MCV-89 MCH-29.8 MCHC-33.6 RDW-13.9 RDWSD-45.1 Plt ___
___ 11:30AM BLOOD Neuts-53 Bands-0 ___ Monos-3*
Eos-10* Baso-0 ___ Metas-1* Myelos-0 AbsNeut-0.90*
AbsLymp-0.56* AbsMono-0.05* AbsEos-0.17 AbsBaso-0.00*
___ 11:30AM BLOOD ___ PTT-23.1* ___
___ 11:30AM BLOOD Glucose-109* UreaN-12 Creat-0.9 Na-134
K-6.4* Cl-98 HCO3-22 AnGap-14
___ 01:50PM BLOOD Glucose-116* UreaN-10 Creat-1.0 Na-140
K-3.9 Cl-101 HCO3-25 AnGap-14
___ 11:30AM BLOOD ALT-26 AST-65* AlkPhos-41 TotBili-0.6
___ 01:50PM BLOOD LD(LDH)-485*
___ 11:30AM BLOOD Lipase-45
___ 11:30AM BLOOD cTropnT-<0.01
___ 11:30AM BLOOD Albumin-3.7
DISCHARGE LABS
==========
___ 07:40AM BLOOD WBC-4.3 RBC-3.67* Hgb-10.9* Hct-33.4*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.3 RDWSD-47.5* Plt ___
___ 07:40AM BLOOD Neuts-45 Bands-9* ___ Monos-4*
Eos-1 Baso-0 ___ Metas-4* Myelos-13* Promyel-2* NRBC-3*
AbsNeut-2.32 AbsLymp-0.95* AbsMono-0.17* AbsEos-0.04
AbsBaso-0.00*
___ 07:40AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-1+*
___ 07:40AM BLOOD Plt Smr-NORMAL Plt ___
___ 07:40AM BLOOD Glucose-94 UreaN-8 Creat-0.9 Na-144 K-4.5
Cl-104 HCO3-23 AnGap-17*
___ 07:40AM BLOOD ALT-159* AST-107* LD(LDH)-711* AlkPhos-75
TotBili-0.2
___ 07:40AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.3
IMAGING
======
CXR ___
Relatively linear right basilar opacities which may represent
atelectasis
though the possibility of infection is entirely possible in the
proper
clinical setting.
RUQ U/S ___:
1. No evidence of cholelithiasis or acute cholecystitis.
2. 8 x 5 x 4 mm echogenic lesion in the right hepatic ___
represent
focal fat or hemangioma.
MICROBIOLOGY
==========
___- Blood culture x 2- negative
___- Urine culture negative
___- MRSA Screen- negative
___- Respiratory virus negative
___- Vesicle testing from lip- DFA positive for ___- Strep pneumo urine antigen negative
___- B, D-Glucan <31 (negative)
___- Aspergillus galactomannan negative
___- Respiratory culture sputum- contaminant, culture not done
___- Respiratory culture sputum- culture negative
Brief Hospital Course:
Mr. ___ is a ___ man with a history of high-grade B-cell
lymphoma, C4D7 of R-CHOP, who presented with worsening cough and
a temperature to 100 at home. He was found to have a slight
infiltrate on the right on CXR, along with the clinical
constellation of symptoms suggested a pneumonia. The patient was
started on vancomycin and cefepime, along with scheduled duonebs
and PRN albuterol with good response. Also received filgrastrim
with good response in ___. He was also noted to have a cold sore
which popped up during admission and DFA revealed it was
positive for HSV-1, so was started on acyclovir.
ACTIVE ISSUES
==========
# NEUTROPENIC FEVER: Had been having a productive cough prior to
admission, and had small consolidation on CXR, so most likely
source was respiratory. Other potential sources include UTI, gut
infection, though he remained asymptomatic (no diarrhea or
constipation) and urine cultures were negative. Blood and sputum
cultures, B-D glucan, galactomannan, strep pneumo and legionella
urine antigen, and MRSA screen all were negative. Patient
received vancomycin and cefepime empirically while neutropenic.
Also received symptomatic treatment with scheduled duonebs and
PRN albuterol with good response. He received filgrastim while
neutropenic, originally on 300mg then increased to 480mg. The
patient did hit his nadir WBC on ___, but recovered quickly and
had a ANC of 2320 on discharge. On ___, ANC was 1540, so
patient was transitioned to levaquin to complete a 7 day course
for pneumonia.
#HSV-1
Pt did have a oral ulcer on lip which was positive on DFA for
HSV-1. He did not have any other rashes or vesicles and did not
appear septic, so disseminated HSV was unlikely. Was started on
acyclovir treatment dosing for HSV-1.
# B CELL LYMPHOMA:
Was admitted on C4D7 of R-CHOP. Did hit his nadir ANC on ___ of
40, but counts recovered quickly with filgrastim support. Dr.
___, was made aware of his admission and outpatient follow-up
was arranged.
# GERD
- Continued home Omeprazole 20mg daily
# HBV
- Continued home Lamivudine
# CHRONIC CONSTIPATION
- Continue docusate 100mg daily prn constipation & senna prn
constipation
# ANXIETY
- Continue home Ativan 0.5mg-1mg q8 hours prn nausea/anxiety
# BPH
- Continue Flomax 0.4mg qhs
TRANSITIONAL ISSUES
==============
[]Pt will likely need acyclovir prophylaxis when
immunosuppressed
#HCP/Contact: ___, Phone: ___
#Code: Presumed full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO DAILY:PRN constipation
2. LaMIVudine 100 mg PO DAILY
3. LORazepam 0.5-1 mg PO Q8H:PRN nausea/insomnia/anxiety
4. Omeprazole 20 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN constipation
6. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*15 Tablet Refills:*0
2. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*5
Tablet Refills:*0
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
4. LaMIVudine 100 mg PO DAILY
5. LORazepam 0.5-1 mg PO Q8H:PRN nausea/insomnia/anxiety
6. Omeprazole 20 mg PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
=====
Neutropenic Fever
Herpes simplex virus-1
Secondary
=======
High-grade B-cell lymphoma
Transaminitis
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 shortness of
breath, a cough, and a fever while your white blood cell count
was low.
While you were here, you were treated with antibiotics for a
suspected pneumonia and given a medication to help stimulate
your white blood cell counts to increase. You were also started
on a medication to help with cold sores.
You were discharged home in stable condition.
It is important you keep all of your follows (see below) and
take your medications as prescribed. You should continue to
diligently wash you hands when interacting with people, but you
don't need to wear a mask or gloves. You are allowed to go in
your school or other places with children because you are no
longer neutropenic.
It was a pleasure taking care of you, and we wish you the best
of luck!
Your ___ Care Team
Followup Instructions:
___
|
19779706-DS-16
| 19,779,706 | 27,876,832 |
DS
| 16 |
2171-03-25 00:00:00
|
2171-03-26 12:17:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Morphine Sulfate
Attending: ___.
Chief Complaint:
h/o UC s/p proctocolectomy and ileoanal pouch with rectal ca at
cuff, now s/p laparoscopic end ileostomy, p/w SBO
Major Surgical or Invasive Procedure:
___ Exploratory laparotomy
History of Present Illness:
___ h/o UC s/p proctocolectomy and ileoanal pouch with rectal ca
at cuff, now s/p laparoscopic end ileostomy, p/w SBO now s/p
ex-lap
Past Medical History:
PMH: ulcerative colitis, hypertension, diabetes mellitus
(insulin-dependent without obvious end organ damage), anxiety,
GERD, and one single episode of pancreatitis in his ___.
PSH: total colectomy and ileoanal pouch with diverting ileostomy
and subsequent ileostomy reversal in
Social History:
___
Family History:
Negative for IBD or GI cancers.
Physical Exam:
Gen: NAD
CV: RRR
Resp: nl breathing effort
Abd: ostomy functioning. skin c/d/I. min TTP.
Brief Hospital Course:
Mr ___ presented to ___ holding at ___ on ___ for a
ex lap that identified likely small bowel volvulus. He tolerated
the procedure well without complications (Please see operative
note for further details). After a brief and uneventful stay in
the PACU, the patient was transferred to the floor for further
post-operative management. Significant events included:
___: NGT placed, red rubber placed in ostomy
___: had cont abd pain, taken to OR
___: dc NGT
On ___, the patient was discharged to home. At discharge,
he was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. He will follow-up in the
clinic in ___ weeks. This information was communicated to the
patient directly prior to discharge.
Include in Brief Hospital Course for Every Patient and check of
boxes that apply:
Post-Surgical Complications During Inpatient Admission:
[x] None
Social Issues Causing a Delay in Discharge:
[x] No social factors contributing in delay of discharge.
Medications on Admission:
Medications:
1. Amlodipine 10 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Lisinopril 20 mg PO DAILY
5. Paroxetine 20 mg PO DAILY
6. Glargine 44 Units Bedtime
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Hydrochlorothiazide 25 mg PO DAILY
9. HumaLOG (insulin lispro)
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Hydrochlorothiazide 25 mg PO DAILY
5. Glargine 30 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
6. Lisinopril 20 mg PO DAILY
7. Paroxetine 20 mg PO DAILY
8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*50 Tablet Refills:*0
9. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Ulcerative colitis
Small bowel volvulus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after an exploratory
laparotomy for surgical management of your small bowel
obstruction. You have recovered from this procedure well and you
are now ready to return home. If there is an urgent need for the
surgeon to contact you regarding these results they will contact
you before this time. You have tolerated a regular diet, passing
gas and your pain is controlled with pain medications by mouth.
You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but you should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if you notice that you are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If you are taking narcotic pain
medications there is a risk that you will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If you have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if you develop a
fever. Please call the office if you develop these symptoms or
go to the emergency room if the symptoms are severe. You may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by Dr. ___ Dr. ___. You may
gradually increase your activity as tolerated.
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank you for allowing us to participate in your care! Our hope
is that you will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
19779706-DS-20
| 19,779,706 | 27,583,342 |
DS
| 20 |
2173-03-03 00:00:00
|
2173-03-03 17:37:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine Sulfate / Flomax / oxycodone
Attending: ___.
Chief Complaint:
Fatigue, Malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ UC (s/p total colectomy w/ ileostomy), urostomy, h/o CRC
s/p chemotherapy and radiation therapy, IDDM (h/o DKA) who
presents w/ fatigue, LH, and malaise for 1 day.
Patient previously had a history of ulcerative colitis s/p total
colectomy with ileoanal pouch. In ___, he was found to
have a mass at the rectal cuff, diagnosed on sigmoidoscopy as
moderately differentiated adenocarcinoma. MRI demonstrated T3N1
disease. From ___ to ___, the patient received
neoadjuvant XRT and chemotherapy w/ fluorouracil, followed by
completion proctectomy and J pouch excision in ___. He then
received six cycles of adjuvant FOLFOX from ___ to ___. He
then underwent completion pelvic exenteration with
cystoprostatectomy, ileal conduit creation, and ileostomy
creation in ___.
Patient states that his ileostomy output has been similar volume
but much more watery than usual. He also states that there has
been a darkening and a new malodor to his urostomy output.
Patient states that he essentially felt well until yesterday
early afternoon when he stood up and suddenly felt lightheaded.
Since then he has felt incredibly rundown and dehydrated.
Patient has taken his blood pressure medications at home, and
his systolic blood pressure has been in the ___ to low 100s. He
endorses mild subjective chills, no fevers/rigors, no headache,
no visual changes, no chest pain, no difficulty breathing, no
cough, no palpitations, no abdominal pain, no rash, no
arthralgias.
In the ED, initial vitals: T 103, HR 110, BP 127/69, RR 20, 100%
RA
Exam notable for: dark and cloudy urostomy output as well as
watery ileostomy output. Benign cardiopulmonary exam and
nontender/soft abdomen.
Labs notable for: wbc 28.1 (neutrophilia w/o bands), hgb 12.4,
Na 120, K 6.5, Cr 2.6, Mg 1.2, P 2.1, UA w/ wbc > 182, mod bact,
lg leuk, neg ketones. VBG ___ w/ K 5.8 and lactate 1.9.
EKG w/ HR 98 NS NI peaked T waves
Patient received: Calcium gluconate 2 g, 1 L NS, albuterol neb,
cefepime, insulin regular 10 U (1203), Tylenol ___ mg
Vitals on transfer: T 97.8, HR 99, BP 112/72, RR 17, 98% room
air
Upon arrival to ___, the patient confirms the above history. He
reports that he had several near blacking out episodes starting
the day prior to admission. He felt lightheaded, which he
attributes to dehydration. He took his blood pressure at home
and it was 70/50, so he decided to present to ___ ER. He
endorses chills and extremely watery ileostomy output beginning
the day prior to admission, as well as low back pain for several
days. He describes his ileostomy output as non-bloody, yellow
green (as opposed to brown normally). He denies shortness of
breath, cough, abdominal pain, nausea/vomiting. He denies recent
travel. He was given an additional liter of IVF upon arrival.
Past Medical History:
PMH: ulcerative colitis, hypertension, diabetes mellitus
(insulin-dependent without obvious end organ damage), anxiety,
GERD, and one single episode of pancreatitis in his ___.
PSH: total colectomy and ileoanal pouch with diverting ileostomy
and subsequent ileostomy reversal in
Social History:
___
Family History:
Negative for IBD or GI cancers.
Physical Exam:
ADMISSION EXAM:
VITALS: T 97.7F| HR 131| BP 144/73| RR 14| 99% RA
GENERAL: Patient appears flushed and fatigued
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: tachycardic, otherwise normal S1, S2 without murmurs, rubs,
or gallops
ABD: urostomy draining clear yellow urine from LUQ; ileostomy
draining green liquid output from RUQ; mild epigastric
tenderness, otherwise soft, non-distended.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no lesions noted
NEURO: patient is alert and responding to questions
appropriately
=
=
=
=
=
=
=
=
=
=
================================================================
Pertinent Results:
___ 10:19AM BLOOD WBC-28.1*# RBC-4.06* Hgb-12.4* Hct-36.9*
MCV-91 MCH-30.5 MCHC-33.6 RDW-13.6 RDWSD-45.7 Plt ___
___ 10:19AM BLOOD Glucose-315* UreaN-39* Creat-2.6*#
Na-120* K-6.5* Cl-88* HCO3-15* AnGap-17
___ 10:19AM BLOOD Calcium-8.6 Phos-2.1* Mg-1.2*
Blood culture result
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Ucx:
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 64 I
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ 05:12AM BLOOD WBC-10.7* RBC-3.88* Hgb-11.7* Hct-34.9*
MCV-90 MCH-30.2 MCHC-33.5 RDW-14.2 RDWSD-47.0* Plt ___
___ 06:11AM BLOOD WBC-15.7* RBC-3.85* Hgb-11.8* Hct-34.3*
MCV-89 MCH-30.6 MCHC-34.4 RDW-14.1 RDWSD-45.7 Plt ___
___ 05:52AM BLOOD WBC-18.4* RBC-3.59* Hgb-11.1* Hct-32.2*
MCV-90 MCH-30.9 MCHC-34.5 RDW-13.9 RDWSD-45.7 Plt ___
___ 03:18AM BLOOD WBC-18.2* RBC-3.40* Hgb-10.6* Hct-31.4*
MCV-92 MCH-31.2 MCHC-33.8 RDW-14.2 RDWSD-48.2* Plt ___
___ 02:42PM BLOOD WBC-19.8* RBC-3.51* Hgb-10.9* Hct-31.8*
MCV-91 MCH-31.1 MCHC-34.3 RDW-13.9 RDWSD-45.7 Plt ___
___ 10:19AM BLOOD WBC-28.1*# RBC-4.06* Hgb-12.4* Hct-36.9*
MCV-91 MCH-30.5 MCHC-33.6 RDW-13.6 RDWSD-45.7 Plt ___
___ 02:42PM BLOOD ___ PTT-28.3 ___
___ 05:12AM BLOOD Glucose-184* UreaN-27* Creat-1.3* Na-137
K-3.8 Cl-101 HCO3-22 AnGap-14
___ 06:11AM BLOOD Glucose-248* UreaN-29* Creat-1.4* Na-135
K-3.8 Cl-99 HCO3-21* AnGap-15
___ 05:52AM BLOOD Glucose-302* UreaN-29* Creat-1.5* Na-132*
K-4.1 Cl-97 HCO3-21* AnGap-14
___ 03:18AM BLOOD Glucose-303* UreaN-30* Creat-1.9* Na-133*
K-4.8 Cl-102 HCO3-17* AnGap-14
___ 02:42PM BLOOD Glucose-321* UreaN-39* Creat-2.4* Na-127*
K-4.6 Cl-95* HCO3-14* AnGap-18
___ 10:19AM BLOOD Glucose-315* UreaN-39* Creat-2.6*#
Na-120* K-6.5* Cl-88* HCO3-15* AnGap-17
___ 03:18AM BLOOD ALT-35 AST-17 LD(LDH)-151 AlkPhos-215*
TotBili-1.2
___ 02:42PM BLOOD ALT-44* AST-22 LD(LDH)-150 AlkPhos-253*
TotBili-1.6* DirBili-1.0* IndBili-0.6
___ 02:42PM BLOOD Lipase-5
___ 10:19AM BLOOD TSH-2.3
___ 10:19AM BLOOD Cortsol-35.3*
Renal us:
IMPRESSION:
Mild right hydroureteronephrosis, stable to slightly increased
from prior. No left hydronephrosis.
CT abdomen IMPRESSION:
1. Interval development of mild right-sided
hydroureteronephrosis without
definite obstructing calculus. Mild bilateral perinephric fat
stranding.
These findings are nonspecific and could be seen in the context
of a recently passed calculus, urinary tract infection, or non
radiopaque source of obstruction. Correlation with patient's
clinical symptoms and urinalysis is recommended.
2. No evidence of fluid collection or abscess within the abdomen
or pelvis.
3. Confluent soft tissue within the presacral space is unchanged
from previous and likely postsurgical.
Brief Hospital Course:
###FICU Course
___ w/ UC (s/p total colectomy w/ ileostomy), urostomy, h/o CRC
s/p chemotherapy and radiation therapy, IDDM (h/o DKA) who
presented w/ fatigue, LH, and malaise for 1 day.
# Sepsis due to ecoli bacteremia and UTI
Patient has hypotension to 70/50 reported on day of admission,
as well as a leukocytosis to 28, concerning for infection. While
the patient's urine was concerning given urinalysis finding of
>182 white cells and bacteria, the significance of these
findings was unclear in the setting of the patient's ileal
conduit. A GI source was also suspected given the patient's
history of increased watery ostomy output. Cultures were sent
from the patient's blood and urine, as well as C diff. The
patient was started empirically for vancomycin, cefepime, and
flagyl and CT abdomen/pelvis was obtained demonstrating mild
left hydronephrosis, but otherwise no intraabdominal process
that could explain the patient's infection. However, the
patient's blood and urine cultures resulted positive for E coli,
so he was narrowed to cefepime before being transferred to the
floor, and on the floor he was changed to IV ceftriaxone. Given
possible malabsorption in this patient, he will finish a full
treatment course (2 weeks total) with IV antibiotics at home
given through his port.
# ___:
At presentation, patient had an elevation in Cr to 2.6 from
baseline Cr 1.0. The likely cause was felt to be due to prerenal
azotemia in the setting of poor PO intake given the patient's
illness, as well as increased stool output from the patient's
ostomy. Renal U/S and CT scan were obtained demonstrating mild
left hydronephrosis; however, it was felt that the patient
likely was not obstructed given his excellent urine output.
Urology was notified regardless, given the patient's previous
surgical history. The patient's creatinine eventually improved
after several fluid boluses to 1.3 on the day of discharge. He
was instructed to have repeat labs with his PCP ___ 1 week of
discharge to ensure downtrending. Advised to continue PO and
avoid NSAIDS.
#Hypertension: was on metoprolol during admission given ___.
This improved so home atenolol restarted on discharge.
Lisinopril was held. Can consider restarting once Cr normalizes.
# DM: type 1 DM, has been hyperglycemic in the setting of
infection; ___ consulted. He will follow up with ___ after
DC.
# Anemia: Iron studies in ___ with serum iron 17,
ferritin 131, TIBC 280, and transferrin saturation of 6%,
consistent with iron deficiency or anemia of chronic disease. -
onsider iron repletion as outpatient and further work up prn
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Omeprazole 20 mg PO DAILY
4. PARoxetine 40 mg PO DAILY
5. Pyridoxine 250 mg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Glargine 50 Units Bedtime
Discharge Medications:
1. CefTRIAXone 2 gm IV Q 24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV daily
Disp #*11 Intravenous Bag Refills:*0
2. Glargine 50 Units Bedtime
3. Atenolol 25 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Omeprazole 20 mg PO DAILY
6. PARoxetine 40 mg PO DAILY
7. Pyridoxine 250 mg PO DAILY
8. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do
not restart Lisinopril until you see your PCP and have your
kidney function rechecked.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Sepsis due to E coli urine and blood infection
2. Diabetes Mellitus
3. Acute kidney injury
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 sepsis from a urinary
tract infection - a bacterial infection in your urine spread to
the blood. You were initially sent to the ICU for low blood
pressures, but you improved dramatically with IV fluids and
antibiotics. We will continue antibiotics through the IV at
home to complete a 2 week course. In addition, you were found to
have some kidney impairment and this improved with IV fluids.
Please be sure to drink fluids and avoid NSAIDs as we discussed
and have your labs rechecked within 1 week of discharge.
Followup Instructions:
___
|
19779831-DS-18
| 19,779,831 | 23,163,223 |
DS
| 18 |
2198-11-26 00:00:00
|
2198-11-30 13:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Zolpidem / gabapentin
Attending: ___.
Chief Complaint:
sharp pelvic pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ you G3P3 with h/o fibroids, AUB, and dysmenorrhea who
presented to the ED for worsening pelvic pain. She reported that
she had cramps for a month prior to presentation. She had seen
her PCP ___ ___ for nausea and vomiting and vaginal pain. She was
given medication for N/V and told to follow up with GYN, which
she did on ___. At that time, she had a nexplanon placed for
her h/o dysmenorrhea and AUB.
The norming prior to presentation, she experienced severe sudden
onset sharp pain in her pelvis. She thus presented to the ED.
In the ED she had a Pelvic US that showed:
1. Including a 4.4 cm left ovarian cyst, the left ovary measures
up to 5 cm. Normal vascularity is demonstrated in the left
ovary,
however given the patient's tenderness and size of the ovary
intermittent torsion cannot be entirely excluded. The right
ovary
is normal.
2. Enlarged fibroid uterus.
She was thus admitted to the GYN service.
Past Medical History:
Hypertension
Depression/Anxiety
IBS
Migraines
C-section and tubal ligation
Social History:
___
Family History:
Significant for mother who has hypertension. Her father died
when she was ___ and she does not know why. She has two brothers
and four sisters, all are alive and well. She has two children
who are alive and well. She had another child who died in
infancy of fever back in ___. She denies family history
of cancer. No breast or colon cancer. No heart disease, no
renal or liver disease. No family history of VTE.
Physical Exam:
Gen NAD, appears uncomfortable
CV RRR
Pulm CTAB
Back no CVAT
Abd soft, nondistended, +TTP w/ some guarding/grimacing in L
suprapubic region extending to the flank. no rebound tenderness
Ext no calf tenderness/edema
Pertinent Results:
___ 09:00PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 09:00PM URINE UCG-NEGATIVE
___ 09:45PM URINE RBC-<1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-1
___ 09:45PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:00PM GLUCOSE-89 UREA N-12 CREAT-0.9 SODIUM-139
POTASSIUM-5.2* CHLORIDE-106 TOTAL CO2-20* ANION GAP-13
___ 11:40PM PLT COUNT-202
___ 11:40PM NEUTS-54.6 ___ MONOS-8.2 EOS-1.0
BASOS-0.1 IM ___ AbsNeut-4.52 AbsLymp-2.98 AbsMono-0.68
AbsEos-0.08 AbsBaso-0.01
___ 02:00PM PLT COUNT-171
___ 02:00PM NEUTS-68.2 ___ MONOS-6.2 EOS-0.4*
BASOS-0.3 IM ___ AbsNeut-5.26 AbsLymp-1.89 AbsMono-0.48
AbsEos-0.03* AbsBaso-0.02
___ 02:00PM CALCIUM-7.5* PHOSPHATE-2.5* MAGNESIUM-1.8
___ 02:00PM GLUCOSE-94 UREA N-8 CREAT-0.6 SODIUM-138
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-21* ANION GAP-12
___ 02:14PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
due to severe abdominal pain.
On HD0, Ms. ___ continued to report ___ LLQ pain, worse
since admission. She reported her pain had been inadequately
controlled with pain medication, given that the medication made
her groggy, nauseous and light headed. She was unable to
tolerate PO due to the nausea. She otherwise denied chest pain,
shortness of breath, fever, and chills. That day she was
continually monitored for ruling out hemorrhagic or ruptured
cyst, vs GI source.
On HD1, she continued to have uncontrolled severe pain ___,
similar in characteristics to the pain endorsed on admission.
She also endorsed constipation for about a week and so she was
started on a bowel regimen.
On HD2, she continued with the pain now a ___, radiating to her
left flank. The pain was temporarily relieved by pain
medications. She was able to ambulate and had a bowel movement
with no improvement in pain. She had a CT scan of her abdomen
and pelvic which ruled out kidney stones or any other serious
etiology of patients pain.
Towards the end of HD2, her pain had improved and given negative
imagine, she was discharged home in stable condition with a
follow-up appointment in the outpatient setting the day after
discharge.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
do not take more than 4000mg in 24 hours.
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours
Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*2
3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
do not drink or drive while taking narcotics. ___ make you
drowsy.
RX *hydromorphone 2 mg 1 tablet(s) by mouth every 4 hours Disp
#*4 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service after you presented
to the emergency room with severe abdominal pain. You have been
evaluated by the gynecology team ,and you have recovered well
and the team believes you are ready to be discharged home.
Please call Dr. ___ office with any questions or
concerns. Please follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
Followup Instructions:
___
|
19779848-DS-10
| 19,779,848 | 29,649,336 |
DS
| 10 |
2152-05-20 00:00:00
|
2152-05-20 21:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
sulfamethizole / Levaquin / Penicillins / aspirin /
Cephalosporins
Attending: ___.
Chief Complaint:
Weakness and neglect concerning for stroke
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is an ___ year-old right-handed woman with past medical
history significant for multiple strokes (most recently had
right occipital stroke 1 week ago; placed on Aggrenox), and
recent grand mal seizure (started on Keppra), Hypertension,
Hyperlipidemia, Melanoma, and vascular dementia who was
transferred from OSH for a right frontal intraparenchymal
hemorrhage. She presented from the ___ nursing facility
where she had been placed on ___ after discharge from
hospital admission 1 week prior for stroke/seizure. Per the
patient's granddaughter, Ms. ___ had been at baseline with
normal conversational interaction and no notable motor deficit
in any extremities. On ___, the ___ nursing facility staff
reported Ms. ___ was last normal at 0530 hours, but was found
at 0615 hours to be unresponsive, with no witnessed seizure
activity. Of note, the skilled nursing facility staff reported
a bite on tongue and obtained vitals (T 100.8F, BP 136/96, P
___, R 18 O2 88% RA). Upon transfer to outside hospital, she
was found to have a right frontal intraparenchymal hemorrhage,
was intubated for airway protection, and transferred to ___
for further evaluation.
Neurosurgical evaluation s/p a repeat non-contrast head CT
(unchanged from her outside hospital non-contrast head CT) noted
no surgical evaluation was warranted at this time. Neurology
evaluation demonstrated left sided weakness without withdrawl
from painful stimuli in either the upper or lower extremity.
The patient was intubated but followed commands directed to
right motor activity. Her granddaughter provided additional
information regarding previous
hospitalizations and the history of her current presentation.
Prior to initially being hospitalized for seizure/stroke, she
began making paraphasic errors (words out of sequence), followed
by her right arm coming up to her head, then generalizing with
convulsions and foaming at the mouth. The Outside hospital MRI
per their discharge summary which had been obtained on ___
showed acute/subacute right occipital infarct, old left
occipital infarct, and a possible old right frontal lobe stroke.
She was continued on Aggrenox during that admission and started
on Keppra as an anti-epileptic.
Past Medical History:
- Right occipital stroke in addition to 3 prior strokes per
family
- Seizure disorder (reportedly has history of disease, but was
off meds for ___ years without any event)
- Hyponatremia
- Hypertension
- Hyperlipidemia
- Glucose intolerance
- Vascular dementia (+/- Alzheimers)
- Monoclonal Gammopathy of Unknown Significance
- Thrombocytopenia (Chronic)
- Melanoma (s/p excision, lymph node dissection in ___
- Hiatal hernia
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
Vitals: Tc=98.4, Tmax=99.5, BP=122/39-144/49, HR=57-78,
___, O2: 97% RA
General: Awake, Cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Rhonchorous, no Rales/Wheezes
Cardiac: RRR, no M/R/G
Abdomen: S/NT/ND +BS
Extremities: no edema, ecchymoses scattered throughout.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, awake, oriented only to self. Able to
follow commands with repetitive stimulation in R extremities,
but not in L. Language is fluent with intact repetition and
comprehension. Slow prosody with short answers.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation on right,
with persistent R gaze preference.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Left facial droop, L blunting nasolabial fold
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 3 ___ ___ 2 3 3 3 3 3 3
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 3 2 1
R 2 2 2 2 1
Plantar response was upgoing on left, equivocal on right.
-Coordination: Did not assess
-Gait: Did not assess
Physical Exam on Discharge:
Neurologic:
-Mental Status: Alert, awake, oriented only to self and
hospital. Improved global perseveration (language and motor)
Able to follow commands both extremities R more than left.
Language is fluent with intact repetition and comprehension.
Slow prosody with short answers. Unable to name months of the
year backwards.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch
-Coordination: Able to finger face finger grossly bilaterally
-Gait: Did not assess
Pertinent Results:
SELECTED ADMISSION LABS:
___ 01:40PM BLOOD ___ PTT-29.1 ___
___ 01:40PM BLOOD WBC-13.1* RBC-5.28 Hgb-14.8 Hct-44.6
MCV-85 MCH-28.0 MCHC-33.1 RDW-15.5 Plt ___
___ 01:40PM BLOOD Glucose-135* UreaN-15 Creat-1.0 Na-130*
K-4.5 Cl-98 HCO3-17* AnGap-20
___ 01:40PM BLOOD ALT-12 AST-36 AlkPhos-92 TotBili-0.3
___ 01:40PM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.6 Mg-1.9
___ 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:43PM BLOOD Lactate-1.6
___ 03:56PM BLOOD Type-ART Rates-/___ Tidal V-450 PEEP-5
FiO2-50 pO2-186* pCO2-32* pH-7.49* calTCO2-25 Base XS-2
-ASSIST/CON Intubat-INTUBATED
Relevant Labs:
___ 06:10AM BLOOD Ret Aut-1.2
___ 10:18PM BLOOD CK-MB-4 cTropnT-0.06*
___ 09:34AM BLOOD CK-MB-6 cTropnT-0.07*
___ 03:10AM BLOOD cTropnT-0.07*
___ 06:10AM BLOOD calTIBC-166* Hapto-171 TRF-128*
___ 06:10AM BLOOD %HbA1c-5.9 eAG-123
___ 06:10AM BLOOD Triglyc-64 HDL-50 CHOL/HD-2.1 LDLcalc-43
Microbiology:
___ 8:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
CITROBACTER KOSERI. >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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER ___
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood culture ___: no growth
SELECTED IMAGING STUDIES:
- PORTABLE CHEST: ___, IMPRESSION: Endotracheal tube
tip 3.5 cm from the carina. No definite acute cardiopulmonary
process.
- CT HEAD W/O CONTRAST: ___, IMPRESSION: Unchanged 4.5
x 3.1 cm right frontal intraparenchymal hemorrhage and
intraventricular hemorrhage.
- PORTABLE HEAD CT W/O CONTRAST: ___, IMPRESSION:
Interval decrease in size of right frontal intraparenchymal
hemorrhage with no change in surrounding edema or midline shift.
- MR HEAD W/ CONTRAST; MRA BRAIN W/O CONTRAST; MRV HEAD W/O
CONTRAST; MRA NECK W&W/O CONTRAST: ___, IMPRESSION:
1. Large intraparenchymal hemorrhage in the right frontal lobe
with
associated vasogenic edema. Hemorrhagic infarction is felt
unlikely, as the overlying cortex is intact. Likely etiologies
of this findings likely represent hypertensive hemorrhage or
amyloid angiopathy. An underlying AV malformation, which is
tamponaded by the overlying hemorrhages is also a differential
consideration.
2. Multifocal stenoses of the intracranial vessels likely
reflect
atherosclerotic disease, however, inflammatory causes are also
considered. It
is unlikely to represent hemorrhage-related vasospasm due to
distribution.
3. Cervical vessels demonstrate no stenosis.
Labs on Discharge:
___ 07:10AM BLOOD WBC-4.0 RBC-3.46* Hgb-9.6* Hct-29.3*
MCV-85 MCH-27.6 MCHC-32.6 RDW-16.6* Plt ___
___ 07:10AM BLOOD Glucose-103* UreaN-5* Creat-0.6 Na-140
K-3.3 Cl-111* HCO3-22 AnGap-10
___ 07:10AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.7
Brief Hospital Course:
Ms. ___ is an ___ year-old right-handed woman with past history
significant for multiple strokes, grand mal seizure, HTN, HL,
and vascular dementia who was transferred from OSH with new
right frontal intraparenchymal hemorrhage.
# Neuro: Ms. ___ presented from her skilled nursing facility,
where she had been placed upon discharge for her previous right
occipital stroke hospitalization on ___, with
unresponsiveness, not moving her left side, and with a tongue
bite. Upon transfer to the outside hospital, she was found to
have a right frontal IPH,
was intubated for airway protection, and transferred to ___
for further evaluation. In the ED, the patient was found to be
responsive to commands on the right side with good strength in
her upper and lower extremity; however, she had no antigravity
left extremity movement and of note, had a right gaze preference
without crossing the midline. She had two non-contrast head CT
imaging studies for comparison, one performed at the outside
hospital initially presented to from her skilled nursing
facility and two studies performed at ___ which redemonstrated
the 3.1 x 4.5 cm right frontal intraparenchymal hemorrhage with
surrounding vasogenic edema that causes minimal shift of the
anterior falx towards the left approximately 3 mm with
effacement of the adjacent sulci. This studies were not
significantly changed from each other.
Ms. ___ was brought to the ICU for further monitoring given her
intubation and ventilator dependant respiratory failure. Due to
her recent hospitalization for seizures and questionable
presence of a seizure leading to being found down by her skilled
nursing facility, her Keppra dosage was increased from 500mg
twice a day to 750mg twice a day. On repeat evaluation in the
ICU, the patient was seen to have decreased responsiveness to
commands, but was moving her left lower extremity more
spontaneously, more evident distally. On ___, the patient
was extubated after passing her spontaneous breathing trial. She
was awake, and oriented only to self. She was able to follow
basic commands including squeezing hands with the right upper
extremity, lift her right lower extremity, and lift also her
left lower extremity with much effort. She progressed in terms
of strength and comprehension over the next ___ hours and was
able to grasp fingers with either hand, as well as demonstrate
anti-gravity strength in both upper extremities. She remained
oriented only to self during this time. Over the next few days
she continued to immproved so that upon discharge on *** she was
oriented to self and location, she was able to follow commands,
she was fluent with good repitition, was poorly innattentive in
that she could not do the months of the year backwards, her
strength improved to ___ bilaterally throughout. She passed her
swallow study ___ and was tolerating PO intake.
From an anticoagulation perspective, her Aggrenox was held due
to her hemmorhage. However, on ___ her aspirin of 325mg was
restarted as head CT was stable. On ___ subcut heparin DVT
prophylaxis was started.
Of note, on imaging, she had a right frontoparietal lesion which
was most likely ischemic stroke, but somewhat concerning for
mass lesion. She will have a repeat MRI 6 weeks after discharge
to assess for interval change. She will f/u with Dr. ___ in
stroke clinic.
# Cardiac:
On presentation, patient was allowed to autoregulate blood
pressure if systolic blood pressure remained below 160 mmHg with
Nicardipine IV for any elevated blood pressure. In the ICU, the
Nicardipine was changed to by mouth antihypertensives which
continued maintaining the patient in the desired blood pressure
range. On the floor she was started on lisinopril of 20mg daily
to control her BP. Continued her home ___. Her LDL was
found to be 43 and she was started on her simvistatin 10mg
daily. Her troponins peaked at 0.06.
# ID:
While in the ICU, blood and urine cultures for Ms. ___ were
obtained with the latter coming back positive for a urinary
tract infection. Given the patients allergies, 2 doses of
Fosfomycin was administered. She will need 1 more dose to
complete full course of treatment for complicated UTI. Of note,
an outside hospital blood culture from ___ grew GNR in 1 of ___s strep viridans. The strep viridans was
thought to be a contaminant. The GNRs were not able to be
speciated at ___ and were sent to a reference
lab. Results not availabe at time of discharge. VERY low
suspicion for bacteremia as multiple repeat blood cultures
were negative.
# Endocrine:
Fingerstick glucose checks were performed on a regular basis to
ensure Ms. ___ remained euglycemic. Any elevation was treated
with insulin based on hospital protocol sliding scale. Her
HgBA1c was noted to be 5.9
# GI:
Ms. ___ experienced no gastrointestinal complaints during her
inpatient stay. She was prophylaxed with a H2-Blocker in
accordance with protocol. After extubation, given her
orientation only to self, there was concern for aspiration with
by mouth feeding. The patient had a nasogastric tube placed,
which was repositioned due to questionable confirmatory imaging
complicated by her known hiatal hernia. The patient pulled out
her NG tube on ___, but she plassed her swallow study and was
started on PO nutrition.
# Heme:
Ms. ___ was found to have a hemoglobin drop, in part due to
hemodilutional effect of providing IV fluids and also because
she was tranfused with blood products shortly before transfer to
___, thus, admission hct was above her baseline. Anemia labs
were ordered for the patient which revealed low Fe & TIBC, TF.
retics inapprop low; low TIBC which is c/w Anemia of chronic
disease. No ferritin was sent.
TRANSITIONS OF CARE:
-will need 1 dose of Fosfomycin 3g to complete treatment for UTI
-will have MRI w/ and w/o contrast of the brain to assess for
interval change
-will f/u with Dr. ___ in stroke clinic
-pt with questionable allergy to aspirin, will need to be
monitored (LOW suspicion for allergy as was on aggrenox and
tolerated)
1. Dysphagia screening before any PO intake? (x) Yes - () 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 =43 ) - () No
5. Intensive statin therapy administered? (for LDL > 100) () Yes
- (x) No (if LDL >100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - () unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on antithrombotic therapy? (x) Yes (Type: (x)
Antiplatelet - () Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
-Aggrenox by mouth twice a day
-Keppra 500mg by mouth twice a day (to be increased to 750 mg
bid in 2 weeks)
-Norvasc 5mg by mouth daily
-Zocor 40mg by mouth each evening
-Celexa 20mg by mouth daily
-Aricept 5mg by mouth daily
-Doxycycline 1000mg by mouth twice a day (to be completed
___
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Donepezil 5 mg PO HS
4. Fosfomycin Tromethamine 3 g PO ONCE Duration: 1 Doses
Dissolve in ___ oz (90-120 mL) water and take immediately;
please administer on ___. LeVETiracetam 750 mg PO BID
6. Lisinopril 20 mg PO DAILY
7. Nystatin Oral Suspension 5 mL PO QID
8. Simvastatin 10 mg PO DAILY
9. Aspirin 325 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right frontal parenchymal hemorrhage
Discharge Condition:
Neurologic:
-Mental Status: Alert, awake, oriented only to self and
hospital. Improved global perseveration (language and motor)
Able to follow commands both extremities R more than left.
Language is fluent with intact repetition and comprehension.
Slow prosody with short answers. Unable to name months of the
year backwards.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch
-Coordination: Able to finger face finger grossly bilaterally
-Gait: Did not assess
Discharge Instructions:
Dear Ms. ___,
You were transferred to the ___ from
___ with a small bleed in your brain. We
monitored you carefully and you did well. Gradually, your
symptoms improved.
We have made the following changes to your medications:
STOP
Aggrenox
Zocor
Doxycycline
INCREASE
Keppra to 750mg twice per day
START
Lisinopril 20mg daily
Simvastatin 10mg daily
Nystatin oral suspension 4 times per day as needed for mild
thrush
Fosfomycin 3g for 1 dose on ___
You have been schedule to follow up with your stroke
neurologist, Dr. ___ on in the ___ on the ___
floor of ___ as scheduled below.
On the same day of your appointment with Dr. ___ are
scheduled for an MRI of your head.
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
___
|
19779848-DS-11
| 19,779,848 | 28,292,003 |
DS
| 11 |
2153-05-23 00:00:00
|
2153-05-23 18:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
sulfamethizole / Levaquin / Penicillins / aspirin /
Cephalosporins
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Ms. ___ is a ___ yo RH woman with PMH of multiple strokes (both
ischemic and right frontal IPH) and history of GTC who presented
with seizure activity from nursing home.
Her nursing home, little before 2 pm, her roommate called for
help because the patient "did not look right" and she was found
slumped over in her chair, foaming at the mouth and convulsing.
EMS was called and she continued to convulse about x10 minutes
until EMS got there. O2 sat ranging 85-95, heart rate in
120-150s. She was given midazolam 2.5 mg x2 which stopped the
seizure activity but her respiratory status deteriorated
(recorded unassisted respiratory rate of 5 or so) and she was
intubated given concern for her airway. She was taken to OSH ED
where her CT head was reportedly negative for acute process,
given additional levetiracetam (750 mg x1) and transferred to
___. Her BP was low at OSH ED, SBP down to 70-80s but improved
with fluids.
In ___ ED, she continued to be intubated without clinically
overt seizure activity.
Unable to obtain ROS.
Past Medical History:
___ (per last DC summary):
- Right occipital stroke in addition to 3 prior strokes per
family
- Seizure disorder (reportedly has history of disease, but was
off meds for ___ years without any event)
- Hyponatremia
- Hypertension
- Hyperlipidemia
- Glucose intolerance
- Vascular dementia (+/- Alzheimers)
- Monoclonal Gammopathy of Unknown Significance
- Thrombocytopenia (Chronic)
- Melanoma (s/p excision, lymph node dissection in ___
- Hiatal hernia
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission exam:
General: intubated, off sedation for x5-10 minutes
HEENT: NC/AT; dried blood around mouth
Neck: when head is lifted, lifts off the bed instead of flexing
forward. No flexion noted at the hips.
Pulmonary: CTABL
Cardiac: soft heart sounds, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, warm to touch
Skin: no rashes or lesions noted.
Neurologic:
Patient is intubated. After about 5 minutes off propofol,
responds better to voice. Does not quite open eyes to command.
Patient grabs the examiner's hand very tightly if it is placed
in
her R hand, but does let go when asked to. Can show her thumb,
but does not show two fingers. When asked questions, mouths some
words but examiner could not understand. Appears to have some L
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm and brisk bilaterally. Decreased blink to
threat on L.
III, IV, VI: roving eye movement, with voice, can look to R
fully
but does not look fully to left
V: +corneal bilaterally
VII: Unable to determine facial droop due to ET tube/holder
VIII: looks to voice, R>L
IX, X, XI, XII: unable to test
-Motor: atrophy in arms, increased tone/paratonia. Patient moves
R arm/leg spontaneously at least antigravity, though her finger
grip is quite strong. No spontaneous movement on LUE/LLE but
does
withdraw them from noxious stimuli, LLE more briskly than LUE.
-Sensory: withdraws from noxious stimuli.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was extensor bilaterally.
-Coordination: unable to test
-Gait: unable to test
.
Discharge exam:
98.2 / 98.2 ___ 57-66 18 96-100% RA
GEN: NAD NT ND lying in bed
HEENT: NC/AT MMM no dentition
CV: RRR no m/r/g
Pulm: ctab no r/r/w
Abd: soft nt nd nabs
Extrem: cool, well perfused no /c/ce prominent onchomycosis in
toes
Neuro:
- MS: A&O to self. Knows "hospital" not which, thinks year is
___, month is ___. Days of week in reverse promptly without
difficulty. Interactive, cooperative, follows commands. Language
intact - fluent, repeats normally, comprehends. No dysarthria.
- CN: PERRL 3-> 1.5 ___, EOMI sensation to touch equal, mild
flattening of left nasolabial fold, mild left ptosis, hearing
decreased on right, palate midline, shrug full strength, tongue
midline.
- Motor: 5+ globally except left triceps (5-), left finger
extensors (4+) and left ___ (4 but pain limited). No drift.
Withdraws to Babinski bilaterally.
- Sensory: Globally intact to touch and temperature. FNF
proprioception nl with eyes closed. Romberg deferred.
- Reflexes: 2+ bic, 2+ tric, 1 ___, 2+ left quad 1+ righ tquad
- Cerebellar: No dysmetria, intention tremor
- Gait: deferred
Pertinent Results:
Admission labs:
___ 07:20PM BLOOD WBC-11.7* RBC-4.14* Hgb-12.3 Hct-37.5
MCV-91 MCH-29.8 MCHC-32.9 RDW-15.1 Plt ___
___ 07:20PM BLOOD Neuts-90.9* Lymphs-4.1* Monos-4.7 Eos-0.1
Baso-0.2
___ 07:20PM BLOOD Plt ___
___ 04:04AM BLOOD ___ PTT-21.2* ___
___ 07:20PM BLOOD Glucose-150* UreaN-11 Creat-0.9 Na-143
K-3.7 Cl-107 HCO3-21* AnGap-19
___ 07:20PM BLOOD ALT-13 AST-25 AlkPhos-97 TotBili-0.2
___ 04:04AM BLOOD ALT-14 AST-31 LD(LDH)-222 CK(CPK)-141
AlkPhos-80 TotBili-0.1 DirBili-0.0 IndBili-0.1
___ 07:20PM BLOOD Lipase-28
___ 07:20PM BLOOD cTropnT-0.05*
___ 04:04AM BLOOD CK-MB-6 cTropnT-0.05*
___ 07:20PM BLOOD Albumin-3.0* Calcium-8.7 Phos-3.6 Mg-1.9
___ 07:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:43PM BLOOD Lactate-3.4*
.
Studies:
EKG ___
Normal sinus rhythm with A-V conduction delay. Low voltage in
the precordial leads. No previous tracing available for
comparison.
.
CXR ___
FINDINGS:
Endotracheal tube terminates 2.5 cm above the carina. An
enteric tube distal side port at the level of GE junction/distal
esophagus. Recommend advancement of the skull through the
stomach. Stomach is mildly distended with air. The ascending
aorta appears slightly prominent and there is a prominent
density adjacent to the left heart border, underlying aortic
aneurysm is not excluded versus other mass. Correlate with
prior imaging/history. Depending on this and the clinical
scenario, consider followup chest CT for further evaluation. No
pleural effusion or pneumothorax is seen. The aorta is
calcified. The cardiac silhouette is top-normal. Right
axillary surgical clips are seen.
There is a rounded 4 point cm calcification projecting over the
right upper abdomen, unclear whether external to the patient or
possibly representing a gallstone.
Deformity of the posterolateral right ___ and 6th ribs raise
concern for
fractures of indeterminate age.
.
EEG ___
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of continuous focal slowing and attenuation of faster
frequencies, including the alpha rhythm, over the right
hemisphere. These findings are indicative of a focal structural
lesion in the right hemisphere and are consistent with the
clinical history of a right hemisphere stroke. Additionally,
there is diffuse slowing in both hemispheres which is
indicative of moderate cerebral dysfunction which is
etiologically non-specific. There are occasional left temporal
epileptiform discharges which are indicative of a potentially
epileptogenic focus in the left temporal region. No
electrographic seizures
are seen.
.
___ Head CT
IMPRESSION:
1. No evidence of an acute intracranial process. MRI would be
more sensitive for an acute infarction, if clinically indicated.
2. Cystic encephalomalacia at the site of prior right frontal
hemorrhage.
Stable small chronic left occipital cortical infarct and
multiple chronic
white matter infarcts.
.
___ Liver/Gallbladder ultrasound
IMPRESSION:
1. Minimal sludge in the gallbladder. There are no sonographic
signs of
cholecystitis.
2. No biliary dilatation. No findings to suggest a cause of the
patient's RUQ tenderness.
.
___ Renal ultrasound
IMPRESSION:
No evidence of hydronephrosis. Bilateral simple cysts. Atrophic
left lidney.
.
Discharge labs:
___ 03:28AM BLOOD WBC-3.9* RBC-3.40* Hgb-10.0* Hct-29.9*
MCV-88 MCH-29.3 MCHC-33.4 RDW-15.5 Plt ___
___ 03:28AM BLOOD Plt ___
___ 03:28AM BLOOD ___ PTT-64.6* ___
___ 03:28AM BLOOD Glucose-86 UreaN-6 Creat-0.8 Na-144 K-3.3
Cl-114* HCO3-20* AnGap-13
___ 03:28AM BLOOD ALT-14 AST-24 AlkPhos-88 TotBili-0.2
___ 03:28AM BLOOD Albumin-2.5* Calcium-8.0* Phos-2.2*
Mg-2.1
___ 03:37AM BLOOD Lactate-1.0
Brief Hospital Course:
Mrs. ___ is a ___ yo RH woman with PMH of multiple strokes,
seizures, HTN, HL, and vascular dementia who presented from
nursing home with a prolonged seizure. Neurologic examination
was
notable for L sided weakness, which was documented on her last
admission (though improved prior to discharge), but resolved in
hospital. There was no clear trigger to her seizure - per her
nursing home, she
was still taking Keppra 750 mg BID, there is some concern for
infection given her fevers and leukocytosis though the source is
not clear at this time. She did well in hospital on an increased
Keppra dose and had no further seizures.
.
ACTIVE ISSUES
# Seizures: Multiple strokes in the past and seizures. Patient
presented with a single seizure despite taking her Keppra. She
was initially intubated and sent to the neurologic ICU but did
well and was transferred to the floor on an increased Keppra
dose (1250mg BID). She had no further events on the floor. No
new cause could be found on head CT; she has chronic changes
which predispose her to events. No infectious triggers were
found either (UA, UCx, BCx, CXR); she was briefly on broad
spectrum antibiotics in the emergency department. Increased dose
of Keppra to 1250mg BID.
.
# Anemia: Likely hemoconcentrated at time of admission; baseline
unclear. Stable hemodynamically, clinically. Hct approximately
30.
.
INACTIVE ISSUES
#HTN, HLD: Elevated troponin in ED, HTN but no evidence of acute
coronary syndrome. Patient was monitored on telemetry.
.
# Vascular dementia: Continued treatment regimen including
donepezil, citalopram, mirtazapine.
.
# Question hypothyroid: continued home levothyroxine
.
# MGUS: No evidence of acute change.
.
TRANSITIONAL ISSUES
# SEIZURES: No new cause; monitor for control on INCREASED
Keppra dose (admitted on 750 BID, discharged on 1250mg BID)
.
# LEVOTHYROXINE: Please clarify whether patient should be on
levothyroxine; no dose changes made while in hospital.
.
# INFECTIOUS w/u: Please FOLLOW UP BLOOD CULTURES
.
# ANEMIA: Please follow hematocrit on an outpatient basis.
.
# POSSIBLE CERVICAL SPONDYLOSIS: Consider imaging.
.
# DENSITY ADJACAENT TO LEFT HEART BORDER: Please refer to scans
here; consider follow-up imaging.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acidophilus Probiotic *NF* (acidophilus-pectin, citrus) 100
million-10 cell-mg Oral daily
2. Donepezil 5 mg PO HS
3. FoLIC Acid 1 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Amlodipine 5 mg PO DAILY
6. Simvastatin 10 mg PO DAILY
7. LeVETiracetam 750 mg PO BID
8. Citalopram 10 mg PO DAILY
9. Mirtazapine 7.5 mg PO HS
10. Ferrous Sulfate 325 mg PO DAILY
11. Vitamin D 1000 UNIT PO BID
12. Ascorbic Acid ___ mg PO BID
13. Enoxaparin Sodium 30 mg SC DAILY
14. Docusate Sodium 100 mg PO BID
15. Senna 1 TAB PO BID
16. Polyethylene Glycol 17 g PO DAILY
17. Fleet Enema ___AILY:PRN constipation
18. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Discharge Medications:
1. Citalopram 10 mg PO DAILY
2. Donepezil 5 mg PO HS
3. Ferrous Sulfate 325 mg PO DAILY
4. LeVETiracetam Oral Solution 1250 mg PO BID
5. Mirtazapine 7.5 mg PO HS
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 1 TAB PO BID
8. Vitamin D 1000 UNIT PO BID
9. Simvastatin 10 mg PO DAILY
10. Acidophilus Probiotic *NF* (acidophilus-pectin, citrus) 100
million-10 cell-mg Oral daily
11. Amlodipine 5 mg PO DAILY
12. Ascorbic Acid ___ mg PO BID
13. Docusate Sodium 100 mg PO BID
14. Enoxaparin Sodium 30 mg SC DAILY
15. Fleet Enema ___AILY:PRN constipation
16. FoLIC Acid 1 mg PO DAILY
17. Lisinopril 20 mg PO DAILY
18. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent though not oriented to year
(___) or exact locations (knows this is a hospital.
Level of Consciousness: Alert and interactive.
Activity Status: At baseline.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you during your hospital stay. You
were admitted with a seizure. No new cause of seizure was found.
We increased your Keppra from 750mg two times per day to 1250mg
two times per day. You responded well to this and had no new
seizures. Your hospital course was otherwise uneventful.
Your medication list has changed.
CHANGE
1. Keppra 750mg two times per day to 1250mg two times per day
OTHERWISE, continue all of your pre-admission medications
WITHOUT CHANGE. Please make sure all of your medications are
carefully reconciled. It is unclear whether you have been on
levothyroxine at your nursing home. Please discuss this with the
nursing home physician AS SOON as you return to your facility.
Please return to the emergency department below if you have any
of the "danger signs" below.
Followup Instructions:
___
|
19780070-DS-6
| 19,780,070 | 27,629,023 |
DS
| 6 |
2129-07-20 00:00:00
|
2129-07-20 17:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
Cardiac Catheterization with PCI to RCA ___
History of Present Illness:
Mr. ___ is a ___ y/o male with a history of HTN, tobacco use
disorder, limited medical care who presents s/p cardiac arrest.
History obtained through EMS/ED report, and family.
Per EMS, the patient was in the locker room at his work when a
coworker saw him, went across the room, and then heard a thump.
CPR was started immediately and EMS was called. On arrival, EMS
noted PEA arrest and were able to obtain ROSC with CPR alone. No
medications or shocks were delivered. Rhythm strip showed STE in
II, III, aVF, and reciprocal depressions in aVL.
Per family, the patient had not reported recent symptoms though
typically doesn't. No fever, chills, chest pain, shortness of
breath, cough, abdominal pain, nausea, vomiting or diarrhea. Of
note, he returned from a five day trip to ___ ___ days
ago.
He has had limited medical care, last PCP visit was ___ years
ago. Was noted to be hypertensive during a recent work up for
dental procedure.
In the ED,
Initial Vitals: Temp 35.5 BP 93/67 HR 70 RR 16 96% on vent
Exam: Sedated, unresponsive, PERRL. RRR, CTAB. Spontaneous
movements, gapping, not following commands
Labs:
- Na 139, K 4.2, CO2 15, BUN 21, Cr 1.1, AG 20
- WBC 12.6, H/H 16.5/52.9, plt 238
- ALT 423, AST 265, AP 72, lipase 36
- Trop-T <0.01
- VBG 7.22/41 -> 7.27/44
- Lactate 8.2
- Serum/urine tox negative
- UA: mod blood, 30 protein, 1000 glucose, trace ketones
Imaging:
- CXR: ETT in place. Central pulmonary congestion without
pulmonary edema.
- CT head:
1. No intracranial hemorrhage
2. Hypodensity in the central midbrain could represent an
acute/subacute infarct versus artifact. MRI could further
assess.
3. Fluid in the nasopharynx and ethmoid sinuses compatible with
recent
intubation.
4. Few sclerotic osseous foci suggest bone islands, nonspecific.
- CTA torso: No large pulmonary embolism or dissection
Consults:
- Post-arrest: artic sun pads and TTM, cEEG if not following
commands.
- Cardiology: plan for LHC.
- Neurology: Consulted given hypodensity seen on CT head.
Recommended MRI brain.
Interventions: The patient was intubated upon arrival here.
VS Prior to Transfer: Temp 35.8F BP 113/76 HR 56 RR 16 100% on
vent
The patient was sent to the cath lab, where LHC showed 60%
stenosis of left main, 80% in LAD osteium, and 90% stenosis of
RCA in mid and distal segments. Recommended Csurg evaluation
given severe two vessel disease.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
Hypertension
Social History:
___
Family History:
Father with CVD, died of MI at age ___. MGF died of MI at age ___
as well. Mother is living, does not see a doctor regularly.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: Temp 97.8F BP 132/88 HR 63 RR 20 100% on vent
GEN: WDWN male in NAD. Lying motionless in bed.
HEENT: NC/AT. Sclera anicteric. ETT in place.
NECK: Supple.
CV: RRR with normal S1 and S2. No m/r/g.
RESP: Mechanical ventilations, CTAB without wheezes, rales or
rhonchi over anterior chest.
GI: Soft, non-distended. Normoactive BS. No masses appreciated.
MSK: Cool BLE. No ___ edema or erythema.
SKIN: Dry. No rashes.
NEURO: Pupils 2-3 mm, minimally reactive. Responds to sternal
rub, not to painful stimuli over upper extremities. Does not
follow commands. Moving all extremities.
DISCHARGE PHYSICAL EXAM:
=========================
VS: 98.7, BP 159/89, HR 71, RR 20, O2 sat 92% Ra
Weight: 104.6 kg, 230.6 lbs
GEN: NAD. Laying in bed. Well-appearing.
NECK: Supple. No JVD.
CV: RRR with normal S1 and S2. No m/r/g.
RESP: CTAB without wheezes, rales. Non-labored laying flat.
GI: Soft, non-distended. Normoactive BS. No masses appreciated.
MSK: WWP. No ___ edema or erythema.
SKIN: Dry. No rashes.
NEURO: A&O x3, following commands. Moving all extremities.
ACCESS: RRA without hematoma, ecchymosis, drainage, CSM intact
distally.
Pertinent Results:
ADMISSION LABS
===============
___ 06:33AM BLOOD WBC-12.6* RBC-5.13 Hgb-16.5 Hct-52.9*
MCV-103* MCH-32.2* MCHC-31.2* RDW-12.8 RDWSD-49.0* Plt ___
___ 06:33AM BLOOD Neuts-60 ___ Monos-6 Eos-1 Baso-1
Metas-2* AbsNeut-7.56* AbsLymp-3.78* AbsMono-0.76 AbsEos-0.13
AbsBaso-0.13*
___ 06:33AM BLOOD ___ PTT-25.4 ___
___ 06:33AM BLOOD Glucose-297* UreaN-21* Creat-1.1 Na-139
K-4.2 Cl-100 HCO3-15* AnGap-20*
___ 06:33AM BLOOD ALT-423* AST-265* CK(CPK)-387* AlkPhos-72
TotBili-0.5
___ 06:33AM BLOOD CK-MB-8
___ 06:33AM BLOOD cTropnT-<0.01
___ 12:22PM BLOOD CK-MB-35* MB Indx-2.6 cTropnT-0.44*
___ 06:37PM BLOOD CK-MB-45* MB Indx-2.0 cTropnT-0.29*
___ 04:42AM BLOOD CK-MB-28* MB Indx-2.5 cTropnT-0.18*
___ 06:33AM BLOOD Albumin-4.4 Calcium-8.3* Phos-5.3* Mg-2.1
___ 06:37PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 06:33AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:37PM BLOOD HCV Ab-NEG
___ 06:39AM BLOOD ___ pO2-74* pCO2-41 pH-7.22*
calTCO2-18* Base XS--10
___ 06:39AM BLOOD Glucose-296* Lactate-8.2* Creat-0.9
Na-133* K-3.7 Cl-107 calHCO3-16*
___ 06:39AM BLOOD Hgb-17.0 calcHCT-51 O2 Sat-88
PERTINENT INTERVAL LABS
========================
___ 12:22PM BLOOD ALT-415* AST-270* LD(LDH)-686*
CK(CPK)-1327* AlkPhos-64 TotBili-0.6
___ 06:37PM BLOOD ALT-352* AST-218* LD(LDH)-586*
CK(CPK)-2197* AlkPhos-62 TotBili-0.6
___ 04:42AM BLOOD ALT-266* AST-128* LD(___)-365*
CK(CPK)-1139* AlkPhos-51 TotBili-0.7
___ 02:59PM BLOOD ALT-224* AST-92* LD(LDH)-287* AlkPhos-47
TotBili-0.6
___ 04:42AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.8 Cholest-133
___ 04:42AM BLOOD %HbA1c-6.3* eAG-134*
___ 04:42AM BLOOD Triglyc-97 HDL-39* CHOL/HD-3.4 LDLcalc-75
IMAGING
=========
EEG (___)
-------------
IMPRESSION: This continuous ICU monitoring study was abnormal
due to:
1. Occasional bursts of frontally predominant semi-rhythmic
slowing,
suggestive of dysfunction of deeper structures.
2. Superimposed faster frequencies were likely due to medication
effect.
3. Generalized background slowing suggestive of a moderate to
severe
encephalopathy, non-specific in etiology, however toxic
metabolic
disturbances, infection, or medication effect are possible
causes.
There were no push button events. There were no focal findings,
epileptiform discharges, or electrographic seizures.
CXR (___)
-------------
IMPRESSION:
1. Endotracheal tube in standard position. NG tube should be
repositioned and advanced 8-10 cm.
2. Likely central pulmonary congestion without pulmonary edema.
CTA TORSO (___)
-------------------
IMPRESSION:
1. No evidence of aortic dissection or pulmonary embolism.
2. Borderline aneurysmal enlargement of the proximal common
iliac arteries and proximal left internal iliac artery as
described above.
3. Nasogastric tube is demonstrated with the side port near the
GE junction, recommend advancement so that it is well within the
stomach.
4. Other incidental findings as noted above.
CT HEAD W/O CON (___)
IMPRESSION:
1. No intracranial hemorrhage
2. Hypodensity in the central midbrain could represent an
acute/subacute
infarct versus artifact. MRI could further assess.
3. Fluid in the nasopharynx and ethmoid sinuses compatible with
recent
intubation.
4. Few sclerotic osseous foci suggest bone islands, nonspecific.
CTA HEAD AND NECK (___)
IMPRESSION:
1. No evidence of mass, hemorrhage or infarction. The
hypodensity in the
brainstem seen on the head CT of ___ is not detected on
the current
examination. If further evaluation is indicated, consider MR
imaging.
2. Mild-to-moderate calcified plaque, mild luminal narrowing,
intracranial
ICAs bilaterally. Otherwise, widely patent and normal circle of
___. No aneurysm or large vessel occlusion.
3. Patent bilateral extracranial vertebral and carotid arteries.
Calcified plaque causes 20% luminal narrowing of the right
extracranial ICA by NASCET criteria. Severe luminal narrowing
of the right vertebral artery origin due to calcified plaque.
Remainder of the vertebral and carotid arteries are widely
patent.
4. Ill-defined hypodensity in the supratentorial white matter
bilaterally most likely represents moderate changes of chronic
white matter microangiopathy, however if there is clinical
concern for subacute ischemia, consider MRI for further
evaluation.
5. Note made of coiling of the nasoenteric tube in the oral
cavity; correlate with visual inspection and consider
repositioning.
6. Biapical sub-5 mm pulmonary nodules are likely infectious or
inflammatory.
Other incidental findings, as above.
RECOMMENDATION(S): If there is clinical concern for acute or
subacute
ischemia, MRI is more sensitive for detection of infarction.
TTE (___)
-------------
CONCLUSION:
The left atrial volume index is normal. There is no evidence for
an atrial septal defect by 2D/color Doppler. The right atrial
pressure could not be estimated. There is normal left
ventricular wall thickness with a normal
cavity size. There is mild regional left ventricular systolic
dysfunction with inferior and inferolateral hypokinesis (see
schematic) and preserved/normal contractility of the remaining
segments. Quantitative biplane left ventricular ejection
fraction is 52 %. Left ventricular cardiac index is depressed
(less than 2.0 L/min/m2). There is no resting left ventricular
outflow tract gradient. Mildly dilated right ventricular cavity
with moderate global free wall hypokinesis. Tricuspid annular
plane systolic excursion (TAPSE) is depressed. The aortic sinus
diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal with a
normal descending aorta diameter. The aortic valve leaflets (3)
appear structurally normal. There is no aortic valve stenosis.
There is no aortic regurgitation. The mitral valve leaflets
appear structurally normal with no mitral valve prolapse. There
is no mitral regurgitation. The pulmonic valve leaflets are not
well seen. The tricuspid valve leaflets appear structurally
normal. There is physiologic tricuspid regurgitation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with mild
regional systolic dysfunction and right ventricular cavity
dilation with free wall hypokinesis most consistent with single
vessel coronary artery disease (proximal RCA with right dominant
system distribution).
CLINICAL IMPLICATIONS: Based on the echocardiographic findings
and ___ ACC/AHA recommendations, antibiotic prophylaxis is NOT
recommended.
CXR ___:
IMPRESSION: Endotracheal tube, nasogastric tube, and right IJ
central line appear unchanged in position. There is again seen
cardiomegaly and prominence of the mediastinum, stable. There
is
slight prominence of the pulmonary interstitial markings without
overt pulmonary edema. No focal consolidation, large pleural
effusions, or pneumothoraces are seen.
MRI Head ___:
IMPRESSION:
1. Study is degraded by motion.
2. No acute intracranial abnormality. No infarction.
3. Global volume loss and probable microangiopathic changes as
described.
4. Paranasal sinus disease and nonspecific bilateral mastoid
fluid, as described.
Coronary angiogram: ___ ___:
Findings
Successful PCI for STEMI of the RCA coronary artery, recent
STEMI.
Contrast: 110mls
Brief Hospital Course:
___ year old man without cardiac history of HTN, not on meds, who
had unwitnessed arrest (PEA upon EMS contact) found to have
inferior ST elevations with cardiac catheterization showing
severe two vessel disease, no revascularization d/t undergoing
post-arrest care in the MICU, now s/p TTM (therapeutic
hypothermia). Successfully extubated and transferred out to
floor for evaluation for surgical vs. PCI revascularization.
EVENTS:
___: PEA arrest, with ROSC after CPR. ECG with STE. Came to ED
and transferred to MICU (as CCU border). Intubated and initiated
on therapeutic temperature management. Required levophed,
vasopressor, dopamine. Cath showed severe 2VD. CSURG consulted.
___: TTE ended at 12:00PM
___: Extubated successfully. Started Isordil.
___: Started Metoprolol. MRI of head/brain without intracranial
abnormality. Neuro signed off, as pt neurologically intact, no
need for neuro f/u. Transferred to floor, CNP service.
___: Cardiac catheterization, ___ 1 to RCA, good results, no
complications. Seen by ___ and recommends outpatient cardiac
rehab.
___: HD stable, d/c home.
ACUTE ISSUES
===============
NEUROLOGY
========
#Midbrain hypodensity:
Initial CT head notable for hypodensity in the central midbrain,
that represented infarct vs. artifact. EEG in CCU never revealed
seizure activity. CTA head/neck noted "mild-to-moderate
calcified plaque, mild luminal narrowing, intracranial ICAs
bilaterally as well as "severe luminal narrowing of the right
vertebral artery origin
due to calcified plaque". MRI of head on ___ confirmed no acute
intracranial abnormality. Neurology consulted through
hospitalization. Patient recovered fully without any
neurological deficits.
- Appreciate Neurology recommendations
- Continue with medical management of CAD with lipids, ASA and
BP control.
- No need for further neurology follow up
CV
===
# hypotension
# bradycardia: RESOLVED
Initially required levophed, vasopressin, dopamine while in
MICU.
#S/p cardiac arrest
S/p PEA arrest, ROSC achieved with CPR alone (time down
unknown). CTA without large PE, aortic dissection/aneurysm.
Urine/serum tox screens negative. LHC showed severe 2v disease
though cardiology unsure this is the culprit etiology. Suspect
arrest ___ MI. S/p TTM/hypothermia protocol, now following
commands and extubated on ___.
- Neurology recs, as above.
#Severe 2vessel CAD
#STEMI
STE in the inferior leads in the field. Repeat EKG here without
ischemia. Trop initially negative, peaked at 0.44. ___ showed
severe 2v disease of the RCA and LAD, initially treated with IV
heparin and revascularization delayed until hypothermia protocol
complete. Dr. ___ Cardiac ___ Dr. ___ films
and LAD estimated to be about 40%, and decided patient should be
revascularized with RCA PCI and LAD medically managed. S/p DES
x1 to RCA on ___, with good result. Initially with STE with
ballooning and deployment of stent, given Nitroglycerin, and ECG
without ischemia at end of case. Plavix loaded post procedure.
Patient remained CP free without arrhythmia and hemodynamics
stable post procedure.
- Start Aspirin 81 mg daily, lifelong.
- Start Plavix 75mg daily x at least 12 months.
- Atorvastatin 80mg daily
- GDMT:
- Start B blocker (metop xl 25mg daily
- Start ACE Lisinopril 5mg daily
- ___ consult- outpatient cardiac rehab
- Set up with PCP at ___ Cardiology department is working on
appointment with next available Cardiologist
PULM
=====
#Ventilator dependence
#acute hypoxic respiratory failure: resolved.
Intubated in the ED, unclear indication. Received IV Zosyn x 2
days in MICU for dark yellow sputum while intubated. Now
extubated, doing well. Sputum culture grew moderate staph aureus
and moderate growth haemophilus influenzae. Patient clinically
without symptoms of infection, no WBC, fever, chills, no sputum
production, CXR negative for infiltrate. ID curbside; in
agreement, no further antibiotics.
- off abx, s/p 72 hours
- Monitor for symptoms of PNA/infection
GI
===
#coffee ground emesis: resolved.
Patient noted to have coffee ground emesis from NG tube. CBC
stable. No longer with coffee ground emesis x72 hours.
- d/c PPI
#Transaminitis: resolved.
Suspect ___ shock and hypoperfusion in the setting of cardiac
arrest. Acetaminophen level negative. LFTs normalized. Hepatitis
serologies negative.
GU
===
NONE
HEME
====
#AGMA
#Lactic acidosis: resolved.
Likely ___ cardiac arrest. Peaked at 8.2 upon admission but was
down to 0.8 prior to CCU transfer to floor.
#Leukocytosis: resolved.
Likely stress response ___ cardiac arrest. CXR, CTA
chest/abdomen without infection upon admission. BC with NGTD.
ENDO
=====
#Hyperglycemia
BG 297 in the ED, down to 100s on repeat. No known diabetes.
Likely elevated in the setting of his critical illness. A1C
6.3%.
- Follow with PCP (hasn't had one in years)
- Encourage lifestyle modifications with diet, exercise
# Transitional:
[ ] Patient does not have PCP or ___ Set up with PCP
prior to discharge; Cardiology department is working on
appointment with Cardiologist.
[ ] Outpatient Cardiac rehab once medically cleared by
Cardiologist
[ ] New medication: Lisinopril: PCP to monitor kidney
fx/potassium level and tolerance
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
4. Lisinopril 5 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PEA Arrest
STEMI; Coronary Artery Disease s/p DES to RCA
HTN
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 ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were transferred to ___ because you had a cardiac
arrest and a significant heart attack (STEMI).
WHAT HAPPENED IN THE HOSPITAL?
==============================
- Initially, you required support and close monitoring in the
cardiac ICU.
- You had a cardiac catheterization on ___ to open the blocked
RCA heart artery with stenting. This procedure was successful.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- It is very important to take all of your heart healthy
medications. In particular, Aspirin and Plavix (Clopidigrel)
keep the stents in the vessels of the heart open and help reduce
your risk of having a future heart attack. If you stop these
medications or miss ___ dose, you risk causing a blood clot
forming in your heart stents, and you may die from a massive
heart attack. Please do not stop taking either medication
without taking to your heart doctor, even if another doctor
tells you to stop the medications.
- You should take Atorvastatin 80mg per day at bedtime (best
absorbed when taken in the evening), this medication not only
reduces cholesterol, but has been shown to help decrease risk of
heart attack in the future for people who have coronary artery
(heart) disease.
- You should take Metoprolol succinate 25mg daily: This
medication belongs to a class of medications known as Beta
Blockers. Beta blockers slow the heart down and can lower blood
pressure. They help reduce the amount of work the heart has to
do, and can help to reduce risk of future heart attack.
- You should take Lisinopril 5mg daily: This medication belongs
to a class of medications known as Ace Inhibitors. Ace
Inhibitors help to reduce blood pressure and decrease the amount
of resistance that the heart needs to pump against, which
decreases strain on the heart muscle. It can also help to
protect/improve kidney function in some individuals.
Instructions regarding activity restrictions and care of the
access sites are included with your discharge information.
It is strongly recommended that you attend a cardiac rehab
program in the near future. A referral form was provided to you
that lists the locations of these programs. Please bring this
with you to your follow up visit with your Cardiologist, and
they will inform you when it is safe to begin a program.
- Take all of your medications as prescribed (listed below).
- Follow up with your doctors as listed below.
- You should call an ambulance for any chest pain experienced
after discharge.
It was a pleasure participating in your care.
If you have any urgent questions that are related to your
recovery from your hospitalization or are experiencing any
symptoms that are concerning to you and you think you may need
to return to the hospital, please call the ___ HeartLine at
___ to speak to a cardiologist or cardiac nurse
practitioner.
-Your ___ Care Team
Followup Instructions:
___
|
19780106-DS-3
| 19,780,106 | 27,158,062 |
DS
| 3 |
2125-07-25 00:00:00
|
2125-07-26 06:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Aspirin / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ here with colicky diffuse abdominal pain that started at
8 ___. Patient was eating a steak. No flatus or BM since ___ ___.
No
f/c. No N/V. Tried taking some tums without any change in pain.
No prior episodes. LMP beginning of this month, normal.
Past Medical History:
PMhx: fallopian tube scarring
PShx: Diagnostic laparoscopy (fallopian tubes)
Social History:
___
Family History:
Fhx: Adopted, does not know about IBD/IBS
Physical Exam:
Admission Physical Exam:
98.0 81 100/69 16 100% RA
NAD, A+OX3
no scleral icterus
RRR
CTAB
Distended, mild TTP R umbilical region, no peritoneal signs
no c/c/e
rectal refused
Discharge Physical Exam:
Gen: NAD, alert, responsive
Lungs: CTAB
CV: RRR, pulses intact
Abd: soft, NTND
Ext: no c/c/e
Pertinent Results:
___ 01:45AM URINE HOURS-RANDOM
___ 01:45AM URINE HOURS-RANDOM
___ 01:45AM URINE UCG-NEGATIVE
___ 01:45AM URINE GR HOLD-HOLD
___ 01:45AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 01:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 01:45AM URINE RBC-2 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-7
___ 01:45AM URINE MUCOUS-RARE
___ 12:40AM GLUCOSE-97 UREA N-12 CREAT-0.9 SODIUM-137
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-13
___ 12:40AM estGFR-Using this
___ 12:40AM ALT(SGPT)-14 AST(SGOT)-24 ALK PHOS-61 TOT
BILI-0.3
___ 12:40AM LIPASE-44
___ 12:40AM ALBUMIN-4.7
___ 12:40AM WBC-9.6 RBC-4.28 HGB-13.4 HCT-38.8 MCV-91
MCH-31.2 MCHC-34.5 RDW-11.6
___ 12:40AM NEUTS-59.9 ___ MONOS-6.5 EOS-3.9
BASOS-1.0
___ 12:40AM PLT COUNT-304
TECHNIQUE: MDCT axial imaging was obtained from the lung bases
to the pubic
symphysis following the administration of intravenous and oral
contrast
material. Coronal and sagittal reformats were completed.
DLP: 372.9 mGy-cm.
FINDINGS:
CT ABDOMEN WITH CONTRAST: The lung bases are clear. The
visualized heart and
pericardium are unremarkable. The liver enhances homogenously
without any
focal lesions or intra- or extra-hepatic biliary dilatation.
The portal vein
is patent. The gallbladder, pancreas, spleen and adrenal glands
are
unremarkable. The kidneys enhance and excrete contrast
symmetrically without
any focal lesions or hydronephrosis. The stomach is distended
with oral
contrast. There are multiple dilated loops of small bowel with
contrast
passing through with a gradual transition point in the right mid
abdomen
(2:43). This may represent early or partial small-bowel
obstruction, possibly
due to an internal hernia although there are no significant
signs of this.
The intra-abdominal large bowel is unremarkable. There is no
free fluid, free
air or lymphadenopathy within the abdomen. The aorta and its
major branches
are patent.
CT PELVIS: The bladder, rectum and sigmoid colon are
unremarkable. Uterus is
unremarkable. A corpus luteum in the right adnexa is noted.
There is no free
fluid, free air or lymphadenopathy in the pelvis. The appendix
is normal.
OSSEOUS STRUCTURES: There are no concerning osseous lesions.
IMPRESSION: Dilated loops of small bowel with a gradual
transition point in
the right mid abdomen, which may reflect an early or partial
small-bowel
obstruction. Although there are no specific signs, this may be
due to an
internal hernia.
COMPARISONS: PA and lateral chest radiographs from ___.
FINDINGS: Single upright radiograph is provided. The lungs are
clear without
focal consolidation, pleural effusion, or pneumothorax. The
cardiomediastinal
silhouette is normal. The imaged upper abdomen demonstrates no
evidence of
free air, but loops of dilated bowel in the left hemi-abdomen.
IMPRESSION:
1. No evidence of free air. Dilated loops of bowel in the left
abdomen.
2. No acute cardiopulmonary process.
Brief Hospital Course:
___ is a ___ yo F with prior abdominal surgery
admitted on ___ for < 24 hours of colicky abdominal pain,
no flatus, abdominal distention, thought to be concerning for
possible bowel obstruction. She was admitted to the acute care
surgery service for observation. While inpatient, the patient's
abdominal exam was monitored. Her hemodynamic status was
monitored, and her pain level was frequently assessed. She was
placed on NPO status with IVF initially while awaiting return of
bowel function. She was then advanced to clears, and
subsequently advanced to regualar diet, which she tolerated
well, without any nausea, vomiting, or distension. Upon
discharge, the patient was tolerating a regular diet,
ambulating, voiding, and had well controlled pain. She was
encouraged to follow-up in the acute care surgery clinic in one
month.
Medications on Admission:
Lorazepam PRN
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call or return to ED if fever > 101, abd pain unresolved for 24
hrs, chest pain, shortness of breath, nausea, vomiting or any
other concerns.
Admitted with partial small bowel obstruction and treated
conservatively. Discharged home tolerating diet with return of
bwowel function.
Followup Instructions:
___
|
19780160-DS-17
| 19,780,160 | 24,396,683 |
DS
| 17 |
2173-04-13 00:00:00
|
2173-04-13 19:39:00
|
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 and abdominal pain
Major Surgical or Invasive Procedure:
___: ERCP with stent placement.
.
___: Removal of indwelling port-a-cath
History of Present Illness:
___ s/p ___ ___ (Dr. ___ for ampullary adenocarcinoma,
T4N1 with negative margins but lymphovascular invasion. He has
been undergoing chemo but had his last cycle in ___. He was
feeling his usual self until ___ when he awoke overnight with
fevers/chills to 101.7 at home. He had chills and
came to ___ for care. The only other symptoms he
endorses is recent polyuria over last 2 nights, urinating
approximately every ___ hours and normal brown colored loose
stool. He denies any abdominal pain, N/V,intolerance of POs,
chest pain, SOB.
At ___ scan showed small hypodensities in the
periphery of the liver new when compared to scan month prior. He
also had less pneumobilia than prior. His labs at ___ showed
a lactate initially of 2.8 to 3.1. His LFTs were elevated with
Tbili 6.45, AP 1272, ALT 203, AST 219, Lipase 55. His WBC was
5.5
and Hct 37. He had troponin checked that were 0.017 to 0.127.
His EKG showed sinus rhythm and RBBB.
Past Medical History:
GERD
coronary artery disease (stented x2, most recently with DES, no
current angina)
Benign Hypertension
High cholesterol
Ampullary adenocarcinoma
Social History:
___
Family History:
Mother (dementia), father (lung cancer), brother (congenital GI
disease). No family history of any GI/pancreatic malignancy.
Physical Exam:
Vitals: 98.4, 65, 127/74, 16, 93% RA
AAOX3 NAD
NO SCLERAL ICTERIC
RRR
CTAB
SOFT, NON TENDER NON DISTENDED
NO EDEMA
Pertinent Results:
___ 06:15AM BLOOD WBC-8.1 RBC-3.64* Hgb-10.8* Hct-34.5*
MCV-95 MCH-29.6 MCHC-31.3 RDW-15.3 Plt ___
___ 06:15AM BLOOD Glucose-121* UreaN-30* Creat-0.9 Na-145
K-3.6 Cl-109* HCO3-28 AnGap-12
___ 06:15AM BLOOD ALT-46* AST-19 AlkPhos-594* TotBili-2.3*
___ 06:15AM BLOOD Calcium-8.5 Phos-2.8 Mg-2.0
BLOOD CULTURE Final ___
Aerobic bottle: ESCHERICHIA COLI
Anaerobic bottle: ESCHERICHIA COLI
Subsequent critical value
1. ESCHERICHIA COLI
Target Route Dose RX AB
Cost M.I.C. IQ
------ ----- ------------------ ------ --
------ -------- ------
AMPICILLIN S
<=2
AMP/SULBAM S
<=2
AMOX/CLAV S
<=2
CEFAZOLIN S
<=4
CEFTAZIDIME S
<=1
CEFTRIAXONE S
<=1
CIPROFLOXACIN S
<=0.25
ERTAPENEM S
<=0.5
GENTAMICIN S
<=1
IMIPENEM S
<=0.25
LEVOFLOXACIN S
<=0.12
PIP/TAZ S
<=4
TOBRAMYCIN S
<=1
TRIM/SULFA S
<=20
___ ECG:
Sinus tachycardia. Right bundle-branch block. Left anterior
fascicular block. Compared to the previous tracing of ___ the
rate is faster. T waves are now more inverted in leads V2-V3,
likely due to difference in lead positioning. No other
significant change.
___ ECG:
Sinus tachycardia. Right bundle-branch block. Left anterior
fascicular block. Compared to the previous tracing of this date,
no significant change.
___ ERCP:
Impression: Mucosa suggestive of short segment ___
esophagus
Altered surgical anatomy consistent with a pylorus preserving
Whipple. A colonoscope was used because of the patient's
surgical anatomy.
The biliary limb was marked with SPOT tattoo. This limb was at
an acute angle relative to the pylorus, and was somewhat
difficult to enter.
The biliary limb was normal.
The biliary orifice was initially difficult to identify. A
limited injection of the pancreatic duct was performed to
confirm the location of this anastamosis. The pancreatic duct
was normal.
The HJ/biliary orifice was then identified. The surrounding
mucosa was somewhat ulcerated and edematous. Cannulation of the
biliary duct was successful and deep with a sphincterotome using
a free-hand technique. Upon cannulation copious amount of
sludge, pus, and debris was expelled from the bile duct.
The intrahepatics were normal. There were filling defects in the
bile duct at the bilary-enteric anastomosis.
A ___ striaght plastic biliary stent was placed successfully
into the bile duct. Excellent flow of bile, pus, and debris,
post stent placement.
After the ERCP, Cold forceps biopsies were performed for
histology of the biliary orifice.
Otherwise normal ercp to the biliary limb
PATHOLOGY: Pending
Brief Hospital Course:
The patient is ___ male status post Whipple on ___
(Dr. ___ for T4N1 ampullary adenocarcinoma presented with
fevers and abdominal pain. The patient was transferred from
___ for treatment of acute cholangitis and bacteremia. The
patient was admitted to the ICU to work up his elevated troponin
and persistent tachycardia. Cardiology was consulted and their
recommendations were followed. His EKG was unchanged compare to
prior one. Cardiology recommended stop follow troponin, restart
home Atenolol and ASA, give Lasix if fluid overloaded. The
patient was started on Zosyn to treat acute cholangitis, his
tachycardia subsided. On ___ he underwent ERCP. During
ERCP, there was a biliary stent placed with good flow; the
distal esophagus looked like ___ the findings were
consistent with ampullary CA recurrence with brush biopsy was
taken. On ___, blood cultures from ___ came back positive
for pan sensitive E-coli and ID was consulted. Patient was
transferred on the floor, diet advanced to regular, LFTs started
to downward. ID recommended to stop Zosyn, start PO Cipro and
Flagyl, and remove indwelling port. On ___, port-a-cath was
removed, and patient was discharged home on 10 more days of PO
antibiotics.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
omeprazole 20', atenolol 75', ASA 81'
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin [Cipro] 750 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*28 Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*42 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
6. Atenolol 75 mg PO DAILY
7. Calcium Carbonate 500 mg PO QID:PRN indigestion
Discharge Disposition:
Home
Discharge Diagnosis:
1. Acute cholangitis.
2. E.coli bacteremia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ___ surgery service for treatment
of acute cholangitis and Ecoli bacteremia. You underwent an ERCP
with stent placement. You were found to have ___
esophagus. You will need to return in 3 weeks for a repeat EGD
and stent removal. At that time, biopsies of your esophagus will
be taken as well.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
___
|
19780167-DS-12
| 19,780,167 | 22,279,795 |
DS
| 12 |
2116-07-04 00:00:00
|
2116-07-04 14:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
___ guided left hip aspiration
History of Present Illness:
___ is a ___ year old woman w/PMH polysubstance use
presenting with hip pain. The pain started when she woke up
yesterday morning. She initially presented to ___
yesterday where she received Tylenol, had an x-ray performed
which she reports was unremarkable, and was discharged. She
re-presented to ___ today for worsening hip pain. She reports no
trauma to the hip and the pain has been preventing her from
walking. She has noticed swelling of the hip, subjective fevers,
and chills. She denies lower extremity weakness or paresthesias.
She endorses prior IVDU (cocaine) approximately ___ months prior
to presentation. At ___, she had an x-ray and CT which she
states
were unrevealing. There was plan for MRI of the hip, however the
scanner was not functioning at ___ and she was transferred here
for further management. She received one dose of vancomycin and
ceftriaxone and was transferred to the ___ ED.
In the ED:
- Initial vital signs were notable for: T 99.0 HR 90 BP 119/79
RR
14 SpO2 99% RA
- Exam notable for: uncomfortable appearing, TTP over L greater
trochanter
- Labs were notable for:
WBC 12.8 Hgb 13.2 Plt 225
CRP 173
Utox: benzo positive, opiate positive, cocaine positive
- Studies performed include:
XR L hip - There is no acute fracture or dislocation. Joint
spaces are preserved. There are no gross degenerative changes.
There is no suspicious lytic or sclerotic lesion. There is no
soft tissue calcification or radio-opaque foreign body.
- Patient was given:
IV Morphine Sulfate 4 mg
IV Morphine Sulfate 4 mg
IV Ketorolac 15 mg
- Consults:
Ortho - recommend ___ aspiration of L hip, weight bearing and ROM
as tolerated
Vitals on transfer: T 98.7 HR 91 BP 121/70 RR 18 SpO2 98% RA
Upon arrival to the floor, patient endorses continued hip pain.
She denies chest pain, shortness of breath, diarrhea, dysuria,
other muscle/joint aches or pains.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
Polysubstance use
Heart murmur since childhood
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
===========================
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
systolic murmur heard best at ___
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
MSK: LLE with ROM limited by pain, strength exam limited by
pain,
full ROM and ___ strength RLE. Tenderness to palpation over L
greater trochanter, no surrounding erythema. DP pulses 2+ b/l
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. AOx3.
PSYCH: appropriate mood and affect
DISCHARGE EXAM
================================
GENERAL: Alert and interactive. In no acute distress.
EYES: NCAT. PERRL, EOMI. Sclera anicteric and without injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
systolic murmur heard best at LUSB
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
MSK: LLE with normal ROM, mild tenderness to palpation over left
gluteus minimus; gait with slight left limp ___ pain, greatly
improved from admission
SKIN: Warm. No rash.
NEUROLOGIC: CN2-12 intact. AOx3.
PSYCH: appropriate mood and affect
Pertinent Results:
ADMISSION EXAM
==================
___ 03:00PM BLOOD WBC-12.8* RBC-4.51 Hgb-13.2 Hct-40.2
MCV-89 MCH-29.3 MCHC-32.8 RDW-13.0 RDWSD-42.6 Plt ___
___ 03:00PM BLOOD Neuts-81.4* Lymphs-11.8* Monos-5.0
Eos-1.2 Baso-0.2 Im ___ AbsNeut-10.45* AbsLymp-1.52
AbsMono-0.64 AbsEos-0.15 AbsBaso-0.03
___ 06:37AM BLOOD ___ PTT-32.1 ___
___ 03:00PM BLOOD Glucose-89 UreaN-8 Creat-0.7 Na-141 K-3.7
Cl-106 HCO3-24 AnGap-11
___ 06:37AM BLOOD ALT-102* AST-156* LD(LDH)-670* AlkPhos-62
TotBili-0.4
___ 06:37AM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.3 Mg-2.0
___ 03:00PM BLOOD CRP-173.4*
IMAGING STUDIES
======================
HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT Study Date of
___ 2:20 ___: There is no acute fracture or dislocation.
Joint spaces are preserved. There are no gross degenerative
changes. There is no suspicious lytic or sclerotic lesion.
There is no soft tissue calcification or radio-opaque foreign
body. Normal bowel gas pattern.
___ MRI MSK PELVIS W&W/O CO:
MICROBIOLOGY RESULTS
======================
BLOOD CULTURE ___ NGTD
URINE CULTURE ___ PENDING
___ 9:08 am JOINT FLUID Source: Left Hip.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
DISCHARGE LABS
=======================
___ 06:30AM BLOOD WBC-8.2 RBC-3.70* Hgb-10.8* Hct-32.7*
MCV-88 MCH-29.2 MCHC-33.0 RDW-13.1 RDWSD-41.9 Plt ___
___ 06:30AM BLOOD Glucose-95 UreaN-11 Creat-0.7 Na-147
K-4.2 Cl-111* HCO3-24 AnGap-12
___ 06:30AM BLOOD ALT-60* AST-25 CK(CPK)-564*
___ 04:30PM BLOOD HBcAb-NEG HAV Ab-POS*
___ 09:14AM BLOOD HBsAg-NEG IgM HAV-PND
___ 07:46AM BLOOD HBsAb-NEG
___ 03:00PM BLOOD CRP-173.4*
___ 09:14AM BLOOD CRP-93.2*
___ 07:46AM BLOOD CRP-43.1*
___ 06:30AM BLOOD CRP-18.8*
___ 04:30PM BLOOD HIV Ab-NEG
___ 09:14AM BLOOD Lyme Ab-NEG
___ 04:30PM BLOOD HCV Ab-NEG
___ 04:30PM BLOOD HCV VL-PND
Brief Hospital Course:
TRANSITIONAL ISSUES
========================
[] Left lower extremity: Weightbearing as tolerated, range of
motion as tolerated.
[] Discharged with 1 week of NSAIDs for left hip pain (improving
at time of discharge).
[] Please get HepB vaccination.
[] F/u ___ IgM, HCV VL, urine Chlamydia trachomatis and
Neisseria gonorrhoeae
[] She will need to avoid cocaine and other substance, ideally
cut back on smoking and eventually.
[] Please check CBC, BMP, CK, CRP, ESR in a week to make sure
they are trending down and back to normal.
[] Not currently amenable to smoking cessation but would benefit
from ongoing smoking and cocaine cessation counseling.
[] PCP appointment made for ___ for HCA at ___. The
appointment is currently temporarily held. AY must call ___
Health insurance to switch from Partners ___ to
___ with BIDCO. After calling Mass Health, ___ must call
___ at ___ to give updated insurance details to permanently
hold her appointment. AY's PCP is ___
(resident Dr. ___ # ___. This
information was detailed and confirmed with AY ___.
SUMMARY:
===========
___ is a ___ w PMH of polysubstance use disorder presenting w/
atraumatic
hip pain, fevers, leukocytosis, and elevated inflammatory
marker, with joint
aspiration reassuring against septic arthritis. Ultimately MRI
revealed gluteal
muscle inflammation and her picture was most consistent with
cocaine-induced
myositis.
ACTIVE ISSUES:
==================
#L Hip Pain
#Left gluteal myositis
Acute onset unilateral hip pain originally c/f septic vs
inflammatory arthritis given leukocytosis with elevated CRP and
ESR. Seen my orthopedics and rheumatology. Infectious workup
pursued given initial concern for reactive arthritis: negative
for HIV, neg for Lyme Ab. GC/chylamidia pending on ___. Joint
aspiration with negative gram stain, thus pt was not started on
antibiotics, but treated symptomatically. Symptom improved
significantly with Tylenol, Ketorolac, and PRN tramadol. AST/ALT
and CK level were elevated and trended down with treatment. MRI
of left hip showed muscle edema. Most likely myositis iso
cocaine use. Pt was transitioned to po NSAIDs 1 day prior to
discharge, counsled to take with food and follow up with PCP.
#Polysubstance use disorder
Occasional EtoH, ___ ppd tobacco, intranasal cocaine, former IV
cocaine use. Hx of prior IVDU(cocaine) approximately ___ months
prior to presentation. Tox
screen pos for benzos, opiates, cocaine. Pt was consulted on the
importance of stopping drug use,
she ultimately declined to speak with addiction psychiatry
however expressed agreement in abstaining
from substances.
#Tobacco use disorder
Given nicotine patches while inpatient. Counseled on the
importance of smoking cessation to prevent arterial disease. Not
currently amenable to quitting at this time.
CHRONIC/STABLE ISSUES:
======================
#Heartmurmur
Present since childhood. Monitored and stable. No recent history
of IVDU.
#CONTACT: ___
Relationship: OTHER
Phone: ___
#CODE: full (presumed)
>30 min spent on discharge planning including face to face time
Medications on Admission:
None
Discharge Medications:
1. Naproxen 500 mg PO BID:PRN Pain - Moderate
Take with food.
RX *naproxen 500 mg 1 tablet(s) by mouth BID PRN Disp #*20
Tablet Refills:*0
2. Nicotine Patch 21 mg/day TD DAILY
Do not use patches while smoking cigarettes. Once you have quit
smoking, apply patches as directed.
RX *nicotine 21 mg/24 hour apply to arm as directed once a day
PRN Disp #*14 Patch Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
#Acute left hip pain
#Myositis, possibly cocaine induced
#Substance abuse disorder (benzo, opioid and cocaine)
#Tobacco use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had sudden onset pain of your left hip
WHAT HAPPENED TO ME IN THE HOSPITAL?
-We took imaging of your left hip to look at the tissue, joints,
and bones.
-We took fluid from your left hip and blood from the body to
analyze.
for viral or bacterial infections. No infections were diagnosed.
-You had lab tests done which demonstrated possible
myositis(inflammation of your muscles)
-You were treated with NSAIDs which helped with both pain and
inflammation and your symptom improved a lot.
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.
- Make sure to take your NSAIDs with food, as they can irritate
your stomach.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19780382-DS-21
| 19,780,382 | 25,235,156 |
DS
| 21 |
2163-05-12 00:00:00
|
2163-05-13 14:31:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine Sulf / Percocet / Vicodin
Attending: ___
Chief Complaint:
Pulmonary Embolus
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ yo F with history of lower back pain, s/p L4-L5
laminectomy/discectomy ___ who now presents with acute
shortness of breath and right-sided chest pain which radiates to
her anterior chest. She reports that she has been doing well
postoperatively working with ___ with improving lower back pain,
However, around 3pm on ___, she noted onset of sharp right
sided chest pain worse with breathing. She was unable to take a
deep breath ___ pain. She has had a mild mough which is
non-productive and without blood. She tried to take a nap and
woke up around 5:30pm with the same symptoms, so called her ___
who recommended calling her PCP who recommended an ED
evaluation. She denies any recent leg pain or swelling. No
fevers, cancers or clotting disorders
.
In the ED, VS were 98.5, 55, 100/44, 20, 100% 2L. Ddimer was
obtained and elevated at 1213. CTA revealed Right segmental and
subsegmental PE. Neurosurgery was consulted regarding the
question of anticoagulation in the setting of recent surgery.
They recommended starting heparin but with tight PTT goal of
60-80 without bolus. She was given morphine for pain control
which worked well (pt reportedly with anaphylactic reaction to
codeine during last admission). She was guaiac negative in the
ED. She was also noted to be bradycardic to the high ___
in the ED. EKG was unremarkable with the exception of
bradycardia.
.
On the floor, she reports persistent pain over her right
anterior chest with respiration. VS are 111/55 52 97% 2L.
.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
Depression
HTN
Lower back pain s/p L4-L5 laminectomy/discectomy in ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission:
VS - 111/55 52 97% 2L.
GENERAL - Alert, interactive, uncomfortable appearing from pain
and dyspenea. Choppy sentences ___ dyspenea
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - RRR, nl S1-S2, no MRG
LUNGS - Shallow breaths ___ splinting from pain, but otherwise
clear
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout,
BACK: Well healing midline lumbar incision with steristrips
intact
.
D/c:
Tmax=c 98.6, BP (100-134/47-67), 50-53, 99 RA
..
*Physical EXAM:
GENERAL - Alert, interactive, resting comfortably, NAD.
HEENT - Pupils 3-2mm, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - brady, regular rate, nl S1-S2, no MRG
LUNGS - Shallow breaths ___ splinting from pain, but otherwise
clear
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses.
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout,
BACK: Well healing midline lumbar incision with steristrips
intact
Pertinent Results:
CT Chest:
NDICATION: Recent surgery, acute onset right-sided chest pain,
dyspnea,
please evaluate for pulmonary embolism.
COMPARISON: Comparison is made to CT abdomen and pelvis
performed ___ and chest radiograph performed ___.
TECHNIQUE: Non-contrast axial images were obtained of the chest.
Subsequently, intravenous contrast was administered and arterial
phase imaging
was performed.
FINDINGS:
CTA CHEST: The pulmonary vasculature is well opacified. There is
a filling
defect evident within the right lower lobe posterior basal
segmental and
subsegmental pulmonary vasculature consistent with acute
pulmonary embolism
(3:39). The main pulmonary artery is not enlarged. There is no
evidence of
right heart strain. Heart size is normal without pericardial
effusion.
Atherosclerotic changes are evident within the aortic arch. The
thoracic
aorta is of normal caliber throughout.
CT CHEST: No central lymphadenopathy evident. There is a small
hiatal hernia
identified.
The airways are normal to the subsegmental level. Possible trace
right
pleural effusion with adjacent compressive atelectasis. No focal
opacifications are evident within the lungs. No pulmonary nodule
is
identified.
Though this exam is not tailored for subdiaphragmatic
evaluation, there is no
heterogeneity within the liver to suggest mass. An incompletely
visualized
left intrahepatic biliary duct is dilated.
A small bone island identified in a mid thoracic vertebrae as
well as endplate
sclerosis and degenerative changes. No lytic or blastic lesions
identified.
IMPRESSION:
1. Right lower lobe posterior basal segmental and subsegmetnal
embolus with a
trace right pleural effusion and adjacent compressive
atelectasis.
2. Left intrahepatic bilary duct dilatation incompletely
visualized. Recommend
evaluation with ultrasound to assess for possible obstruction.
___ discussed Finding #2 with Dr ___ at 8:52
AM on ___
via telephone at time of discovery.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___: TUE ___ 3:07 ___
-------
ECHO
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). 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 appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
---
Lower extremity doppler
FINDINGS: Waveforms in the common femoral veins are symmetric
bilaterally
with appropriate response to Valsalva maneuvers. In both lower
extremities,
the common femoral, proximal greater saphenous, superficial
femoral and
popliteal veins are normal with appropriate compressibility,
wall-to-wall flow
on color Doppler analysis and response to waveform augmentation.
Wall-to-wall
flow and compressibility are also present in the posterior
tibial and peroneal
veins bilaterally.
IMPRESSION: No deep venous thrombosis in either lower extremity.
---
___ 06:18AM BLOOD WBC-7.1 RBC-3.51* Hgb-10.6* Hct-33.1*
MCV-94 MCH-30.2 MCHC-32.1 RDW-13.3 Plt ___
___ 07:17AM BLOOD WBC-7.4 RBC-3.38* Hgb-10.4* Hct-31.6*
MCV-94 MCH-30.9 MCHC-32.9 RDW-13.4 Plt ___
___ 07:27AM BLOOD WBC-7.8 RBC-3.28* Hgb-10.0* Hct-30.5*
MCV-93 MCH-30.6 MCHC-33.0 RDW-13.4 Plt ___
___ 09:45PM BLOOD WBC-10.4 RBC-3.69* Hgb-11.4* Hct-33.7*
MCV-92 MCH-30.9 MCHC-33.8 RDW-12.8 Plt ___
-
___ 04:06PM BLOOD ___ PTT-79.5* ___
___ 06:18AM BLOOD ___ PTT-150* ___
___ 07:17AM BLOOD ___ PTT-61.6* ___
___ 07:27AM BLOOD ___ PTT-80.3* ___
___ 12:50PM BLOOD ___ PTT-80.0* ___
___ 06:20AM BLOOD ___ PTT-61.8* ___
___ 09:45PM BLOOD ___ PTT-31.7 ___
===
___ 06:18AM BLOOD Glucose-93 UreaN-6 Creat-0.8 Na-138 K-4.7
Cl-103 HCO3-30 AnGap-10
___ 06:20AM BLOOD ALT-50* AST-26 AlkPhos-66 Amylase-19
TotBili-0.3
___ 06:20AM BLOOD Lipase-12
___ 06:18AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.0
___ 06:20AM BLOOD Albumin-3.3* Calcium-9.0 Phos-4.9* Mg-1.9
___ 10:28PM BLOOD D-Dimer-1213*
___ 08:40PM URINE Color-Straw Appear-Clear Sp ___
___ 08:40PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 08:40PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-2
___ 08:40PM URINE Mucous-RARE
Brief Hospital Course:
___ year old female past medical history of smoking,
hypertension, 8 days s/p back surgery for lumbar spinal stenosis
who presents with sudden onset shortness of breath and pleuritic
chest pain, positive d-dimer and right segmental PE on CTA.
PE: The patient was admitted from the ED with a positive d-dimer
and CTA showing PE. Given her recent back surgery, neurosurgery
recommended heparin gtt at 60-80 while bridging to coumadin. The
patient was started on coumadin 5mg. Once she was therapeutic on
coumadin for more than 24 hours the heparin was stopped. On
___, she was supratheraputic on 5mg of coumadin. Therefore,
her dose was held on ___, her day of discharge. She will be
discharged on 2mg per day of coumadin. Lower extremity doppler
showed no signs of DVT. Her entire hospital stay she required no
supplemental oxygen and could ambulate 100% on RA.
Hypotension and bradycardia: During her hospitalization, the
patients heart rate was in the low ___ and blood pressure in the
low 100's to high ___. Her blood-pressure medications were held.
Due to concern for possible right heart strain, an echo was
performed which showed no abnormalities. Her low blood pressure
and bradycardia was asymptomatic as the patient was able to walk
and mentate with a low heart rate and blood pressure. We believe
that this was caused by narcotic analgesia.
Transitional issues:
1. Monitoring anticoagulation. Patient will require at least 3
months of coumadin. Goal INR ___. Patient was discharged with an
INR of 4 on ___. She was instructed to hold ___ dose
and take 2mg the following day.
2. CT Chest Incidental Finding: Though this exam is not tailored
for subdiaphragmatic evaluation, there is no heterogeneity
within the liver to suggest mass. An incompletely visualized
left intrahepatic biliary duct is dilated. Recommend evaluation
with ultrasound to assess for possible obstruction.
Medications on Admission:
docusate sodium 50 mg Capsule Sig: ___ Capsules PO BID (2
times a day).
-oxycodone-acetaminophen ___ mg Capsule Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
- diazepam 2 mg Tablet Sig: ___ Tablets PO Q8H (every 8 hours)
as needed for spasm.
- amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-escitalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
-valsartan 160 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
-HCTZ 25 mg daily
-Dilaudid PRN
.
Discharge Medications:
1. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. diazepam 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasm.
3. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every ___
hours as needed for pain: do not drink alcohol. do not consumer
more than 4gm in one day.
4. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
5. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Coumadin 1 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*120 Tablet(s)* Refills:*1*
8. Outpatient Lab Work
Please check INR. Please fax results to ___.
___.
Discharge Disposition:
Home With Service
Facility:
___
___:
1. Pulmonary Embolism
Secondary:
s/p L4-L5 laminectomy/discectomy in ___
Depression
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for anticoagulation after having a pulmonary
embolus. Blood clots are not uncommon especially after major
back and spine surgery. Going forward you will need to take
coumadin for at least the next 3 months, (perhaps longer
depending on your PCP's preference). During your
hospitalization, we performed ultrasound of your legs and heart.
There are no clots in your legs. Your heart is pumping normally.
Please ask your doctor about restarting your medications for
high blood pressure. Your blood pressure in the hospital was on
the low side so your blood pressure medications were held.
Coumadin keeps your blood thin and prevents you from having more
blood clots. While this medication is very effective, you need
to have your INR (coumadin levels) monitored. This way if you
INR becomes too high or too low, your PCP can adjust your
coumadin accordingly. Your goal INR is ___.
Be sure to talk with your doctor if you are planning any major
diet changes, such as a weight-reducing diet, of if you plan to
add any nutritional supplements.
Please be aware that coumadin interacts with many drugs and
foods.
Vitamin K is needed for normal blood clotting. When you are
taking an oral anti-coagulant medication such as warfarin
(Coumadin), high amounts of Vitamin K can work against the
medication. The following guidelines will help control the
amount of Vitamin K you are getting from the foods you eat. To
help the medicine perform well, you should follow these
guidelines:
Avoid grapefruit and cranberry products.
If you eat spinach, turnip greens, other leafy greens, broccoli,
___ sprouts, kale, parsley (except as a garnish or minor
ingredient), natto (a ___ dish), liver, or green tea, be
sure to eat a consistent amount week to week.
Eat all other foods as you normally would.
Tell your doctor if you are thinking about changing your current
eating habits. Tell your doctor if you are planning to:
Eat more or less vegetables.
Change to a vegetarian style of eating.
Follow a special meal plan to lose or gain weight.
Changing your eating habits may mean that you will be getting
more or less Vitamin K in the foods you eat. If you change your
eating habits, your doctor may want to check your blood more
frequently to see how the Coumadin therapy is working.
We have made the following changes to your medications.
Please start: Coumadin 4mg once a day at 4pm everyday. Please
note that this may have to be adjusted by your doctor.
If you experience any of the danger symptoms listed below come
back to the emergency department.
Followup Instructions:
___
|
19780620-DS-18
| 19,780,620 | 27,507,996 |
DS
| 18 |
2170-06-21 00:00:00
|
2170-06-21 15:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
headches, nasuea, gait disturbance
Major Surgical or Invasive Procedure:
___ Bilateral Craniotomies for Subdural hematoma evacuation
History of Present Illness:
Patient is a ___ year old gentleman who developed nausea on
___ and then on ___ developed headaches and loss of
appetite. He also then had two episodes of emesis. On ___
he noticed mild confusion and gait disturbance. Today he went to
the urgent care at the ___ where he works for
evaluation. Imaging revealed large bilateral subdural hematomas
that are chronic appearing in nature. He was then transferred to
___ for further management and care. He currently denies
dizziness, changes in vision, hearing or speech, bowel or
bladder
changes.
Past Medical History:
Prostate Ca s/p prostatectomy, cholecystectomy, GERD,
emphysema
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: ? slight right ptosis which may be baseline
Pupils: PERRL EOMs intact without nystagmus
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person and ___
Language: Speech fluent in Portugese with good comprehension and
repetition. Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
2mm bilaterally. Visual fields are grossly full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Coordination: normal on finger-nose-finger bilaterally
DISCHARGE EXAM:
neurologically intact, bilateral incisions c/d/i with staples
Pertinent Results:
CXR ___:
Single portable view of the chest. The lungs are clear of
consolidation where not obscured by overlying cardiac leads.
The cardiomediastinal silhouette is within normal limits.
Surgical clips project over the lower chest/upper abdomen in the
midline. No acute osseous abnormalities.
CT Head ___ post-op:
IMPRESSION: Decrease in extent of bilateral subdural hematomas
with small
amount of residual high-density material representing blood.
Decrease in mass effect on the adjacent brain. Expected
pneumocephalus and fluid within the extraaxial space.
Radiology Report CHEST (PORTABLE AP) Study Date of ___ 9:33
AM
IMPRESSION:
1. Interval intubation with an endotracheal tube having its tip
approximately 6 cm above the carina. The lungs appear well
inflated without evidence of focal airspace consolidation,
pleural effusions or pneumothorax. No evidence of pulmonary
edema. Overall cardiac and mediastinal contours are stable.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
9:15 AM
IMPRESSION: Decreased extent of hypodense bilateral subdural
hematomas with increased hyperdense component, representing
acute on chronic subdural hemorrhage, compared to the most
recent prior CT of ___. Decreasedmass effect on the
underlying brain and decreased post-operative
pneumocephalus.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
1:27 ___
IMPRESSION:
No significant change in extent of bilateral acute on chronic
subdural
hematomas along the cerebral convexities compared to the most
recent prior CT performed 4 hr earlier. Unchanged mass effect
without midline shift or
downward herniation. Unchanged bifrontal pneumocephalus.
NOTE ADDED IN ATTENDING REVIEW: Given the unchanged appearance
over the
four-hour interval, the focal hyperattenauting material,
symmetrically located
directly at the craniotomy sites more likely represents
implanted surgical
material, such as DuraGen, rather than focal acute hemorrhage.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
2:41 ___
IMPRESSION:
1. Minimally decreased bilateral acute on chronic subdural
hematomas.
2. Expected postsurgical changes, including pneumocephalus which
is decreased from prior exam.
CXR ___:
No acute infectious process.
LENIS ___:
No evidence of deep vein thrombosis in either leg
Brief Hospital Course:
Patient presented to ___ ER on ___ as a transfer from OSH for
evaluation of a bilateral chronic subdural hematomas. He was
seen, examined, and admitted to the ICU for monitoring and care
with plan for operative intervention on ___. Pre-op workup was
initiated including CXR, EKG, type and screen, NPO, and IV
fluids. Informed consent was obtained from the patient and his
daughter. He remained stable overnight into ___ and was
awaiting OR. He was taken to the operating room on the afternoon
of ___/.4 for bilateral mini-craniotomies for evacuation of
bilateral subdural hematomas. he tolerated the procedure well
and remained intubated on transfer to ICU post-operatively. his
head of bed remained flat given his pneumocephalus.
on ___- patient was awake and following commands, but remained
intubated.
On ___, the patient's diet was advanced, The patients head of
the Bed was raised to 30 degrees. The bilateral subdural drains
were discontinued without difficulty. A NCHCT was performed
which was stable.
On ___, The patient was neurologically intact in the morning.
At lunchtime the patient had a very brief acute episode of
agitation and pulled out his peripheral IV access. The patient
Dilantin level was 15.7 and therapeutic. Given agitation a
NCHCT was performed which was stable. The patient was
transferred to the floor. The patient was out of bed and
ambulating. He tolerated a regular diet. The patient had a
infrequent cough but no fever.
___ he was noted to be febrile and was started on antibiotics
for klebsiella that grew out from sputum culture. On ___ he was
afebrile, and his culture showed gram positive and negative rods
in cocci, pairs, and clusters. He was also evaluated by ___ and
OT and cleared for home. He also underwent LENIs which were
negative. On ___ discussion was had with ID regarding PO
regimen and he was changed to PO Levofloxacin for 7 days. He was
deemed fit for discharge to home without services. He was given
prescriptions for required medications, instructions for
followup, and all questions were answered prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Cyproheptadine 4 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Sucralfate 1 gm PO BID
5. Lorazepam 1 mg PO DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Cyproheptadine 4 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Sucralfate 1 gm PO BID
5. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
7. Levofloxacin 750 mg PO Q24H Duration: 7 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*7
Tablet Refills:*0
8. Phenytoin Sodium Extended 100 mg PO TID
RX *phenytoin sodium extended [Dilantin Extended] 100 mg 1
capsule(s) by mouth three times a day Disp #*90 Capsule
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Subdural Hematomas
Respiratory Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Your wound was closed with staples you must wait until after
they are removed to wash your hair. You may shower before this
time using a shower cap to cover your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Advil, and Ibuprofen
etc.
You may resume taking your Aspirin 81mg daily on ___
You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCPs
office, but please have the results faxed to ___.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101° F.
Followup Instructions:
___
|
19780708-DS-13
| 19,780,708 | 24,665,426 |
DS
| 13 |
2153-11-18 00:00:00
|
2153-11-27 22:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Left arm weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is an ___ year old male with a history of hypertension
who presents with 4 days of left arm weakness. He says that 4
days prior, he was getting his blood pressure checked; after the
cuff was placed he noticed his left arm was weak. He also
noticed pain in his neck. He denies any numbness, tingling, or
weakness in any of his other extremities. No headache, visual
changes, fevers. He came to medical attention after he notified
police that he had lost his wallet and ID; thereafter he was
sent to the ED at ___ for his persistent left arm weakness.
There, he got a CT of his head and neck which revealed some
degenerative changes in his ___. He denies any history of
trauma or fall. His medical history is significant for
hypertension and glaucoma; he says he lost all of his
medications recently. He admits to difficulty with memory recall
and he cannot remember exactly which medications he takes and
how he lost them. Review of systems otherwise negative.
In the ED, an MRI was attempted as per Neurology team's
suggestion, however the patient felt anxious and short of breath
and MRI was not performed. He was admitted for re-peat attempt
at imaging in the morning.
Past Medical History:
GERD
HTN
Glaucoma
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
BP 170/80, HR 80, temp 98, RR 12, 98% RA
Gen: Dark-skinned male in no apparent distress
Neuro: Focal left-sided deltoid and infraspinatus weakness, no
appreciable sensory abnormalities; tenderness appreciable
overlying C3-C5 along midline of ___ and slightly to the left
Cardiac: Nl s1/s2 RRR, no JVP elevation
Pulm: dry crackles present bilaterally at lung bases
Abdomen: soft, nontender, non distended normative bowel sounds
Ext: no edema noted
PHYSICAL EXAM ON DISCHARGE:
Unchanged from admission
Pertinent Results:
Lab Results on Admission:
___ 06:10AM BLOOD WBC-4.9 RBC-3.76* Hgb-11.8* Hct-33.9*
MCV-90 MCH-31.4 MCHC-34.8 RDW-12.9 Plt ___
___ 06:10AM BLOOD ___ PTT-31.5 ___
___ 01:30PM BLOOD Glucose-95 UreaN-22* Creat-0.9 Na-139
K-4.4 Cl-104 HCO3-23 AnGap-16
___ 01:30PM BLOOD Calcium-9.6 Phos-3.3 Mg-1.7
___ 06:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:10AM BLOOD CRP-4.5
___ 06:10AM BLOOD TSH-0.85
___ 06:10AM BLOOD VitB12-236* Folate-13.3
STUDIES:
___ ECG: Normal sinus rhythm. Q wave in leads V1-V2 and a
minuscule R wave in lead V3.No previous tracing available for
comparison. Consider prior anteroseptal myocardial infarction,
although these changes may be solely related to altered lead
placement as well.
___ MR ___: IMPRESSION:
1. Extensive degenerative disc, endplate, and uncovertebral and
facet joint
disease, in combination with ossification of the posterior
longitudinal
ligament, results in severe multilevel spinal canal and neural
foraminal
stenosis, as detailed above.
2. Despite kyphotic angulation and "bowstringing" of the spinal
cord, as well
as severe compression, above, there is no convincing abnormality
of spinal
cord intrinsic signal to suggest myelomalacia or edema.
___ MR ___: IMPRESSION:
1. Extremely limited study as the patient was not able to
tolerate additional
imaging. The limited images available of the brachial plexus
appears
unremarkable bilaterally.
2. Degenerative changes in the acromioclavicular and right
glenohumeral
joint.
___ MR Shoulder:IMPRESSION:
1. Muscular edema within the supraspinatus, infraspinatus and
inferolateral
deltoid muscle fibers may represent sequela of brachial plexitis
or
Parsonage-Turner syndrome with also mild fatty atrophy of the
teres minor
muscle.
2. Severe tendinopathy of the distal supraspinatus and
infraspinatus tendons
with intrasubstance partial tearing of junctional fibers.
3. Small rim-rent tear of the distal supraspinatus tendon.
4. Mild tendinopathy of the subscapularis tendon.
5. Longitudinal split tear of long head biceps tendon at
intertubercular
groove level with severe tendinopathy within the rotator
interval.
6. Fraying and tearing of the superior labrum with also tear of
the posterior
to posteroinferior labrum.
7. Moderate glenohumeral osteoarthritis, detailed above.
8. Moderate AC joint degenerative hypertrophic changes.
LAB RESULTS ON DISCHARGE:
___ 06:10AM BLOOD Glucose-97 UreaN-30* Creat-1.1 Na-141
K-4.4 Cl-105 HCO3-26 AnGap-14
___ 06:10AM BLOOD Calcium-9.4 Phos-3.9 Mg-1.8
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: This is an ___ male with
PMH of HTN and PUD who presents with new onset shoulder pain
with biceps, triceps, and shoulder weakness for the past 3 days.
Neck MRI shows severe multilevel spinal canal and neural
foraminal stenosis, and shoulder MRI reveals extensive pathology
as well. The differential diagnosis includes cervical stenosis
vs. biceps and rotator cuff tendonitis vs. Parsonage-Turner
syndrome. Ultimately no role was seen for acute surgical
intervention and patient was discharged for continued workup.
.
ACUTE CARE:
1. Left arm weakness and shoulder pain: Patient experienced ___
days of shoulder pain that was acute in onset. He had ___
strength in the left deltoid, biceps, and triceps. He also had
pain and tenderness in the left shoulder and pain in the upper
arm that was exacerbated by movement. The differential diagnosis
of the pain included cervical stenosis, tendonitis, and cervical
plexus-itis. MRI of the ___ confirmed extensive foraminal
narrowing involving multiple levels of the cord, and MRI
shoulder confirmed biceps and rotator cuff tendonopathy with
labral tear and arthritis of the left shoulder joint. Ortho
___ was consulted and so no role for acute surgical
intervention given that symptoms could be explained either from
extensive MSK disease vs. Parsonage-Turner syndrome. Patient was
discharged with orhtopedics follow-up.
.
CHRONIC CARE:
1. Hypertension: Patient was continued on home losartan and
hydrochlorothiazide
.
2. Glaucoma: Patient was continued on home Dorzolamide
2%/Timolol and tavoprost.
.
3. GERD - Patient was continued on omeprazole.
.
TRANSITIONS IN CARE:
1. FOLLOW-UP: Patient has contact info and instructions to
follow up with PCP, ___, and orthopedic surgery.
2. MEDICATION CHANGES: patient was started on vitamin B12 and
tylenol for pain.
3. CODE STATUS: FULL confirmed
4. CONTACT: Daughter ___ ___
___ on Admission:
losartan
Microzide
Plavix
timolol maleate
omeprazole
nifedipine
Discharge Medications:
1. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. dorzolamide-timolol ___ % Drops Sig: One (1) Drop
Ophthalmic BID (2 times a day).
4. travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic daily
(): apply one drop to each eye in the evening. Space out 5
minutes between other eye drops.
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain: do not take more than 8 tabs daily.
7. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: ___ Syndrome
Secondary: Rotator Cuff tendonitis, cervical arthritis
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 this admission. You
were admitted for left arm weakness and neck pain. You had two
MRI which showed extensive bony disease in the neck and
inflammation of the nerves and muscles and minor tearing of the
tendons of the shoulder joint. Ultimately, the cause of your
weakness and pain is most likely due to the nerve and muscle
inflammation. You were discharged from the hospital with a
follow-up appointment with neurology, orthopedics, and your PCP.
Please make the following changes to your medications:
1. START Vitamin B12 1,000mcg by mouth daily
2. START acetaminophen 500-1,000mg by mouth every six hours as
needed for pain. Do not take more than 8 pills daily.
Please take all other medications as previously prescribed to
you by your outside doctors.
Please keep all of your follow-up appointmentments. Your
neurology follow-up should be made as soon as possible next
week.
Followup Instructions:
___
|
19780933-DS-23
| 19,780,933 | 27,427,852 |
DS
| 23 |
2191-01-08 00:00:00
|
2191-01-09 12:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
cellulitis
Major Surgical or Invasive Procedure:
none this hospitalization
History of Present Illness:
Mr. ___ is a ___ year old male with a hx of CAD s/p LCx (___),
CABG (LIMA -LAD, svg-diag, svg-OM in ___, PVD s/p multiple
SFA stents and toe amps and T2DM was admitted for PCI s/p stent
SVG to OM1 DES (___) who presents after recommendation
from his podiatrist for dehydration (reported high BUN/Cr but
values not sent) with right foot wound and cellulitis.
Patient states that last week he went to the beach and spent a
lot of time in the water. he must have stepped on something
because afterwards over the past week he noted pain and redness
at the site of a prior ulceration on his right foot. Patient was
in increasing amount of pain and started taking Ibuprofen 800mg
TID for the past week. He had some diarrhea associated with the
ibuprofen, 2 loose stools per day, low volume, non bloody. The
patient does not report any acute changes in his shortness of
breath or DOE. He denies n/v, CP, palpitations, cough. Slight
decrease in urination but he has been taking his Furosemide 80mg
BID as prescribed. His outpatient management includes up to 2
liters water per day, Lasix 80 mg BID, and spironolactone which
was started one month ago.
He is currently on disability and walks with a cane. He was seen
by podiatrist this morning and his foot wounds were debrided and
pus was expressed. He has significant erythema extending from
his wound that has been marked and he was referred in for
further evaluation.
In the ED, initial vital signs were:
98.8; 61; 98/47; 18; 100% RA
- Exam notable for: "significant erythema extending from his
wound that has been marked"
- Labs were notable for:
___: ___
CBC: 15.0>8.4/26.5<231
K: 5.9-> repeat 4.7
HCO3: 19
BUN/Cr: 105/3.5 (baseline Cr 1.5)
Glucose: 40-> repeat 58
Studies performed include:
- CXR: No acute intrathoracic process. No focal consolidation,
effusion or PNX.
Patient was given:
___ 17:01 IVF 1000 mL NS Started 250 mL/hr
___ 17:01 IV Ciprofloxacin 400 mg
___ 19:43 IVF 1000 mL NS
___ 19:43 IV Ampicillin-Sulbactam 3 g
___ 19:43 PO OxycoDONE (Immediate Release) 5 mg
Also given juice for glucose 40, repeat ___ 58.
- Vitals on transfer: 97.9, 80, 109/49, 18, 100% RA
Upon arrival to the floor, the patient feels the pain has
improved. He denies CP, SOB, fever. Pleasant and conversant.
States that he does NOT take Plavix although this was listed on
his discharge medication list from ___ after stent
placement. Has not eaten much over the past several days.
Sometimes get hypoglycemic with his glyburide.
Past Medical History:
1. Hypertension
2. CAD s/p Cx stenting in ___ s/p CABG ___ as noted above.
3. CVA approximately ___- patient denies current
deficits. Was on Aggrenox until ___ s/p left
occipital stroke.
4. Type 2 Diabetes
5. PAD s/p stenting of the right SFA following admission for a
right fifth toe gangrenous wound/osteomyelitis. s/p right fifth
toe amputation on ___ s/p LLE angiogram ___
6. Left great toe osteomyelitis/gangrene. s/p extensive left
iliofemoral endarterectomy with saphenous vein patch angioplasty
___: s/p stenting x 5 of the left SFA. ___ left
toe amputation.
7. Melanoma of left leg s/p excision
8. Psoriasis
9. Obesity
Social History:
___
Family History:
Maternal side has heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: 97.3-98.4 112-121/62-68 ___ 18 97-100 RA
GENERAL: AOx3, in minimal discomfort from foot pain
HEENT: EOM intact, sclera anicteric, moist mucous membranes
NECK: Supple
CARDIAC: Midline sternotomy scar, regular rate and rhythm, no
murmurs/rubs/gallops
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
palpation.
EXTREMITIES: No edema. Left foot s/p amputation with e/o
ulcerations w/o s/s infection. Right lower extremity with
plantar ulcer and plantar linear ulceration near heel with e/o
blood on dressing, surrounding skin apprx 1cm in diameter
erythematous, much smaller compared to marking placed on
admission. There no is tenderness above the ankle.
NEUROLOGIC: AOx3, grossly non focal.
DISCHARGE PHYSICAL EXAM:
==========================
Vitals: 97.3-98.4 112-121/62-68 ___ 18 97-100 RA
GENERAL: AOx3, in minimal discomfort from foot pain
HEENT: EOM intact, sclera anicteric, moist mucous membranes
NECK: Supple
CARDIAC: Midline sternotomy scar, regular rate and rhythm, no
murmurs/rubs/gallops
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
palpation.
EXTREMITIES: No edema. Left foot s/p amputation with e/o
ulcerations w/o s/s infection. Right lower extremity with
plantar ulcer and plantar linear ulceration near heel with e/o
blood on dressing, surrounding skin apprx 1cm in diameter
erythematous, much smaller compared to marking placed on
admission. There no is tenderness above the ankle.
NEUROLOGIC: AOx3, grossly non focal.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:25PM WBC-15.0*# RBC-2.74* HGB-8.4* HCT-26.5*
MCV-97 MCH-30.7 MCHC-31.7* RDW-15.0 RDWSD-52.5*
___ 04:25PM NEUTS-85.7* LYMPHS-5.3* MONOS-8.0 EOS-0.3*
BASOS-0.2 IM ___ AbsNeut-___*# AbsLymp-0.79*
AbsMono-1.20* AbsEos-0.04 AbsBaso-0.03
___ 04:25PM GLUCOSE-40* UREA N-105* CREAT-3.5* SODIUM-133
POTASSIUM-5.9* CHLORIDE-94* TOTAL CO2-19* ANION GAP-26*
___ 08:48PM LACTATE-2.9* K+-4.7
___ 04:25PM ___
___ 11:06PM URINE HOURS-RANDOM UREA N-393 CREAT-62
SODIUM-68 POTASSIUM-22 CHLORIDE-48
___ 11:06PM URINE OSMOLAL-340
___ 11:37PM cTropnT-0.12*
INTERVAL LABS:
==============
___ 04:15AM BLOOD WBC-12.9* RBC-2.54* Hgb-7.6* Hct-23.9*
MCV-94 MCH-29.9 MCHC-31.8* RDW-14.6 RDWSD-50.0* Plt ___
___ 04:30AM BLOOD WBC-11.9* RBC-2.65* Hgb-7.7* Hct-25.6*
MCV-97 MCH-29.1 MCHC-30.1* RDW-14.6 RDWSD-51.0* Plt ___
___ 04:20AM BLOOD WBC-9.5 RBC-2.59* Hgb-7.8* Hct-25.2*
MCV-97 MCH-30.1 MCHC-31.0* RDW-14.5 RDWSD-51.2* Plt ___
___ 09:45AM BLOOD WBC-10.7* RBC-2.62* Hgb-7.8* Hct-25.0*
MCV-95 MCH-29.8 MCHC-31.2* RDW-14.5 RDWSD-50.9* Plt ___
___ 04:30AM BLOOD WBC-9.0 RBC-2.60* Hgb-7.7* Hct-24.6*
MCV-95 MCH-29.6 MCHC-31.3* RDW-14.5 RDWSD-49.4* Plt ___
___ 04:15AM BLOOD Glucose-158* UreaN-49* Creat-1.6* Na-139
K-4.6 Cl-102 HCO3-21* AnGap-21*
___ 06:15PM BLOOD Glucose-259* UreaN-51* Creat-1.7* Na-135
K-5.2* Cl-100 HCO3-23 AnGap-17
___ 04:20AM BLOOD Glucose-182* UreaN-74* Creat-2.1* Na-135
K-5.0 Cl-101 HCO3-16* AnGap-23*
___ 09:45AM BLOOD Glucose-137* UreaN-83* Creat-2.4* Na-138
K-5.1 Cl-100 HCO3-19* AnGap-24*
___ 04:30AM BLOOD Glucose-93 UreaN-102* Creat-3.0* Na-136
K-4.7 Cl-100 HCO3-20* AnGap-21*
___ 04:15AM BLOOD Calcium-9.9 Phos-4.8* Mg-1.9
___ 04:30AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.3
___ 04:20AM BLOOD Calcium-9.3 Phos-4.9* Mg-2.6
___ 09:45AM BLOOD Calcium-9.4 Phos-5.5* Mg-2.5
___ 04:30AM BLOOD Calcium-9.2 Phos-5.5* Mg-2.5
___ 06:02AM BLOOD calTIBC-229* Ferritn-518* TRF-176*
IMAGING:
=============
MRI ankle w/o contrast ___:
1. No MRI evidence for acute osteomyelitis involving the mid
foot or hind foot.
2. 6 mm soft tissue ulceration at the plantar aspect of the
heel.
Renal Ultrasound ___:
1. No hydronephrosis or nephrolithiasis.
2. 1.1 x 1.4 cm left lower renal pole complex cystic lesion.
RECOMMENDATION(S): 6-month followup renal MRI for reassessment
of the left lower pole renal complex cystic lesion.
Right Foot XRAY ___:
There has been prior resection of the fifth digit at the MTP
joint. There is soft tissue swelling. There is no bony
destruction to indicate radiographic signs for acute
osteomyelitis. Degenerative changes at the first MTP joint is
seen. No definite soft tissue gas is present. Vascular
calcifications are seen.
MICROBIOLOGY:
=============
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ URINE URINE CULTURE-FINAL
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ URINE URINE CULTURE-FINAL
___ RIGHT FOOT CULTURE
- Pan-sensitive Staph. aureus
- Beta-hemolytic Strep no sensitivities
- Diphtheroids no sensitivities
DISCHARGE LABS:
===============
___ 04:15AM BLOOD WBC-12.9* RBC-2.54* Hgb-7.6* Hct-23.9*
MCV-94 MCH-29.9 MCHC-31.8* RDW-14.6 RDWSD-50.0* Plt ___
___ 04:15AM BLOOD Glucose-158* UreaN-49* Creat-1.6* Na-139
K-4.6 Cl-102 HCO3-21* AnGap-21*
___ 04:15AM BLOOD Calcium-9.9 Phos-4.8* Mg-1.9
___ 11:37PM BLOOD ALT-13 AST-13 AlkPhos-73 TotBili-0.3
DirBili-0.1 IndBili-0.2
___ 06:02AM BLOOD calTIBC-229* Ferritn-518* TRF-176*
___ 04:27PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 03:42PM BLOOD CK-MB-2 cTropnT-0.03*
___ 04:15AM BLOOD CK-MB-2 cTropnT-0.03*
Brief Hospital Course:
___ year old male with a hx of CAD s/p LCx (___), CABG (LIMA
-LAD, svg-diag, svg-OM in ___, PVD s/p multiple SFA stents
and toe amps, and T2DM who presented after recommendation from
his podiatrist for dehydration (reported high BUN/Cr but values
not sent) with right foot wound and cellulitis, now improved.
# Right foot skin/soft tissue infection
Concern for expanding cellulitis at site of right foot
ulceration, s/p debridement and expressment of pus from
outpatient podiatry on ___. Given significant exposure to
water and diabetes, treatment with an antipsuedomonal agent,
Zosyn, was started. Anaphylactic rxn to vancomycin in the past
and so treated w/doxycycline instead. Foot Xray without evidence
of foreign body and MRI negative for osteomyelitis. Consult
obtained from ID for abx recommendations. Ultimately, his
antibiotic regimen included: Zosyn ___ - ___, Doxycycline ___
- ___ and Ciprofloxacin ___ - ___. As an outpatient he will
continue Doxycycline 100mg BID PO 10 days (until ___ and
Ciprofloxacin 500mg PO BID for 10 days (until ___
- Pain control w/ 5mg oxycodone Q4H:prn as outpatient, provided
20 pills, counseled to down-titrate, partial fill if needed and
if worsening pain/redness or other concerning symptoms to call
PCP ___.
- Patient was evaluated by physical therapy, found to be safe
for home with heel offloading shoe
# Acute Renal Failure. Cr on admission 3.5 elevated from
baseline ___, now improving to 1.6 (on ___. Based on urine
spin on ___, appears to be interstitial nephritis from NSAIDs.
No evidence of ATN. Renal ultrasound showed no evidence of
hydronephrosis. No indication for dialysis during
hospitalization. Lasix and spironolactone were initially held on
admission but restarted prior to dc. Lisinopril was held on
discharge and pt will have creatinine checked on dc. Pt was
advised to avoid NSAIDs.
# Chest Discomfort. Most episodes of discomfort were on
___. Patient believed it was due to GERD and felt very
different from when he has had a heart attack. After drinking
liquids he developed dyspeptic symptoms, which would then
resolve. Symptoms were not exertional and not associated with
diaphoresis. EKG done on ___epression in
V5, new from prior EKGs. His ___ EKG as well showed increased
ST depression in V5. There was no other evidence of possible new
ischemia on EKG. Out of an abundance of caution, obtained two
troponins on ___, both were 0.03, improved from 0.12 at
admission and with CK-MB of 2.
# Anion Gap Metabolic Acidosis. Patient presented with AGMA with
AG 20, now 15. Most likely in the setting of acute renal failure
and uremia. Slowly improving as renal function returned to
baseline.
# Acute on Chronic Anemia. H/H ___ on admission, below
baseline Hgb ___ in ___. No evidence of acute bleed. Likely
dilutional given patient at baseline. Iron studies consistent
with anemia of chronic disease, which may be attributed to his
diabetes and renal failure. Patient's H/H remained stable.
Consider further workup as outpatient and ensure up to date with
colonoscopy.
# Leukocytosis: presented with WBC 15, 9.5 on ___. Most likely
___ skin/soft tissue infection. He has been afebrile with
lactate normalized. UA and urine cx negative. CXR without any
focal processes. Blood cultures were NGTD at discharge. Patient
was transitioned to doxy/cipro (___) for 10 days as above
# sCHF (EF 30% post bypass in ___ Chronic (w/o
decompensation):
BNP on admission 25,440. CXR without evidence of volume
overload. s/p 1L IVF in the ED. Clinically did not appear volume
overloaded. His furosemide and spironolactone were restarted on
___, can consider restarting patient's lisinopril as
outpatient if renal failure improves. Would continue standing
weights as outpatient, modification of diuretics if needed.
# DM Type 2 and Hypoglycemia:
Glucose on admission 40, s/p juice with improvement to 58.
Patient takes Glyburide at home. Hypoglycemia is a common side
effect of oral antidiabetic medications and glyburide is renally
cleared. Likely exacerbated by decreased PO intake. At discharge
held glyburide given that renal failure not fully resolved.
Patient received only intermittent doses of insulin for blood
sugars 177-210 on sliding scale. Would continue to hold
glyburide at discharge, pending improvement in renal function
and check glucose daily. Can restart as outpatient after
discussion with PCP. Alternatively can use agents such as qHS
lantus which may be safer and lead to less hypoglycemia.
# Diarrhea: Non bloody and small volume. Occurring after
Ibuprofen use. C diff was negative. Resolved by time of
discharge with presence of mild constipation, improved with
bowel regimen.
TRANSITIONAL ISSUES:
====================
- 6-month followup renal MRI for reassessment of the left lower
pole renal complex cystic lesion.
- Please avoid taking baths and prolonged water exposure to the
right foot for next 2 weeks
- Narcotics are TEMPORARY for foot pain, advise down-titration
and patient counseled extensively on red flags of worsening
cellulitis, knows to call PCP/podiatrist if any worsening.
___ PMP checked, and no aberrant prescribing. Received
two day course of narcotic from his podiatrist at initial
presentation of cellulitis.
- F/u pending blood cultures
- Held glyburide at discharge due to renal failure, can restart
after renal function improves. Would monitor fingersticks once
daily.
- Held lisinopril at discharge due to renal failure, would
restart at low dose when improved.
- Avoid all NSAIDs given finding of interstitial nephritis from
NSAIDs at admission
Contact: ___ (wife): ___
Code Status: DNR/DNI, confirmed
DISCHARGE WEIGHT: 93.7kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. GlyBURIDE 5 mg PO BID
5. Lisinopril 5 mg PO DAILY
6. Metoprolol Tartrate 25 mg PO BID
7. Spironolactone 25 mg PO DAILY
8. Furosemide 80 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth q8h:prn Disp #*60
Tablet Refills:*0
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*16 Tablet Refills:*0
3. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*16 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
Duration: 20 Doses
Please take as needed and taper dose frequency as appropriate
for pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4h:prn Disp #*20 Tablet
Refills:*0
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth once a day Disp #*30 Packet Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth BID:prn Disp
#*60 Tablet Refills:*0
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Furosemide 80 mg PO BID
11. Metoprolol Tartrate 25 mg PO BID
12. Spironolactone 25 mg PO DAILY
13.Outpatient Lab Work
ICD10: N17.9
Please obtain CHEM10 on ___ and fax to:
___. MD ___
___, ___
Phone: ___ Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Right foot cellulitis
Acute on chronic kidney failure
Acute on chronic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You came into the
hospital because of a skin infection at the site of a chronic
foot ulcer. Our imaging studies showed that there was no
infection of the bone. We have placed you on oral antibiotics to
treat your infection that you should take until ___.
During your admission, you also had decreased kidney function
that had been improving throughout your stay. We restarted your
diuretic medications prior to discharge. Be sure to obtain
laboratory tests on ___ to monitor for kidney
function.
It is important to remember:
- take your 2 antibiotics (ciprofloxacin, doxycycline) every day
and even if you are feeling better please take your full course
of antibiotics
- continue your diuretic medications (furosemide,
spironolactone)
- please get your kidney function checked on ___ (you can
take your prescription for lab work to any lab that accepts your
insurance, and they will send the results to your primary care
doctor)
- please avoid baths as this can lead to re-infection of your
heel, instead shower and pat your right foot dry for the next 2
weeks
- please do NOT take your lisinopril or glyburide until seeing
your primary care doctor. Check your sugars daily.
Thank you for letting us participate in your care.
-Your ___ team
Followup Instructions:
___
|
19780933-DS-24
| 19,780,933 | 25,751,349 |
DS
| 24 |
2191-02-11 00:00:00
|
2191-02-11 11:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
Right foot pain
Major Surgical or Invasive Procedure:
___: Right Lower Extremity Angiogram with PTA of SFA stents
and popliteal with drug-coated balloons x3
___: Right Heel Debridement
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with a history of CAD s/p
CABG/PCI, HFrEF, PVD s/p stents/amputations, T2DM who was
recently admitted ___ for a right foot infection and acute
kidney failure who presents to the ED with worsening pain in his
right foot.
Mr. ___ had been feeling better upon his last discharge. He
feels that after he completed his course of antibiotics
(doxycycline / ciprofloxacin) on ___ his foot slowly started
getting worse again. Over the past week his pain in the right
foot has returned, he quantifies it at ___ and states it is
not as bad as it was upon his first admission. He was prescribed
hydromorphone 2mg q6h prn by his PCP for pain but he did not
feel much improvement. Today he was seen by his PCP who felt the
area of erythema around his foot had worsened and decided to
send him to the ED.
In the ED, initial vitals: 98.9 | 66 | 83/41 | 18 | 100% RA
-Exam: Right plantar ulceration with surrounding erythema and
exquisite tenderness
-Labs significant for:
*14.0 > 10.1/32.8 < 232, N:81.1
* Na 130, K 6.4 hemolyzed, BUN 58 / Cr 1.9
* K:5.9, Lactate:3.3
-Surgery consulted: No signs of necrotizing fasciitis on CT,
defer to podiatry
-Podiatry consulted:Bedside I&D performed with culture sent.
Agree with admission to ICU. Podiatric Surgery to follow.
-Imaging significant for:
*CT Low Ext W/O C Right: No evidence of subcutaneous gas or
fluid collection. No acute fractures.
*CXR: No acute cardiopulmonary process
*Foot XR: No radiographic evidence of osteomyelitis
-Patient was given:
___ 13:55 IV Piperacillin-Tazobactam 4.5 g
___ 14:52 IV Clindamycin 900 mg
___ 14:52 IVF 1000 mL NS 500 mL
___ 15:33 IV Linezolid ___ mg
___ 15:33 IVF NS 500 mL
On transfer, vitals were: 98.5 | 61 | 104/55 | 21 | 100% RA
On arrival to the MICU, patient complained of pain in his right
foot and thirst.
Past Medical History:
1. Hypertension
2. CAD s/p Cx stenting in ___ s/p CABG ___ as noted above.
3. CVA approximately ___- patient denies current
deficits. Was on Aggrenox until ___ s/p left
occipital stroke.
4. Type 2 Diabetes
5. PAD s/p stenting of the right SFA following admission for a
right fifth toe gangrenous wound/osteomyelitis. s/p right fifth
toe amputation on ___ s/p LLE angiogram ___
6. Left great toe osteomyelitis/gangrene. s/p extensive left
iliofemoral endarterectomy with saphenous vein patch angioplasty
___: s/p stenting x 5 of the left SFA. ___ left
toe amputation.
7. Melanoma of left leg s/p excision
8. Psoriasis
9. Obesity
Social History:
___
Family History:
Maternal side has heart disease
Physical Exam:
Admission exam:
---------------
Vitals: Please see Metavision
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, ___ non-palpable bilaterally but
dopplerable, heel ulceration in the right plantar surface with
erythema and exquisite pain on palpation
SKIN: Multiple psoriatic plaques in knees and elbows.
NEURO: AOx3, grossly non-focal
Discharge Physical Exam:
Vitals: T:97.9 HR:92 BP:121/76 RR:16 ___
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, ___ non-palpable bilaterally but
dopplerable, right heel wound present (6x4cm area)post
debridement with improved erythema and tenderness
NEURO: AOx3, grossly non-focal
PULSE:
R: d/d/d
L: p/d/d
Pertinent Results:
Admission labs
___ 01:00PM BLOOD WBC-14.0* RBC-3.50*# Hgb-10.1*#
Hct-32.8*# MCV-94 MCH-28.9 MCHC-30.8* RDW-14.6 RDWSD-49.9* Plt
___
___ 01:00PM BLOOD Neuts-81.1* Lymphs-10.6* Monos-6.4
Eos-0.9* Baso-0.4 Im ___ AbsNeut-11.33*# AbsLymp-1.48
AbsMono-0.89* AbsEos-0.13 AbsBaso-0.05
___ 01:00PM BLOOD ___ PTT-29.0 ___
___ 01:00PM BLOOD Glucose-125* UreaN-58* Creat-1.9* Na-130*
K-6.4* Cl-92* HCO3-20* AnGap-25*
___ 01:00PM BLOOD CK(CPK)-49
___ 01:00PM BLOOD proBNP-5817*
___ 01:24AM BLOOD Calcium-9.2 Phos-4.3 Mg-1.9
___ 01:18PM BLOOD Lactate-3.3* K-5.9*
Discharge Labs
___ 07:50AM BLOOD WBC-7.7 RBC-2.94* Hgb-8.4* Hct-27.0*
MCV-92 MCH-28.6 MCHC-31.1* RDW-14.5 RDWSD-47.6* Plt ___
___ 07:57AM BLOOD Glucose-110* UreaN-24* Creat-1.3* Na-137
K-4.1 Cl-98 HCO3-23 AnGap-20
___ 07:57AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.0
Micro
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
WOUND CULTURE (Final ___:
ESCHERICHIA COLI. MODERATE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h. Ampicillin available on request.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
Sensitivity testing per ___ (___).
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
ESCHERICHIA COLI. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
(___).
STAPH AUREUS COAG +. SPARSE 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---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
IMAGING:
--------
CT lower ext ___
IMPRESSION:
No evidence of subcutaneous gas or fluid collection. No acute
fractures.
CXR ___
No acute cardiopulmonary process.
OPERATIVE NOTES:
-----------------
___
PREOPERATIVE DIAGNOSIS: Nonhealing ulcers of the right heel.
POSTOPERATIVE DIAGNOSIS: Nonhealing ulcers of the right heel.
PROCEDURE:
1. Ultrasound-guided access to the left common femoral artery.
2. Selective catheterization of the right external iliac artery,
second order vessel.
3. Abdominal aortogram.
4. Right lower extremity angiogram.
5. Balloon angioplasty of the right superficial femoral artery
and popliteal arteries with drug-coated balloons.
ASSISTANT: ___, MD.
CONTRAST VOLUME: 40 cc Visipaque.
FLUOROSCOPY TIME: 14.5 minutes.
RADIATION DOSE: 136 mGy.
INDICATIONS: This is a ___ gentleman with a history of
diabetes and severe peripheral vascular disease, who previously
underwent right SFA stenting by Dr. ___ in ___. He recently
presented with right heel cellulitis and an ulcer that he
reports started when he stepped on something sharp at the beach.
His noninvasive arterial studies showed an ABI of 0.61 on the
right side and significant right aortoiliac and
bilateral tibial disease. He was thus consented for a right
lower extremity angiogram and potential intervention.
DETAILS OF PROCEDURE: The patient was brought to the operating
room and placed supine on the OR table. His bilateral groins
were prepped and draped in the 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 and free of limiting calcification.
The vessel was noted to be large, consistent with the patient's
history of a prior left femoral endarterectomy and patch
angioplasty with greater saphenous
vein. Images of the ultrasound guidance were stored in the
___ medical record for documentation purposes. We
confirmed the site of our puncture with fluoroscopy, and this
was noted to be over the left femoral head. There was some
difficulty passing the micropuncture needle, but we
eventually were able to advance it over the wire. Through the
micropuncture sheath, we advanced an Amplatz wire, anticipating
that it would be difficult to place a sheath. Over the Amplatz,
we were able to place a ___ sheath in the left groin. We
advanced an Omni Flush catheter into the abdominal aorta to the
level of the L1 vertebral body. We then performed an abdominal
aortogram. This revealed a
patent infrarenal abdominal aorta without evidence of aneurysm
or ectasia. The bilateral renal arteries were patent with brisk
nephrograms, better on the left than the right side. The
bilateral iliac systems were patent, without significant
hemodynamically significant stenosis. We then
got up and over the aortic bifurcation using a stiff angled
Glidewire and the Omni Flush catheter. We selected the right
external iliac artery with the catheter and performed a right
lower extremity angiogram. This revealed a moderately- diseased
right common femoral artery, a patent right profunda artery, and
a patent SFA. The previously placed stents along the length of
the SFA were patent, although there were several areas of focal
stenosis along the length of the SFA. Lower down, the above- and
below-knee popliteal arteries were patent, although moderately
diseased and heavily burdened with calcium. In the leg, all 3
tibial vessels were patent and continued down into the foot.
The DP and ___ were patent,
although diminutive, in the foot. At this point, Dr. ___
___ the radiographic images, and we elected to
intervene. Therefore, the sheath within the left groin was
upsized to a ___ 45 ___ sheath. In order to do this,
we had to ___ dilate the tract with a short ___ 10cm
sheath. We were then able to guide the sheath into the
right common femoral artery. Using the stiff angled glide and a
torque device, we were able to guide our wire down through the
stents. We were able to confirm that we stayed intraluminal by
forming a loop at the tip of our wire and advancing this down
through the stents. We then performed
balloon angioplasty over the entire course of the multiple SFA
stents. This was performed using three 5 x ___ IN.PACT
drug-coated balloons, as well as one 5 x 80 IN.PACT drug-coated
balloon, the most distal of which extended outside of the most
distal SFA stent into the behind-the-knee popliteal artery.
Each balloon was inflated full for a full 3 minutes.
A completion angiogram showed a technically-successful result.
We then checked 1 more image of the foot to ensure that we had
not embolized anything distally, and this confirmed that we had
not. Therefore, at this time, we elected to terminate the
procedure. All catheters and wires
were removed. A ___ wire was advanced into the ___
sheath, and the sheath was backed out until the level of the
aortic bifurcation. The ___ was then advanced into the
abdominal aorta. We then attempted closure of our arteriotomy
with a Perclose closure device. However, given
the extensive and heavily scarred left groin, the Perclose
misfired. We, therefore, administered 30 mg of protamine and
held manual pressure for 30 minutes. This resulted in excellent
hemostasis without evidence of groin hematoma. The patient
tolerated the procedure well. There were no
immediate complications. Dr. ___ was present for the entirety
of the procedure.
ANGIOGRAPHIC FINDINGS:
1. Patent infrarenal abdominal aorta without aneurysm or focal
ectasia, patent bilateral renal arteries with brisk nephrograms,
left greater than right.
2. Patent bilateral iliac artery systems.
3. Patent, but moderately diseased, right common femoral artery,
patent right profunda, and patent SFA. The previously-placed
SFA stents are patent, but with multiple areas of in-stent
restenosis. These lesions
were treated with a total of 4 drug-coated balloons: Three 5 x
___ IN.___ drug-coated balloons and one 5 x 80 IN.___
___ drug-coated balloon.
4. The above- and below-knee popliteal arteries are patent.
5. All 3 tibial vessels are patent within the lower leg and
provide flow to the foot.
___
PREOPERATIVE DIAGNOSIS: Abscess, right heel.
POSTOPERATIVE DIAGNOSIS: Abscess, right heel.
PROCEDURE: Excisional debridement of eschar and fat, right
heel. Total area debrided 30 square cm.
ANESTHESIA: The patient had a popliteal nerve block in the
holding area by a member of the anesthesia team. This was
supplemented by IV sedation.
INDICATIONS: The patient is a ___ diabetic male who was
admitted urgently to the hospital with a cellulitis and
infection of his right heel. He had a long-standing eschar at
the base of the right heel. He subsequently underwent a
revascularization procedure. He is now brought to the operating
room for excisional debridement of eschar and
infected tissue. The operative procedure was discussed with the
patient, and he understands and accepts.
OPERATION: The patient was brought into the operating room and
placed in the supine position. The patient had a popliteal
nerve block placed in the holding area by a member of the
anesthesia team. The right foot was then prepped and draped in
the usual sterile manner. A time-out procedure was initiated.
The patient, site, and side were all appropriately identified.
Attention was now directed to the base of the right heel,
where he had an approximately 6 cm x 5 cm necrotic eschar on
the plantar heel pad. Using sterile forceps and a #15
scalpel blade, the eschar was sharply excised from the
surrounding normal tissue. Upon elevating the eschar, there
was a moderate amount of purulent material and liquified fat
noted. The eschar was excised in its entirety and removed
from the operative field. There was noted to be significant
liquefaction of the fat pad with purulent drainage. Using
sterile rongeur, the liquefied fat was excised and removed
from the operative field. The specimen was submitted to
Pathology and to Microbiology for examination. Sharp
excisional debridement was continued of the fat pad and
necrotic tissue until this was taken down to good, healthy,
bleeding tissue. It was noted this was taken down to the
level of the plantar fascia and to the calcaneus. However,
the calcaneus itself was completely covered, and there was no
extension of the purulence proximally or distally. The wound
was now irrigated with copious amounts of saline solution.
The wound was once again inspected for any remaining necrotic
tissue or liquified fat. The edges were freshened with a #10
scalpel to good, healthy, bleeding edges. The wound was once
again irrigated with copious amounts of saline solution. A
dressing was now applied consisting of Adaptic, sterile
gauze, and Kling. There were no intraoperative
complications. The patient tolerated the procedure well. He
was taken to the recovery room awake, alert, and in stable
condition.
Brief Hospital Course:
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MICU COURSE
Initially SBPs in ___ on arrival to ED, lowest in mid ___.
Patient was mentating and well appearing at all times but did
have elevated lactate prompting concern for septic shock given
concurrent soft tissue infection. Rapid improvement with 500cc
of NS. Patient weight is 89kg, below 93kg from prior discharge
and has ___ and hyponatremia suggesting volume depletion. Right
heel ulcer with purulent secretions obtained in podiatry's
bedside I&D. Given diabetes and PVD as well as recent admission
patient is at increased risk for resistant GNRs including
Pseudomonas as well as MRSA, started on Linezolid and Zosyn, ID
is following. Patient will undergo non-invasive arterial studies
and be taken for debridement in OR with Podiatry ___.
Fractionated metoprolol will be continued. Recent diagnosis of
NSAID induced AIN during previous admission but Cr is 1.9 from
1.6 upon discharge. Likely secondary to diuresis with
furosemide/spironolactone, which are being held. Urine lytes
were ordered. ___ was consulted for uncontrolled diabetes.
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SIRS COURSE (___)
Patient without complaints upon arrival.
#Hypotension: Fractionated metoprolol was continued, home
diuretics held in the setting of history of hypotension. He
received 1x 500cc NS over 2hr on ___ for soft BPs but was
otherwise normotensive.
#Right foot soft tissue infection: WBC continues to downtrend
and the surrounding erythema and warmth have resolved with
antibiotic treatment. NIAS (___) with best ABI 0.61 on R, 1.33
on L. Podiatric Surgery following, requested vascular evaluation
prior to any procedure in case the patient required a vascular
intervention to increase distal blood flow. Dr. ___
patient's primary cardiologist, visited and ordered venous
mapping and arteriogram for ___. I&D culture returned with
E.coli sensitive to Zosyn, discontinued Linezolid. CRP elevated.
BCx, ESR still pending on transfer to Vascular Surgery.
#Acute Renal Failure: Baseline Cr 1.6 on last discharge (after
ibuprofen-induced AIN). Possible causes include hypotension
leading to ATN, AIN ___ antibiotic use. Rising Cr to 1.9-->2.1
on ___ likely in the setting of low SBPs overnight. We
continued to hold home diuretics and administered 500cc NS as
above.
#Systolic heart failure/CAD s/p CABG: The patient remained
euvolemic to volume deplete on exam. We continued his ASA and
atorvastatin as well as his fractionated metoprolol.
#Type 2 Diabetes Mellitus: HbA1c 7.7-->6.8, but may be
inaccurate given anemia of chronic disease which may lead to
decreased erythrocyte lifespan. Intermittent hypoglycemia on
admission likely due to reduced renal clearance of glyburide and
metformin which are now held. He received an ISS and home Lantus
guided by ___ during his admission on SIRS. Home glyburide
and metformin were held. He will require significant outpatient
follow-up to better manage his DM.
==Chronic Issues==
#Anemia of chronic disease: At baseline H/H, continue to
monitor.
==VASCULAR SURGERY==
The patient was transferred to vascular surgery service on
___. He underwent a RLE Angiogram and PTA of SFA stents and
popliteal with drug coated balloonsx3 on ___. He tolerated
the procedure well and was sent to the PACU post operatively and
when appropriate transferred to the floor. He was switched to
Ceftriaxone post operatively per ID and a PICC line was placed
for poor peripheral access and long term antibiotic need. On
___ he underwent Right Heel debridement and tolerated the
procedure well. Wet to dry dressing were applied until ___
and a wound vac was placed and will remain per Podiatry until
follow up appointment with every 3 day dressing changes. Per ID
recommendations Flagyl was added on ___ to the antibiotic
treatment and he will continue with IV Ceftriaxone 2 gm Q24H and
Flagyl 500mg Q8H until ___ and will follow up with
infectious disease in a couple weeks regarding antibiotic final
plans. Due to hyperglycemia, his glyburide was increased from
5mg BID to 10 mg BID during this admission and he is to be
discharged with 10mg BID dosage.
He is now ready for discharge. At the time of discharge, he is
tolerating regular diet. He is in stable condition with better
glucose control. He is discharged with wet to dry dressing and
wound vac will be placed at the Rehab facility.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Furosemide 80 mg PO BID
5. Metoprolol Tartrate 25 mg PO BID
6. Spironolactone 25 mg PO DAILY
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
8. MetFORMIN (Glucophage) 1000 mg PO DAILY
9. GlyBURIDE 5 mg PO DAILY
10. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Mild
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 mg IV once a
day Disp #*38 Intravenous Bag Refills:*0
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*90
Tablet Refills:*0
3. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
4. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth three
times a day Disp #*114 Tablet Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*30 Capsule Refills:*0
6. GlyBURIDE 10 mg PO BID
RX *glyburide 5 mg 2 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 40 mg PO QPM
10. Docusate Sodium 100 mg PO BID:PRN constipation
11. Furosemide 80 mg PO BID
12. MetFORMIN (Glucophage) 1000 mg PO DAILY
13. Metoprolol Tartrate 25 mg PO BID
14. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Non-healing Right Heel Ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity: Non-weight bearing on the right lower extremity
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after a
peripheral angiogram and placement of stents in your artery.
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 also had debridement of your right heel
done during this admission. 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.
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent and Foot Debridement Discharge
Instructions
MEDICATION:
Take Aspirin 81mg once daily
Take Plavix (Clopidogrel) 75mg 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
Antibiotics: You were started on Ceftriaxone (IV 2gm Daily)
and Flagyl (PO 500mg Q8H)as antibiotics to treat your foot
wound. You will remain on the antibiotics until ___.
CHANGES TO MEDICATION:
- You were started on antibiotics Ceftriaxone (2gm Q24H) and
Flagyl (500mg Q8H) during this hospital admission. Please
continue taking the antibiotics until at least ___.
- You were also started on Plavix during this admission. Please
take Plavix for 3 months as prescribed unless your surgeon
states otherwise
- Your diabetes medications were changed during this admission.
Please check your glucose QACHS. Please take Glyburide 10mg BID
and Metformin 1000mg Daily with Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog Humalog Humalog Humalog
___ mg/dL
71-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 1 Units
201-250 mg/dL 3 Units 3 Units 3 Units 2 Units
251-300 mg/dL 4 Units 4 Units 4 Units 3 Units
301-350 mg/dL 5 Units 5 Units 5 Units 5 Units
351-400 mg/dL 6 Units 6 Units 6 Units 6 Units
> 400 mg/dL 7 Units 7 Units 7 Units 7 Units
Once sugars are 100-140 before meals and <180 after meals, can
come off insulin sliding scale.
LAB MONITORING RECOMMENDATIONS:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
CEFTRIAXONE: WEEKLY: CBC with differential, BUN, Cr, AST, ALT,
TB, ALK PHOS
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 please do not put any weight on the right
foot. Please remain non-weight bearing on the right side until
you see Podiatry in clinic
Your incision in the groin 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
You are going to rehab with wet to dry dressing. Please place
and change the wound vac every 3 days until you see Podiatry in
clinic.
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
No driving until you are no longer taking pain medications
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
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:
___
|
19780995-DS-18
| 19,780,995 | 28,210,136 |
DS
| 18 |
2169-01-22 00:00:00
|
2169-01-22 20:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
atenolol
Attending: ___.
Chief Complaint:
incidental subacute stroke found on
imaging
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PI:
___ yo who has a hx of afib (not on anticoagulation), HTN,
hyperlipidemia, alcohol abuse, newly diagnosed dm, who recently
saw neurology as an outpatient found to have small subacute
stroke on imaging for workup of cognitive decline.
Patient tells me he started noticing issues understanding what
others were saying to him and confusion ___ weeks ago. Said he
noticed acutely. Since this time he has had difficulty
"perceiving" things. He has trouble understanding what others
are
saying to him and that he is "listening but not listening". He
has had increased issues with word finding. Most notable to him
has been his issues with math which is typically a strength of
his. Over the last few weeks has had difficulty with the mental
math he has to do at work and having problems "following"
everything. He was having difficulty balancing his check book
the
other day per his wife. In addition he noticed that he forgot to
take his medications for a few days and forgot his wife's
birthday. Overall thinks that he is improving and that his
"processing is coming back" but says that he will still have
"bouts" of this where he will "get confused at simple things".
No
issues with ADLs or long term memory.
In addition he endorses feeling unsteady on his feet for the
past
month or so. This is worse at night with the lights off but has
not fallen from this. He has been having a headache for the past
~4 days as well. This is atypical for him. Headache is mild,
behind his eyes and bitemporal. He has not had to take any
medications for the headaches. Headaches have never woken him up
from sleep, no changes in vision with headaches. He has chronic
neck pain that he previously got steroid injections ___ years
ago. Has mild tingling in his left pink, ring, and middle
fingers
over the past 4 months.
He has a history of a fib s/p ablation ___ years ago and has never
been on anticoagulation. He says that since it was discovered he
has been on 325mg ASA. He endorse feeling like he has been going
in and out of A fib for the past few months, but denies feeling
this way when his confusion/memory symptoms started. He recently
had a holter monitor that did not show any episodes of a fib.
He has a history of alcohol abuse and recently in remission. His
last drink was ~1 month ago.
He denies any slurring of his words, vision changes, weakness,
changes in bowel or bladder function, fevers, weight loss,
On neuro ROS,
The pt endorses headaches as described above, tinnitus (chronic
issue), difficulty with gait and language as described above.
finger parasthesias as described above
the pt denies loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, or hearing
difficulty. Denies focal weakness No bowel or bladder
incontinence or retention.
On general review of systems,
Endorses recent weight loss of 30lbs but this has been
intentional as he has been dieting and exercising since his
diagnosis with diabetes. Endorses some night sweats a few months
ago but these have improved. Palpitations as described above
the pt denies recent fever or chills. No Denies cough,
shortness of breath. Denies chest pain or tightness, Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
PMH:
HTN
HLD
Diabetes Type ii
Alcohol use disorder, recently in remission
Afib s/p ablation
Cervical spondylosis with radiculopathy
Tobacco use
Social History:
___
Family Hx:
Uncle with mild cognitive changes in his old age but no family
with dementia
Maternal GM and Aunt with strokes in their ___.
Heart disease runs in family
Family History:
Family Hx:
Uncle with mild cognitive changes in his old age but no family
with dementia
Maternal GM and Aunt with strokes in their ___.
Heart disease runs in family
Physical Exam:
**********
Physical Exam:
Vitals: T97.8, HR 74, BP 159/75, RR18, 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended, normal active bowel sounds
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x BI, ___, ___.
Able to relate history without difficulty. Unable to name ___ at ___ and says "ok that's it"), able to do DOWB
quickly, 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. Calculation intact
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk, right pupil
irregular
. 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.
-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 Gastroc
L 5 5 ___ ___ 5 5
R 5 5 ___ ___ 5 5
-Sensory: No deficits to light touch, pinprick,
mild early extinction to vibration in toes (R 4 seconds L 7
seconds), proprioception intact in feet bilaterally, Romberg
absent.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally. No pec jerk, no cross
adductors, and no clonus bilaterally
-Coordination: mild intention tremor bilaterally, Normal
finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. able to take a few steps in tandem walk but difficult,
___ negative
DISCHARGE EXAM
=-==================
General: Awake, cooperative, NAD.
Neurologic:
-Mental Status: Alert, oriented x BI, ___, ___.
Able to relate history without difficulty. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk, right pupil
irregular
. 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.
-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 Gastroc
L 5 5 ___ ___ 5 5
R 5 5 ___ ___ 5 5
-Sensory: No deficits to light touch, pinprick,
mild early extinction to vibration in toes (R 4 seconds L 7
seconds), proprioception intact in feet bilaterally, Romberg
absent.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
-Coordination: mild intention tremor bilaterally, Normal
finger-tap bilaterally. No dysmetria on FNF
-Gait: Not tested
Pertinent Results:
Admission Labs
==============
___ 05:25PM BLOOD WBC-6.6 RBC-4.35* Hgb-14.2 Hct-40.9
MCV-94 MCH-32.6* MCHC-34.7 RDW-11.8 RDWSD-40.5 Plt ___
___ 05:25PM BLOOD Neuts-57.9 ___ Monos-7.1 Eos-3.8
Baso-0.5 Im ___ AbsNeut-3.84 AbsLymp-2.00 AbsMono-0.47
AbsEos-0.25 AbsBaso-0.03
___ 05:25PM BLOOD ___ PTT-30.3 ___
___ 05:25PM BLOOD Plt ___
___ 05:25PM BLOOD Glucose-82 UreaN-16 Creat-0.9 Na-143
K-4.0 Cl-107 HCO3-25 AnGap-11
___ 05:25PM BLOOD ALT-23 AST-26 AlkPhos-99 TotBili-0.5
___ 05:25PM BLOOD Lipase-73*
___ 05:25PM BLOOD cTropnT-<0.01
___ 05:25PM BLOOD Albumin-4.3 Calcium-9.5 Phos-3.8 Mg-2.0
Cholest-143
___ 08:24PM BLOOD %HbA1c-7.7* eAG-174*
___ 05:25PM BLOOD Triglyc-245* HDL-32* CHOL/HD-4.5
LDLcalc-62 Homocys-PND
___ 05:25PM BLOOD CRP-2.0
___ 05:45AM BLOOD Trep Ab-PND
___ 05:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
PERTINENT LABS
========================
___ 05:25PM BLOOD Triglyc-245* HDL-32* CHOL/HD-4.5
LDLcalc-62 Homocys-PND
___ 05:25PM BLOOD cTropnT-<0.01
IMAGING
================
Radiology ReportCHEST (PA & LAT)Study Date of ___ 4:58
___
IMPRESSION:
No acute intrathoracic process.
Radiology ReportCTA HEAD AND CTA NECKStudy Date of ___
8:51 ___
IMPRESSION:
1. New ill-defined hypodensity in the left corona radiata,
compatible with the
reported subacute left corona radiata infarct on the recent
outside MRI. No
acute hemorrhage or mass effect.
2. Extensive paranasal sinus disease is again demonstrated, with
evidence of
ongoing inflammation, including aerosolized secretions in the
left frontal
sinus.
3. Minimal calcified plaque at the right common carotid artery
bifurcation
without stenosis by NASCET criteria. Otherwise, normal neck
CTA.
4. No evidence for flow-limiting stenosis in the major
intracranial arteries.
5. Emphysema at the included lung apices. 2 mm micronodule in
the apical left
upper lobe, in an area obscured by motion artifact on the prior
neck CT, but
likely related to small airways disease.
Transthoracic Echocardiogram Report
Name: ___ ___ MRN: ___ Date: ___ 12:27
IMPRESSION: No structural cardiac source of embolism (e.g.patent
foramen ovale/atrial septal
defect, intracardiac thrombus, or vegetation) seen. Mild
symmetric left ventricular hypertrophy
with normal cavity size, and regional/global systolic function.
Mild right ventricular cavity dilation with normal systolic
function. No valvular pathology or pathologic flow identified.
Normal estimated pulmonary artery systolic pressure. Mild
thoracic aortic enlargement.
Brief Hospital Course:
This is a ___ M w/ hx of afib (not on anticoagulation), HTN,
hyperlipidemia, alcohol abuse, newly diagnosed dm, who recently
saw neurology as an outpatient found to have small subacute
stroke on imaging for workup of cognitive decline. The patient
described his cognitive decline as acute in onset, and was even
able to name the date on which is symptoms started. He also
reported the sensation of unsteadiness at onset of symptoms
which have improved. Additionally, the patient has noted feeling
that he was going back into atrial fibrillation. Since the start
of his symptoms, he has noticed some improvement, though he
continues to have trouble with word finding and recall. Vessel
evaluation of the head and neck with CTA was unrevealing. MRI
that was done at atrius prior to presentation showed subacute
left corona radiata infarct, which based on imaging could have
occurred around the time of symptom onset. Risk factor w/u
notable for A1c of 7.7, LDL of 62 (currently on statin
medication), history of afib not on AC. We did not capture afib
during the hospitalization. He underwent echo which did not
reveal a structural cause for his stroke, it did show some LVH.
We ultimately started the patient on apixaban, stopped his
aspirin, and continued him on atorvastatin. We reached out to
his cardiologist to discuss anticoagulation initiation. We set
him up with a ziopatch for continued cardiac monitoring, which
should be followed up by his cardiologist. Regular exercise and
a nutritious well rounded diet is very important, and avoiding
smoking and excess alcohol use for good health.
We considered other causes of rapid cognitive decline, however
given history of sudden onset and subsequent improvement this
seems less likely. B12 had previously been checked and was
normal (475); MMA and homocysteine were also checked and pending
at time of discharge. Ammonia had been checked and was normal,
as had TSH (0.75), chemistry, and CBC. We also sent syphilis
screen, pending at time of discharge. We considered further
workup with LP, however given history and subsequent improvement
decided against this; this could be considered if there were
progressive decline as an outpatient.
Transitional Issues
==================
[] Patient noted to have mod/severe sinus disease on MRI,
consider ENT referral in the outpatient setting; asymptomatic so
did not consult as inpatient
[] Noted to have a platelet count of 113, consider further
evaluation in the outpatient setting with iron studies
[] Patient started on apixaban 5mg PO BID
[] Patient started on thiamine given report of significant
alcohol use (though his thiamine levels were normal when checked
by his primary neurologist, and he is no longer drinking)
[] F/U ziopatch results with cardiologist
[] Incidentally found 2mm pulmonary nodule, could consider 12
month follow up see below
5. Emphysema at the included lung apices. 2 mm micronodule in
the apical left
upper lobe, in an area obscured by motion artifact on the prior
neck CT, but
likely related to small airways disease.
RECOMMENDATION(S): For incidentally detected multiple solid
pulmonary
nodules smaller than 6 mm, no CT follow-up is recommended in a
low-risk
patient or a high-risk patient, though an optional noncontrast
chest CT
follow-up in 12 months could be electively pursued in a
high-risk patient, if
clinically warranted (and assuming that there are no outside
chest or neck CTs
for comparison). See the ___ ___ Guidelines for
the
Management of Pulmonary Nodules Incidentally Detected on CT" for
comments and
reference: ___.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL =62 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () 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
[x] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - () 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 in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - x No. If no, why not? - patient at baseline functional
status
9. Discharged on statin therapy? (x Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? () Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - If no, why not (I.e.
bleeding risk, etc.) () N/A
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Atorvastatin 40 mg PO QPM
2. Sotalol 80 mg PO BID
3. Gemfibrozil 600 mg PO BID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Aspirin 325 mg PO DAILY
6. Losartan Potassium 25 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Thiamine 100 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Gemfibrozil 600 mg PO BID
5. Losartan Potassium 25 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Sotalol 80 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Diagnoses
============
Acute ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were hospitalized due to findings on your MRI scan 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. We believe that the four weeks of confusion and
memory problems that you have been having likely resulted from
this stroke.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Atrial Fibrillation
Hyperlipidemia
Hypertension
Newly diagnosed diabetes
We are changing your medications as follows:
We are stopping your aspirin
You are starting a blood thinning medication called apixaban.
When you are taking apixaban, you need to be wary of bleeding as
this is a strong blood thinning medication
We started you on a vitamin that people who drink alcohol are
often deficient in.
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:
___
|
19781369-DS-15
| 19,781,369 | 25,899,032 |
DS
| 15 |
2168-03-15 00:00:00
|
2168-03-19 16:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
cetirizine
Attending: ___.
Chief Complaint:
lightheadedness and falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ old ___ woman with a history
of lightheadedness and syncope who presents with frequent
syncope for rule out seizure.
Patient reports a ___ year history of intermittent dizziness with
frequent episodes of "passing out." The dizziness is most
similar to lightheadedness and within the past few months, she
is consistently dizzy every day and passes out up to 3 times per
day. For the most part, she knows when she is going to pass out
because there is a sensation of dizziness lasting an unclear
amount of time prior to her vision getting blurry and
"darkening" followed by falling to the ground. It is unclear if
there is loss of consciousness, but patient notes that she
maintains awareness during the dizziness and blurred vision.
Usually, she is confused for a few seconds after falling to the
ground and then feels back to her baseline. There is some
feeling that she is shaking or shivering afterward. Some
episodes have resulted in hitting her face or teeth in various
other injuries. She denies any tongue biting or urinary
incontinence for any of the episodes. For about a third of the
episodes, she reports whole body shaking. The dizziness is
worse with standing, but is also present with lying down.
Other symptoms that are sometimes but not always present are
clamminess of the hands, feeling sweaty, but no palpitations.
There is not always warning of dizziness prior to losing
consciousness.
She has been extensively evaluated for this issue, including
with EKG, Holter monitoring, TTE and laboratory evaluation, all
of which were normal. Further cardiac testing, she was
evaluated by Dr. ___ in BI cardiology. Etiology was felt
to be vagally mediated.
She denies any sensation of déjà ___, gastric rising or abnormal
smell. She has no history of prior seizures, though the passing
out episodes began when she was about ___. Family history is
notable for mother with 3 seizures after an AVM treatment. She
has no personal history of meningitis or encephalitis. There is
no history of traumatic brain injury. No history of febrile
seizure.
She first saw Dr. ___ in clinic on ___ who recommended
an extended routine sleep deprived EEG as well as autonomic
testing. Autonomic testing completed on ___ was consistent
with exaggerated postural tachycardia. Results of the EEG are
pending. MRI head with and without contrast was unremarkable.
Given the frequency of events, she was sent to the ED for
continuous EEG monitoring to capture spells.
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, per HPI
Past Medical History:
Eczema
Social History:
___
Family History:
Mother with a vascular malformation which was complicated by
seizure.
Physical Exam:
Admission Physical Exam:
Vitals: T: 99.0 P: 104 R: 16 BP: 119/70 SaO2: 100% RA
Orthostatic checked while IVFs running:
Lying: BP 96/55 HR 74
Standing (after 3 minutes): BP 107/75 HR 84
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, ___
Abdomen: soft, ___
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
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: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to ___ bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-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
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS. Romberg absent.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal ___
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. ___, normal stride and arm
swing.
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
Discharge Physical Exam:
Physical Exam:
Vitals: ___, BP 103/64, HR 77, RR 16, O2 100 RA
General: Awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, ___
Abdomen: soft, ___
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
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: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to ___ bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-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
R 5 ___ ___ 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
Romberg absent.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Normal ___
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. ___, normal stride and arm
swing.
Pertinent Results:
___ 01:55PM BLOOD ___
___ Plt ___
___ 05:30AM BLOOD ___
___ Plt ___
___ 01:55PM BLOOD ___
___ Im ___
___
___ 05:30AM BLOOD ___ ___
___ 01:55PM BLOOD ___
___
___ 05:30AM BLOOD ___
___
___ 01:55PM BLOOD ___
___ 05:30AM BLOOD ___
___ 01:55PM BLOOD ___
___ 01:55PM BLOOD ___
___
Brief Hospital Course:
Ms. ___ is a ___ old ___ woman with a history
of
lightheadedness and syncope (associated with LOC and body
convulsions) who presented for evaluation of frequent syncope
for rule out seizure. No clear trigger however they tended to
occur more when she changed position suddenly or ambulated. Most
of the features of her history were more consistent with a
vasovagal syncope/POTS with the full body convulsions
representing likely syncopal convulsions.
Her exam was ___ and normal except with exaggerated
elevated HR upon standing. Patient underwent EEG with syncopal
event in question captured, event. There was no EEG correlate
therefore event was not due to seizure. Patient's HR would
increase from 78 to >150 with standing leading to diagnosis of
POTS by cardiology. She was started on Florinet and discharged
home.
Transition of Care:
- encourage adequate fluid and salt intake
- started florinet 0.1mg daily
- PCP can consider ___ of florinef (max 0.3mg daily). If
ineffective can consider switching to midodrine
- repeat bmp as outpatient in 1 week to monitor for hypokalemia
(PCP to coordinate)
- ___ with PCP
- ___ with cardiology and neurology prn
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Fludrocortisone Acetate 0.1 mg PO DAILY
RX *fludrocortisone 0.1 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Postural orthostatic tachycardia syndrome (POTS)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ for evaluation of your
fainting spells and dizziness.
You were diagnosed with Postural orthostatic tachycardia
syndrome (POTS) which is a condition characterized by too little
blood returning to the heart when moving from a lying down to a
standing up position causing you to faint.
Your fainting spells are not due to seizures.
You were seen by cardiology and started on Florinet. Please
follow up with your PCP regarding possible increase in this
medication based on your symptoms.
Followup Instructions:
___
|
19781754-DS-7
| 19,781,754 | 27,094,193 |
DS
| 7 |
2171-11-06 00:00:00
|
2171-11-06 09:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
___
Rigid and flexible bronchoscopy with stent removl
History of Present Illness:
Mr ___ is a ___ year old male with a hx of afib on xarelto,
asthma, OSA, steroid induced DM and TBM s/p stent placement who
is admitted to the hospital for bronchoscopy and stent removal.
In brief, he is a ___ year old male with a hx of severe
persistent
chronic asthma that required multiple hospitalization for
exacerbations. Over the past ___ years he reports that he
generally spends less than one week at home between
readmissions.
During 1 of his hospitalizations he was found to have TBM on a
CT
scan and he was transferred to ___ for further management. At
___ he underwent a bronchoscopy which showed TBM and a stent
was placed on ___. He reports that his symptoms
immediately improved after the stent placement. The symptoms
consisted of shortness of breath and coughing. In addition, he
has had no more asthma exacerbations since that stent placement.
Most recently in the past week, he reports that he has been
having more cough and shortness of breath as well as pain when
coughing. Today he comes to the hospital for admission for
bronchoscopy and stent removal. He reports that he is having
intermittent episodes of cough, shortness of breath and pain
with
coughing. He denies any chills, fevers, chest pain,
palpitations, nausea, headache, dizziness, unintentional weight
loss, and syncope.
Past Medical History:
Severe persistent asthma
Severe tracheomalacia
GERD
OSA
Steroid induced diabetes
Ventral hernia
Vitamin D deficiency
Paroxysmal Atrial Fibrilation
Vocal Cord Dysfunction
Obsesity
Osteoarthritis
HTN
L shoulder osteonecrosis, rotator cuff tear
HLD
Depression
Anxiety
Social History:
___
Family History:
Extensive family history of asthma: mother, father, sister,
aunts
___ cancer in father
Physical ___:
Temp: 98.8 HR: 80 BP: 127/67 RR: 16 O2 Sat: 95% RA
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Neck supple/NT/without mass
[x] Trachea midline
RESPIRATORY
[x] no increased work of breathing
[ x ] Abnormal findings: generalized wheezing on auscultation
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] No edema
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] mildly D
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] No facial asymmetry
[x] Cranial nerves intact
MS
[x] No edema
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl
SKIN
[x] No rashes/lesions/ulcers
[ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW
RDWSD Plt Ct
___ 05:20 5.7 3.17* 8.4* 28.7* 91 26.5 29.3* 17.7*
58.5* 197
___ 18:45 6.1 3.30* 8.7* 29.7* 90 26.4 29.3* 17.9*
58.4* 219
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 05:20 109*1 9 1.1 141 4.8 99 26 16
Brief Hospital Course:
Mr. ___ was admitted to the hospital and taken to the
Operating Room where he underwent a rigid and flexible
bronchoscopy with Y stent removal. He tolerated the procedure
well and returned to the PACU in stable condition. He maintained
stable hemodynamics and his breathing felt "comfortable". His
oxygen saturations were 99-100% on 3 liters of O2.
He was placed of tapering low doses of Prednisone and his blood
sugars were < 160 off of Metformin and insulin. He continued to
progress well without any respiratory distress and plans are
being made for surgical repair of his tracheobronchomalacia.
After an uneventful recovery he was discharged back to rehab on
___ with plans to return to ___ for surgical intervention
for his TBM on ___. He is in understanding and agreement
with the surgical plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
3. Citalopram 40 mg PO DAILY
4. ClonazePAM 1 mg PO BID:PRN anxiety
5. ClonazePAM 2 mg PO QHS:PRN sleep
6. Clotrimazole Cream 1 Appl TP BID
7. Diltiazem Extended-Release 360 mg PO DAILY
8. Enoxaparin Sodium 130 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
9. FoLIC Acid 1 mg PO DAILY
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Metoprolol Succinate XL 25 mg PO BID
12. Montelukast 10 mg PO QHS
13. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain -
Moderate
14. Pantoprazole 40 mg PO Q24H
15. Rivaroxaban 20 mg PO QPM
16. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
17. Acetaminophen 975 mg PO Q8H
18. GuaiFENesin-Dextromethorphan (Sugar Free) 10 mL PO QID
19. Ferrous Sulfate 325 mg PO BID
20. Magnesium Oxide 400 mg PO DAILY
21. Polyethylene Glycol 17 g PO DAILY
22. Gabapentin 300 mg PO QHS
23. albuterol sulfate 90 mcg/actuation inhalation QID:PRN
wheezing/SOB
Discharge Medications:
1. ClonazePAM 1 mg PO TID:PRN anxiety
2. Acetaminophen 975 mg PO Q8H
3. albuterol sulfate 90 mcg/actuation inhalation QID:PRN
wheezing/SOB
4. Atorvastatin 40 mg PO QPM
5. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
6. Citalopram 40 mg PO DAILY
7. ClonazePAM 2 mg PO QHS:PRN sleep
8. Clotrimazole Cream 1 Appl TP BID
9. Diltiazem Extended-Release 360 mg PO DAILY
10. Ferrous Sulfate 325 mg PO BID
11. FoLIC Acid 1 mg PO DAILY
12. GuaiFENesin-Dextromethorphan (Sugar Free) 10 mL PO QID
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Magnesium Oxide 400 mg PO DAILY
15. Metoprolol Succinate XL 25 mg PO BID
16. Montelukast 10 mg PO QHS
17. OxyCODONE (Immediate Release) 15 mg PO Q6H:PRN Pain -
Moderate
18. Pantoprazole 40 mg PO Q24H
19. Polyethylene Glycol 17 g PO DAILY
20. Rivaroxaban 20 mg PO QPM
21. Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
tracheobronchomalasia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital for removal of your tracheal
stent and you are now ready for discharge.
* You will need to allow some time for the tissue to heal post
stenting to optimize a better surgical outcome.
* You should continue all of your medications including your
blood thinner and you will be notified of a surgical date with
instructions on when to hold your blood thinner.
* If you have any questions or concerns regarding this
hospitalization, call Dr. ___ at ___
* Your surgery is currently scheduled for ___
Followup Instructions:
___
|
19781816-DS-19
| 19,781,816 | 20,200,492 |
DS
| 19 |
2157-10-26 00:00:00
|
2157-10-28 20:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Spironolactone
Attending: ___.
Chief Complaint:
chest pressure with exertion
Major Surgical or Invasive Procedure:
cardiac catheterization ___ ___
History of Present Illness:
___ with history of DM2, hypertension, hyperlipidemia, ischemic
CMP (EF25%)with ICD, 2 vessel CAD, moderate aortic stenosis
presents with exertional chest tightness and shortness of
breath. Patient reports chest tightness when walking for several
years, but much more frequent in the past week, occurring almost
daily with minimal exertion. Episodes last for a few minutes and
resolve with rest.
Today, when trying to get from the ___ parking lot to his
seat, he had to stop 4 times due to chest tightness and
shortness of breath. He was pale, sweaty, lightheaded, short of
breat. No radiation, no nausea. At ___, EKG showed new left
bundle branch block. He was given aspirin and transported here.
Was given SL nitro in the ambulance but feels CP resolved prior
to this.
In the ED, initial vitals were 0 98.4 89 100/86 16 97% ra. Labs
notable for trop, CK negative x 1, Cr 1.5 (1.0 in ___. CXR
negative. ECG intially showed LBBB but repeats returned to
patient's baseline. Patient was seen by cards attdg who
recommended admission for ___.
Currently, denies any chest pressure. Denies any recent fevers,
chills, cough, abdominal pain, nausea, vomiting, lower extremity
pain or swelling, PND, orthopnea, weight gain, syncope,
palpitations.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, black stools or red
stools. All of the other review of systems were negative.
Past Medical History:
CAD s/p successful PTCA and rheolytic thrombectomy of the RCA in
___ rpt cath ___ showed occluded RCA, 70% lesion in circ and
30% in LAD
Ischemic cardiomyopathy EF 25%
s/p ICD implant ___ Degree AVB
moderate AS
Diabetes
Hypertension
Hyperlipidemia
Tonsillectomy as a teen
Arthritis
Social History:
___
Family History:
His younger brother has colon CA. His father died from a CVA at
age ___. Mother died of breast Ca.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3 120/69 64 20 98%RA 115.9kg
General: well-appearing, obese, NAD, AOx3
HEENT: dry MM
Neck: no JVD
CV: RRR, ___ harsh systolic murmur at RUSB radiating to carotids
Lungs: CTAB, no w/r/r
Abdomen: obese, s/nt/nd, +BS
Ext: trace pitting edema in the ankles b/l, ___
DISCHARGE PHYSICAL EXAM:
VS: 98.3 116/78 53 16 96% RA
GENERAL: AOx3.NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: no JVD , supple
CARDIAC: regular rhythm and rate
LUNGS: clear to auscultation bilaterally
EXTREMITIES: No c/c/e.
Pertinent Results:
PERTINENT RESULTS:
___ 07:25PM BLOOD CK-MB-3
___ 07:25PM BLOOD CK(CPK)-111
___ 07:25PM BLOOD cTropnT-0.01
___ 02:41AM BLOOD CK(CPK)-110
___ 02:41AM BLOOD CK-MB-5 cTropnT-0.05*
___ 07:29AM BLOOD CK(CPK)-118
___ 07:29AM BLOOD CK-MB-5 cTropnT-0.06*
___ 07:25PM BLOOD WBC-8.1 RBC-4.75 Hgb-14.4 Hct-42.2 MCV-89
MCH-30.2 MCHC-34.0 RDW-13.7 Plt ___
___ 06:25AM BLOOD WBC-4.7 RBC-4.07* Hgb-12.7* Hct-35.9*
MCV-88 MCH-31.3 MCHC-35.5* RDW-13.4 Plt ___
___ 07:25PM BLOOD Glucose-164* UreaN-28* Creat-1.5* Na-141
K-4.3 Cl-106 HCO3-25 AnGap-14
___ 06:25AM BLOOD Glucose-125* UreaN-15 Creat-1.3* Na-141
K-4.0 Cl-106 HCO3-28 AnGap-11
___ 04:37AM BLOOD ALT-34 AST-29 AlkPhos-47
___ 06:10AM BLOOD TotBili-0.4
___ 06:25AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.3
___ 08:00AM BLOOD %HbA1c-7.2* eAG-160*
ECGs:
___ 7 ___ ECG
Sinus rhythm. Baseline artifact. Left axis deviation. Left
bundle-branch
block. Compared to the previous tracing of ___ the QRS
complex is now
significantly wider in a left bundle-branch block pattern.
Criteria for prior inferior myocardial infarction are not seen
on the current tracing. Other findings are similar.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
83 ___ 69 -36 131
___ 9 ___ ECG
Sinus rhythm with prolonged P-R interval. Left axis deviation.
Left
ventricular hypertrophy with secondary repolarization
abnormalities. Compared to tracing #1 QRS complex is
significantly narrower with resolution of the previous left
bundle-branch block.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 ___ 43 -15 155
___ ECG
Sinus rhythm with ventricular premature beats. Intraventricular
conduction delay. Left ventricular hypertrophy with secondary
repolarization abnormality. Compared to the previous tracing no
significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
63 ___ 63 -7 165
___ ECG
Sinus rhythm. Left axis deviation. Left ventricular hypertrophy
with
secondary repolarization abnormality. Poor R wave progression.
Consider prior anterior wall myocardial infarction of
indeterminate age. Compared to the previous tracing of ___
the rate has increased. The axis is more leftward. There is only
one ventricular premature beat seen towards the end of the
tracing.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 ___ -30 146
STUDIES:
___ CXR
No acute cardiopulmonary process.
___ Cardiac Catheterization
Assessment & Recommendations
1. Three vessel CAD
2. Known occluded RCA. New proximal LAD lesion, worsening of
LAD lesion and overall stable LCX lesion.
3. Evaluate for CABG. If turned down, consider LAD and LCX
stenting (feasible percutaneously)
4. Discussed with Dr. ___.
___ Transthoracic Echocardiogram
The left atrium is mildly elongated. There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity is
mildly dilated with mild-moderate regional systolic dysfunction
with severe hypokinesis of the basal half of the inferior and
inferolateral walls and inferior septum. The remaining segments
contract well (LVEF = 35 %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets are severely thickened/deformed. There is
moderate aortic valve stenosis (valve area 1.0-1.2cm2). 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 no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild left ventricular
cavity dilation with regional systolic dysfunction c/w CAD (PDA
distribution). Moderate aortic valve stenosis. Mild aortic
regurgitation. Mild mitral regurgitation. Increased PCWP.
Dilated aortic sinus.
Compared with the report of the prior study (images unavailable
for review) of ___, aortic stenosis is now present, the
left ventricular cavity is now mildly dilated, and the severity
of aortic stenosis has increased.
CLINICAL IMPLICATIONS:
The patient has moderate aortic valve stenosis. Based on ___
ACC/AHA Valvular Heart Disease Guidelines, if the patient is
asymptomatic, a follow-up echocardiogram is suggested in ___
years.
___ Carotid Ultrasound
There is right antegrade vertebral artery flow.
There is left antegrade vertebral artery flow.
Impression: Right ICA with no stenosis.
Left ICA with <40% stenosis.
Brief Hospital Course:
___ with CAD s/p PTCA in ___ with repeat catheterization in
___ showing 2-vessel disease, ischemic cardiomyopathy with LVEF
25% s/p ICD placement, hypertension, hyperlipidemia, type II
diabetes, and moderate AS here presents with progressive chest
pressure/pain with exertion over the past several months found
to have NSTEMI, 3-vessl coronary artery disease and moderate
aortic stenosis best managed by coronary artery bypass graft
surgery.
# NSTEMI
Troponins mildly elevated to 0.06 by third set, no ECG changes
consistent with ischemia. He was placed on a heparin drip for 48
hours. Cardiac catheterization revealed significant 3-vessel
disease most amenable to treatment with CABG. Cardiothoracic
surgery was consulted, and their pre-operative recommendations
were carried out. They scheduled him for CABG/aortic valve
replacement as below on ___. Given the length of time
until surgery, Mr. ___ was evaluated for his ability to
go home. He was able to ambulate around the medical floor as
well as up one flight of stairs without angina. He was
discharged home with a new prescription of isosorbide
mononitrate to limit his angina with exertion as well as
aspirin, atorvastatin 80 mg (switched from simvastatin 40 mg),
and his home carvedilol, furosemide and lisinopril. Mr.
___ was provided with detailed instructions about
symptoms that should prompt him to present to the emergency
department.
# Aortic Stenosis
Moderate aortic stenosis found on TTE. As this will likely
require intervention in the next few years, Mr. ___ will
get aortic valve replacement along with his CABG. He has decided
that he wants to have a mechanical aortic valve replacement for
its longevity, and he is willing to be on coumadin.
# Rate related left bundle branch block
Initial ECG upon presentation with heart rate of 83 revealed
left bundle branch block. Block resolved with decrease in heart
rate.
# ischemic cardiomyopathy
Throughout his admission there was no evidence of decompensate
heart failure. He was continued on his home lasix dose. His
lisinopril was initially held as explained below, but he was
discharged on his home regimen as detailed above.
# acute kidney injury
Upon presentation Mr. ___ creatinine was 1.5. Urine
lytes resulted in a fractional excretion of urea of 40%. His
lisinopril was held and his creatinine improved in one day to
1.2. His lisinopril was restarted after the improvement in his
creatinine. His historic baseline from ___ was 1.0, but it is
unclear what his more recent baseline is given his longstanding
hypertension and diabetes. Attention to this as a transitional
issue
# Type II Diabetes
His metformin and Pioglitazone were held while inpatient, but he
was continued on his glargine as well as a sliding scale of
insulin. His blood glucose was well controlled during his
inpatient stay, and he was restarted on his home regimen upon
discharge.
# Hypertension
His home medications were continued as above.
# Hyperlipidemia
He was at first continued on his home simvastatin, then switched
to atorvastatin 80 mg after he ruled in for NSTEMI. He is
discharged on atorvastatin 80 mg.
continue home simvastatin
# TRANSITIONAL ISSUES
- He is provided with detailed instructions on what should
prompt him to present again to the emergency department
- He will contacted with an appointment with his PCP ___.
___ in the next two days
- He will have a follow-up appointment with Dr. ___,
his outpatient cardiologist, on ___
- He is scheduled for CABG and aortic valve replacement with Dr.
___ on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 60 mg PO DAILY
2. MetFORMIN (Glucophage) 850 mg PO TID
3. Lisinopril 40 mg PO DAILY
4. Pioglitazone 15 mg PO DAILY
5. Aspirin EC 325 mg PO DAILY
6. Carvedilol 12.5 mg PO BID
7. Simvastatin 40 mg PO DAILY
8. Glargine 40 Units Bedtime
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Furosemide 60 mg PO DAILY
4. Glargine 40 Units Bedtime
5. Lisinopril 40 mg PO DAILY
6. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate [Imdur] 30 mg 1 tablet extended
release 24 hr(s) by mouth daily Disp #*30 Tablet Refills:*0
8. Nitroglycerin SL 0.3 mg SL PRN cp
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tab sublingually up to 3
times as needed Disp #*30 Tablet Refills:*0
9. Mupirocin Nasal Ointment 2% 1 Appl NU BID Duration: 5 Days
RX *mupirocin calcium [Bactroban Nasal] 2 % 1 application
intranasal twice a day Disp #*10 Unit Refills:*0
10. MetFORMIN (Glucophage) 850 mg PO TID
11. Pioglitazone 15 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
3 vessel coronary artery disease
non-ST elevation myocardial infarction
moderate aortic stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had chest pain.
You had a cardiac catheterization which showed that you had
plaques in all three of your main coronary arteries (which
supply the heart muscle with blood and oxygen). The plaques are
a slow build-up of cholesterol and blood products from years of
high blood pressure, diabetes, and high cholesterol. The best
treatment for this is to have a cardiac bypass surgery to avoid
a large heart attack. This is scheduled for ___.
There are several medication changes which can also help reduce
your risk of a heart attack. These are included on the next
page. One of the new medications is a long-acting
nitroglycerine medication called isosorbide mononitrate.
It was a pleasure taking care of you in the hospital!
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19781920-DS-18
| 19,781,920 | 21,727,642 |
DS
| 18 |
2157-12-03 00:00:00
|
2157-12-03 20:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac Cath ___
History of Present Illness:
Mr. ___ is a ___ h/o depression with SI, CAD s/p MI to RCA
presents from psychiatric facility with chest pain. Pt stated
that he voluntarily admitted himself to this psych facility 2
days prior to admission to be "weaned off his psychiatric
drugs." The pt was then told by the staff that he was not going
to be able to leave voluntarily and he became mentally agitated
which caused him to have substernal CP, pressure like, with
diaphoresis and radiation to L arm and back. Relieved with SL
nitro at facility. The pain then returned and this time not
relieved with SLNTG at which time he was transfered to ___ ED
for evaluation. EKG on admission notable for NSR @ 85, NA, NI,
1mm Q waves in inferior leads. He was placed in OBs in ED and
r/o for MI. He underwent a pharm stress which was read as fixed
defect. Pt was continuing to have CP while in the ED. A repeat
EKG was obtained which showed new TWI in III, aVF. Pt claims to
have had similar to episodes of CP over the past year and would
like to be further evaluated. Overnight cards attending
requested admission for cardiac cath.
In the ED, initial vitals were 97.6 88 120/84 15 100% 4L he was
quickly weaned to RA.
On review of systems, the patient denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. The patient denies
recent fevers, chills or rigors. The patient denies exertional
buttock or calf pain. All of the other review of systems were
negative.
Cardiac review of systems is notable for absence dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
inferior wall MI @ ___
Depression prior psych admits for SI
HL
HTN
Social History:
___
Family History:
Significant cardiac disease in his family, father died of MI in
___, multiple uncles died in ___ with MIs as well, Brother had
MI
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T= 97.8 BP= 128/94 HR= 84 RR= 18 O2 sat= 96%RA
GENERAL: NAD. Oriented x3. flat affect.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with flat JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
radial 2+ b/l
PSYCH: stable mood, flat affect
DISCHARGE PHYSICAL EXAMINATION:
VS: T98.2 BP 122/93 (SBP 115-138) HR68 RR18 Pox 98%RA
wt: 113.9 kg <- 114 kg I:1033mL O: 325mL
GENERAL: NAD. Oriented x3. Flat affect.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with flat JVP.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. Left radial access site is c/d/i.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
radial 2+ b/l
PSYC: stable mood, flat affect
Pertinent Results:
___ 08:49PM GLUCOSE-110* UREA N-27* CREAT-0.8 SODIUM-140
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-21* ANION GAP-16
___ 08:49PM estGFR-Using this
___ 08:49PM cTropnT-<0.01
___ 08:49PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
___ 08:49PM WBC-9.6 RBC-4.57* HGB-15.0 HCT-42.8 MCV-94
MCH-32.8* MCHC-35.0 RDW-12.9
___ 08:49PM NEUTS-61.5 ___ MONOS-8.3 EOS-1.0
BASOS-0.8
___ 08:49PM PLT COUNT-294
___ 08:49PM BLOOD cTropnT-<0.01
___ 04:00AM BLOOD cTropnT-<0.01
___ 09:00PM BLOOD CK-MB-2 cTropnT-<0.01
EKG: SR @ 104, NA, NI, TWI in III, AVF
Pharm Stress Test (___):
Left ventricular cavity size is slightly dilated.
Rest and stress perfusion images reveal a mild to moderate fixed
defect in the inferior wall. Gated images reveal hypokinesis in
the inferior wall. The calculated left ventricular ejection
fraction is 45%.
IMPRESSION: Mild to moderate fixed defect in the inferior wall
with associated hypokinesis. LVEF 45%.
Cardiac Catheterization (___):
Coronary angiography: right dominant
LMCA: Normal
LAD: Minor lumen irregularities. The LAD gave rise to a
large diagonal branch that was also free of significant disease.
LCX: Minor lumen irregularities. Up to ___ in the
proximal LCx. The LCx gave rise to a large bifurcation OMB.
It
was free of significant disease.
RCA: Minor lumen irregularities up to ___ in the
proximal,
mid, and distal RCA. The PDA was a medium sized vessel. The
right posterolateral branch was a medium to large vessel.
Interventional details
The procedure was performed from the left radial artery without
complications
Assessment & Recommendations
1. Non obstructive coronary artery disease
2. Medical therapy
DISCHARGE LABS:
___ 07:20AM BLOOD ___ PTT-53.9* ___
___ 07:20AM BLOOD Glucose-118* UreaN-18 Creat-0.9 Na-141
K-4.3 Cl-105 HCO3-29 AnGap-11
___ 07:20AM BLOOD Mg-2.0
___ 07:10AM BLOOD Triglyc-72 HDL-77 CHOL/HD-2.8 LDLcalc-126
Brief Hospital Course:
Mr. ___ is a ___ with PMH of depression and CAD (with
inferior MI at age ___ who presents with CP concerning for
unstable angina.
# Unstable Angina: Pt has been ruled out with CE and has had a
stress which was read as fixed defect which would correspond
with his prior MI hx. Due to persistence of CP in the ED and
subtle EKG changes cards attending recommended admission for
cardiac cath. Pt continued to have chest pain and was started on
heparin drip and Nitro drip with resolution of chest pain. He
had cardiac catheterization on ___ which showed
non-obstructive CAD with a ___ stenosis in the proximal LCx
and ___ in the proximal, mid, and distal RCA. Lipid profile
was TC:217 HDL:77 LDL:126. We continued ASA 81mg, started
atorvastatin 40mg, and metoprolol 25mg bid.
# CORONARIES: Per pt he suffered inferior MI at ___ y/o involving
RCA. He denies stent placement. He has had cath in ___ but not
clear about results or where the test was performed. Pt had a
cardiac catheterization on ___ which showed non-obstructive
CAD. We continued aspirin 81 mg daily, started atorvastatin 40mg
daily, and metoprolol Tartrate 25 mg PO BID
# Depression: Pt came on ___ from outside psych facility.
He was seen by psych while in house and he was started on
Duloxetine 60 mg PO DAILY
and trazodone 50mg qhs PRN insomnia. His mood stable currently.
No evidence of SI currently. Psychiatry thinks he is safe for
discharge home and can follow up with his outpatient
psychiatrist and psychologist.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 12.5 mg PO BID
hold for sbp < 100 or hr < 55
2. Simvastatin 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
4. Duloxetine 60 mg PO DAILY
RX *duloxetine [Cymbalta] 60 mg 1 capsule(s) by mouth Daily Disp
#*30 Capsule Refills:*0
5. traZODONE 50 mg PO HS:PRN insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth HS:PRN insomnia Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Unstable Angina
Coronary Artery Disease
Secondary:
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You came to the
hospital because you were having chest pain. You had a cardiac
catheterization which did not show any significant lesions that
could be fixed but does identify coronary artery disease. Your
chest pain resolved with medical management. Please follow up
with your primary care doctor and psychiatrist as an outpatient.
Followup Instructions:
___
|
19782315-DS-12
| 19,782,315 | 24,544,327 |
DS
| 12 |
2136-01-20 00:00:00
|
2136-01-20 13:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ y/o F who fell at her nursing facility.
By report, the patient was found in her bed this AM with
bruising on her left-shin and right hand. Fall was unwitnessed.
Patient states that she crawled back into bed. Denies LOC or
head strike.
Patient was previously followed at ___. Had a series
of falls recently and was moved to an assisted living facility
at ___. Had another fall this past ___ with head strike
after which her memory declined further. She was moved to the
dementia unti approximately two weeks ago. The patient is trying
to establish care with Dr. ___ at ___ but
has not done so yet.
In the ED, initial VS were 96.7 60 108/70 16 100%. Laboratory
work-up showed mild renal insufficiency but was otherwise
unremarkable. A CT of her pelvis showed a left inferior pubic
ramus fracture. Hip, knee, head, and spine radiographs were
unremarkable. The patient was seen by ___ who found that she
could not ambulate due to pain. MS baseline per family. Admitted
for pain control and early ___. Received tylenol and tramadol in
the ED. VS on transfer 70 123/60 18 100%.
ROS: Unable to complete ___ patient's dementia
Past Medical History:
- Dementia
- CAD s/p MI ___ years ago with stenting
- Depression
- Vitamin B12 deficiency
- Hypothyroidism
Social History:
___
Family History:
Non-contributory
Physical Exam:
On Admission:
VS - 98.4 150/68 66 18 100%RA
GENERAL - NAD, comfortable, appropriate, making jokes
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, I-II/VI systolic
murmur
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - intact but dry and with bruising
NEURO - awake, A&Ox1-2, CNs II-XII grossly intact, muscle
strength ___ throughout, sensation grossly intact throughout,
somewhat unsteady gait
On Discharge:
VS - 98.6 136/60 84 18 94%RA
GENERAL - NAD, comfortable, appropriate, making jokes
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, I-II/VI systolic
murmur
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - intact but dry and with bruising
NEURO - awake, A&Ox1-2, CNs II-XII grossly intact, muscle
strength ___ throughout, sensation grossly intact throughout,
somewhat unsteady gait
Pertinent Results:
On Admission:
___ 07:45PM BLOOD WBC-10.9 RBC-3.87* Hgb-10.8* Hct-34.0*
MCV-88 MCH-28.0 MCHC-31.9 RDW-15.3 Plt ___
___ 07:45PM BLOOD Neuts-77.0* Lymphs-14.6* Monos-6.0
Eos-2.1 Baso-0.3
___ 07:45PM BLOOD Glucose-113* UreaN-29* Creat-1.2* Na-139
K-4.8 Cl-105 HCO3-27 AnGap-12
___ 08:12PM BLOOD Lactate-1.2
On Discharge:
___ 06:40AM BLOOD WBC-8.5 RBC-3.34* Hgb-9.2* Hct-30.4*
MCV-91 MCH-27.6 MCHC-30.3* RDW-15.6* Plt ___
___ 07:05AM BLOOD Glucose-98 UreaN-29* Creat-1.1 Na-141
K-4.8 Cl-109* HCO3-23 AnGap-14
Reports:
Knee Film - IMPRESSION: No evidence of acute fracture or
dislocation.
Pelvis Film - IMPRESSION: No evidence of acute fracture or
dislocation.
Hip Film - IMPRESSION: No evidence of acute fracture or
dislocation.
CXR - IMPRESSION: No acute intrathoracic process.
CT Spine - IMPRESSION: 1. No evidence of acute fracture or
prevertebral soft tissue swelling. 2. Severe degenerative
changes of the cervical spine as described above. If suspicion
for cord injury or ligamentous injury is high, MRI is
recommended of choice. 3. Heterogeneous thyroid gland. A thyroid
ultrasound may be obtained in the non-emergent setting for
further characterization if necessary. 4. A small pocket of air
is noted adjacent to the thyroid gland on the left and may be
post-procedural. Correlation with history and physical
examination is recommended.
CT Head - IMPRESSION: No acute intracranial process.
CT Pelvis - IMPRESSION: 1. Left superior and inferior pubic
ramus fracture, minimally distracted. 2. Possible tiny fracture
to the anterior left lateral sacral ala. 2. Diverticulosis. No
evidence of diverticulitis
Brief Hospital Course:
Ms. ___ is an ___ year-old woman with advanced dementia and a
history of CAD who presented ___ after an unwitnessed fall
at her nursing facility. Found to have superior and inferior
pelvic rami fractures.
ACTIVE ISSUES
-------------
#. Pelvic Fracture - The patient was brought to ___ after an
unwitnessed fall at her nursing facility. In the emergency room,
spine, head, knee, hip and chest radiographs were unremarkable.
A CT scan of the patient's plevis reveal inferior/superior
fractures. An ECG was not concerning for ischemia and laboratory
testing showed no evidence of infection.S he was seen by
physical therapy in the ED who found the patient unable to
ambulate due to pain. She was admitted for pain control and
early phyiscal therapy. On the floor the patient's pain ws
controlled. Seen by ___ who recommended rehab stay.
#. Urinary Tract Infection - The patient was noted to have
urinary frequency. A UA was consistent with a UTI but the urine
culture showed mixed flora. The patient was treated with a 3-day
course of cefpodoxime and her symptoms improved.
#. Delerium - The patient initially suffered delerium in the
setting of new environment and pelvic pain. Her delerium
improved over the course of her hospital stay and with treatment
of her UTI.
# Irregular heart rhyhtm - intermittently irregular, with one
EKG caputuring premature atrial contractions. Felt to be a
benign rhythm. Electrolytes normal. Beta blocker continued.
CHRONIC ISSUES
--------------
#. Coronary artery disease - The patient had a myocardial
infarction with ___ ___ years ago. Unkwnown type of
stent. She has been on clopidogrel since. This was continued in
house along with her statin and bblocker. Continued use of
clopidogrel in the setting of frequent falls should be discussed
with her outpatient provider.
#. Depression - Continued Escitalopram and held ativan in
setting of fall. Ativan was not restarted on discharge.
#. Dementia - Continued exelon.
TRANSITIONAL ISSUES
-------------------
#. Consider stopping clopidogrel as risks may outweigh benefits
#. Consider echocardiogram for ? syncope workup as part of eval
of falls
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Clopidogrel 75 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Escitalopram Oxalate 10 mg PO DAILY
5. Vitamin D 800 UNIT PO DAILY
6. Lorazepam 0.5 mg PO BID
7. Cyanocobalamin 1000 mcg IM/SC MONTHLY
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Lumigan *NF* (bimatoprost) 0.01 % ___ HS
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Exelon *NF* (rivastigmine) 9.5 mg/24 hour Transdermal Every
24 hours
Discharge Medications:
1. Atorvastatin 10 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Escitalopram Oxalate 10 mg PO DAILY
4. Exelon *NF* (rivastigmine) 9.5 mg/24 hour Transdermal Every
24 hours
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Lumigan *NF* (bimatoprost) 0.01 % ___ HS
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Vitamin D 800 UNIT PO DAILY
10. Acetaminophen 650 mg PO Q6H:PRN Pain
11. Quetiapine Fumarate 25 mg PO HS:PRN Agitation
12. Cyanocobalamin 1000 mcg IM/SC MONTHLY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pelvic Rami Fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___!
You were admitted to the hospital due to a fracture in your
pelvis. In the hospital we treated you with pain medications and
had you seen by physical therapy. You were also treated for a
urinary tract infection. You did well and will continue your
physical therapy at a rehabilitation center.
See below for instructions regarding follow-up care:
Followup Instructions:
___
|
19782826-DS-16
| 19,782,826 | 23,699,230 |
DS
| 16 |
2182-12-20 00:00:00
|
2182-12-21 17:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Penicillins / Statins-Hmg-Coa Reductase Inhibitors
/ pentamidine isethionate / Percocet / codeine / oxycodone
Attending: ___.
Chief Complaint:
Skin tear
Major Surgical or Invasive Procedure:
SKIN GRAFT SPLIT THICKNESS FROM RIGHT THIGH TO RIGHT FOREARM
History of Present Illness:
Ms. ___ is a ___ y/o female with history of ESRD on HD and
Afib
on Coumadin p/w a skin tear.
Per ED, patient was at her primary care doctor's office today
when she was trying to get up on the examining table she slipped
and was falling was caught by the doctor on her right arm. This
caused a right arm skin tear it was covered at the doctor's
office and she was sent to the ED. She otherwise denies any
other
symptoms no fevers chills chest pain shortness of breath no
syncopal episode she did not hit her head.
In the ED, vitals T 97.6, HR 58, BP 163/74, RR 18, O2 100% RA.
Physical exam revealed large right forearm skin tear extending
from the proximal dorsal forearm to 3 cm proximal to the wrist
through the dermis to the muscle fascia with loss of tissue.
Otherwise unremarkable. Labs remarkable for Cr 6.3 (baseline),
Hgn 10.6, INR 1.8. Pt was given prednisone, amiodorone,
oxycodone
x2, clindamycin.
Imaging: Humerus AP & Lat ordered, Forearm AP & Lat Right,
ordered.
Plastic surgery and hand surgery were consulted. Hand surg
recommended split thickness skin graft and volar resting splint
after washout. Recommended starting IV clindamycin and admission
to medicine for a graft tomorrow. Recommend half dialysis prior
to surgery.
Upon arrival to the floor, patient reports that she is feeling a
little nauseated from the pain medicine she received in the ED.
Otherwise, her pain is well controlled and she has no
complaints.
ROS: 10-pt ROS negative except per above.
Past Medical History:
Hypothyroidism
Chronic kidney disease (s/p kidney transplant x2, ___ and ___
Granulomatosis with polyangiitis
HTN
Asthma
Hypercholesterolemia
Atrial fibrillation (on Coumadin)
ITP
Social History:
___
Family History:
- Father died of MI in ___
- Colon, liver, kidney cancer on mother's side
Physical ___:
ADMISSION EXAM
===============
VS: Reviewed, see OMR
GENERAL: Alert, in NAD
HEENT: NC/AT, EOMI, MMM
NECK: Supple, non-tender, no LAD
HEART: RRR, normal S1/S2, no m/r/g
LUNGS: CTAB, breathing comfortably without use of accessory
muscles
ABDOMEN: Soft, non-tender, + bowel sounds
EXTREMITIES: R forearm in splint, trace edema in ___ ___, no
cyanosis or clubbing
SKIN: Warm, well perfused, large areas of echymosses on L arm
and
dry, peeling skin on ___
NEURO: Oriented, CN II-XII grossly intact, Strength ___ in
proximal R thigh, otherwise ___ strength in ___ extremities.
Decreased sensation in R thigh
DISCHARGE EXAM
===============
Vital Signs: 98.2, 130/50, 55, 16, 97% on RA
General: Pleasant and conversant, lying in bed in NAD
CV: Loud holosystolic AVF turbulence blurring S1 and S2 heard
throughout chest
Lungs: CTAB anteriorly, no wheezes/crackles/rhonchi
Extremities: Ecchymoses noted on arms bilaterally. the R forearm
is dressed w/ clean wrapping, no evidence of bleeding, no
surrounding erythema or induration. R leg has longitudinal
bandages on anterior thigh from graft. No active bleeding, no
surrounding erythema or induration.
Pertinent Results:
ADMISSION LABS
===============
___ 01:50PM GLUCOSE-85 UREA N-51* CREAT-6.3* SODIUM-141
POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-29 ANION GAP-19*
___ 01:50PM estGFR-Using this
___ 01:50PM WBC-7.2 RBC-3.28* HGB-10.6* HCT-34.4 MCV-105*
MCH-32.3* MCHC-30.8* RDW-14.9 RDWSD-58.2*
___ 01:50PM NEUTS-62.2 ___ MONOS-8.7 EOS-1.8
BASOS-0.6 IM ___ AbsNeut-4.46 AbsLymp-1.86 AbsMono-0.62
AbsEos-0.13 AbsBaso-0.04
___ 01:50PM PLT COUNT-152
___ 01:50PM ___ PTT-36.2 ___
MICROBIOLOGY
=============
None.
IMAGING
========
FOREARM AP & LAT ___
There is no fracture or focal osseous abnormality. Bones are
diffusely
demineralized. Irregularity of the soft tissues is noted
particular along the dorsal surface of the midforearm. Surgical
clips noted in the region of the antecubital fossa. Dense
atherosclerotic calcifications are noted.
DISCHARGE LABS
===============
___ 05:00AM BLOOD WBC-7.2 RBC-2.92* Hgb-9.8* Hct-31.1*
MCV-107* MCH-33.6* MCHC-31.5* RDW-15.0 RDWSD-58.8* Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-94 UreaN-25* Creat-5.0*# Na-136
K-4.7 Cl-93* HCO3-28 AnGap-15
___ 04:55AM BLOOD Calcium-8.2* Phos-5.9* Mg-2.4
Brief Hospital Course:
Ms. ___ is a ___ y/o female with history of ESRD on HD, Afib
on Coumadin, p/w a skin tear on right forearm and is now s/p
repair w/ skin autograft in OR on ___.
ACTIVE/ACTUTE ISSUES
=====================
# Skin tear
The patient presented after a fall in which she sustained a
significant skin tear injury. She went to the OR on ___ with
hand surgery for a split thickness graft. There were no surgical
complications. She tolerated the procedure well and
recovered appropriately post op. She was started on clindamycin
for infection prophylaxis, to be continued until ___. She was
given Tylenol ___ Q8 and Dilaudid ___ Q4 PRN for pain, to
good effect. She was also started on Vitamin A for enhanced
wound healing. Her Coumadin was held for the procedure and
should be re-started 72 hours post op. A follow up appointment
in the surgery clinic has been scheduled.
# Bradycardia
The pt's home medications include metoprolol succinate 100mg and
amiodarone 100mg daily. On admission, her HR was found to be
40-60s and remained persistently low throughout admission.
Currently she is asymptomatic while in hospital but she states
that lately she has been having episodes of lightheadedness upon
standing. There is concern that bradycardia may be a
contributing factor to falls. We have been holding pt's home
metoprolol and amiodarone while inpatient. On discharge, her
amiodarone was re-started. The pt should discuss w/ her
outpatient cardiologist regarding restarting this medication.
# Falls
The pt states she falls four to five times per year and
attributes her falls to proximal muscle weakness from chronic
steroid use. She denies prodrome, LOC during these falls or
confusion afterward, so unlikely to be syncopal or epileptic in
nature. Due to concern that bradycardia may be a contributing
factor to falls, her home dose of metoprolol was held and not
re-started this admission. Recommend further evaluation of this
problem as an outpatient.
CHRONIC/STABLE ISSUES
=======================
# ESRD on HD ___
The patient received HD on ___.
# Afib
The patient has been in normal sinus rhythm, however HR has been
low since admission. Pt's home meds include Coumadin,
metoprolol, and amiodorone. Her Coumadin was held for her
procedure, to be resumed 72hrs post op (___). Her
amiodarone was originally held due to bradycardia, but restarted
on day of discharge. She was not re-started on metoprolol due to
persistent low heart rates.
# Hypothyroidism
She was continued on home levothyroxine.
TRANSITIONAL ISSUES
====================
[] The pt's Coumadin was held for her procedure. She should
restart her usual Coumadin regimen on ___ and have her
INR checked at her ___ dialysis appointment as per usual.
Please titrate Coumadin dose appropriately to therapeutic goal
(INR ___.
[] The pt was bradycardic during this admission and her home
metoprolol was held. Please re-check pt's heart rate and assess
the patient's need for beta blocker.
- The pt was started on dilaudid for pain control.
- Patient was discharged with clindamycin 600mg PO q8h to
complete a 3 day course of infection prophylaxis on ___.
# Code status: Full, presumed
# Contact: ___
Relationship: Daughter (HCP)
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO EVERY OTHER DAY
2. PredniSONE 10 mg PO EVERY OTHER DAY
3. Warfarin 2.5 mg PO ___ AND ___
4. Warfarin 1.75 mg PO TUES, WED, ___, SAT, SUN
5. Amiodarone 100 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO 6 DAYS/WEEK
7. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 325 mg 2 capsule(s) by mouth every six (6)
hours Disp #*60 Capsule Refills:*0
2. Clindamycin 600 mg PO Q8H Duration: 2 Days
RX *clindamycin HCl 300 mg 2 capsule(s) by mouth every eight (8)
hours Disp #*6 Capsule Refills:*0
3. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth every six (6) hours
Disp #*15 Tablet Refills:*0
4. Vitamin A ___ UNIT PO DAILY Duration: 7 Days
RX *vitamin A 10,000 unit 1 capsule(s) by mouth daily Disp #*6
Capsule Refills:*0
5. Amiodarone 100 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO 6 DAYS/WEEK
7. PredniSONE 5 mg PO EVERY OTHER DAY
8. PredniSONE 10 mg PO EVERY OTHER DAY
9. HELD- Metoprolol Succinate XL 100 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until told by your doctor
10. HELD- Warfarin 2.5 mg PO ___ AND ___ This medication
was held. Do not restart Warfarin until ___
11. HELD- Warfarin 1.75 mg PO TUES, WED, ___, SAT, SUN This
medication was held. Do not restart Warfarin until ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right upper extremity skin tear
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why was I admitted to the hospital?
- You were admitted because you fell and injured your right arm.
What was done while I was in the hospital?
- You had a surgical procedure to repair the skin tear. Skin
from your leg was used as a graft for your right arm.
- You received hemodialysis according to your usual schedule on
___.
- We did not give you your home medications of metoprolol or
amiodarone because your heart rate was low. We also did not give
you Coumadin because it is standard practice to hold that
medication for surgical procedures.
What should I do when I go home?
- You should resume your home medications EXCEPT for metoprolol
and Coumadin.
- Please discuss with your cardiologist at your next appointment
if you should restart this metoprolol.
- You can restart your Coumadin as per your usual schedule on
___. Please have INR checked at your ___ dialysis
appointment as per usual.
- You should continue taking tylenol for pain control, and can
use dilaudid for any severe pain.
- Elevate your R arm with ___ pillows.
- You can use your R arm as tolerated, but do not bear weight.
Weight bearing on your R leg as tolerated.
- Keep soft splint in place and dry for 7 days.
- Take Vitamin A to assist with wound healing.
- We recommend that you call and reschedule your PCP appointment
as it's currently scheduled on the same day you are meeting with
the hand surgeon.
Wishing you all the best,
Your ___ Care Team
Followup Instructions:
___
|
19783470-DS-12
| 19,783,470 | 22,400,414 |
DS
| 12 |
2183-04-25 00:00:00
|
2183-04-27 00:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Cipro
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP with stone extraction
History of Present Illness:
___ yo w/GERD, hiatal hernia, cholelithiasis presents with
abdominal pain. Pain started yesterday morning after a fatty
meal. Located epigastric and RUQ, associated with nausea and
emesis. No diarrhea or fever. Pt went to ___ and was
found to have elevated LFTs and a CBD stone, she was given pain
meds, zofra, and fluids and transferred to BID for ERCP.
Currently pt reports nausea. Pain is increasing as she is due
for medication.
ROS: chronic neck pain, otherwise 10 point ros negative
Past Medical History:
-GERD
-Esophageal spasms
-HTN
-Melanoma
-Hiatal Hernia
PSH: CCY, c-section, melanoma excision
Social History:
___
Family History:
adopted, unknown, son healthy
Physical ___:
Admission PE
VS: 98 157/69 76 20 96%ra
Pain: 3
Gen: nad, lying in bed
Heent: membranes dry
Resp: ctab
CV: rrr no m/r/g
Abd: hypoactive BS, soft, tender epigastrium and RUQ, no rebound
or guarding
Ext: wwp, no e/c/c
Neuro: alert, follows commands, moving all extremities
.
Discharge PE
VSS
General: AAOX3, in NAD
HEENT: MMM, OP clear
CV: RRR, no RMG
Lungs: CTAB, no WRR
Abdomen:
Extremities:
Neurology:
Derm:
.
Pertinent Results:
___ 03:00AM GLUCOSE-143* UREA N-20 CREAT-0.7 SODIUM-139
POTASSIUM-3.0* CHLORIDE-98 TOTAL CO2-28 ANION GAP-16
___ 03:00AM ALT(SGPT)-137* AST(SGOT)-153* ALK PHOS-101
TOT BILI-4.6*
___ 03:00AM LIPASE-16
___ 03:00AM WBC-15.3* RBC-4.28 HGB-12.7 HCT-35.0* MCV-82
MCH-29.6 MCHC-36.2* RDW-15.1
___ 03:00AM NEUTS-93.5* LYMPHS-3.5* MONOS-2.8 EOS-0.1
BASOS-0.1
___ 03:00AM PLT COUNT-197
.
TTE ___
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality due to body habitus. Left
ventricular systolic function is probably normal, a focal wall
motion abnormality cannot be excluded. The right ventricle is
not well seen but is probably normal. No significant valvular
abnormality. Unable to assess pulmonary artery systolic
pressure.
.
___ EKG
Sinus rhythm. Low precordial QRS voltages. Poor R wave
progression likely due
to lead positioning versus normal variant. Compared to tracing
#2 the findings
are similar.
.
___ CXR
FINDINGS: In comparison with the study ___, there is
increasing
indistinctness of engorged pulmonary vessels, consistent with
elevated
pulmonary venous pressure. Mild atelectatic changes are seen at
the bases.
.
___ ERCP
Normal major papilla
Cannulation of the biliary duct was successful and deep with a
sphincterotome
The CBD was dilated to 12mm
Given the elevated bilirubin and MRCP finding of CBD stone,
sphincterotomy was performed in the 12 o'clock position using a
sphincterotome
A stone and sludge were extracted successfully with a balloon
sweep
Otherwise normal ercp to third part of the duodenum
.
Brief Hospital Course:
___ yo F with a PMHx of GERD, HTN, cholelithiasis presents with
RUQ pain, nausea and emesis consistent with biliary obstruction
as well as leukocytosis, s/p ERCP with removal of CBD stone
whose course was complicated by SOB
# Mild Cholangitis with cholelithiasis
The patient presented to ___ with elevated LFT's
including an elevated t. bili (4.6 on admission) and a CBD stone
seen on imaging. The patient was transferred to ___ for an
ERCP. In addition the patient was noted to have a WBC of 15.3.
The patient had an ERCP on ___ which showed a CBD of 12 MM.
A sphincterotomy was performed and stones and sludge was
removed. The patient LFT's down trended and normalized on the
day of discharge. The patient was continued on Unasyn given her
leukocytosis. This was narrowed down to po Augmentin and she
was discharged on 5 additional days to complete a ten day
course. An outpatient elective cholecystectomy should be
considered.
.
# SOB and chest tightness likely due to volume overload
On ___, the patient reported sob with mild hypoxia and chest
tightness with radiation to her left arm. The patient was found
to have new pulmonary edema on CXR and an elevated BNP. She was
treated with Lasix X3 doses with improvement of her symptoms.
The patient denies a h/o CHF and said she had a cardiac work up
about ___ year ago that was negative. The patient had Tn X2 which
were negative and a BNP in the 2365 range. An TTE was done in
house which showed normal LV and RV function and no obvious
valvular abnormalities. The patient symptoms were thought to be
due to pulmonary edema for IVF's in the ___ period
and referred pain from his ERCP. The patient was discharged on
her home medications and was advised to follow up with her
Cardiologist.
.
# Hypokalemia and hypophosphatemia
Likely due to biliary symptoms (nausea, vomiting and diarrhea)
and exacerbated by Lasix. Repleted and normalized.
.
# Diarrhea
The patient had increased frequency of bowel movements while in
house. C. diff was negative, likely antibiotics associated
diarrhea.
.
# Transitional Issues:
- Follow up with PCP ___ ___ weeks and consider referral for
elective cholecystectomy
- Follow up with Cardiologist for routine follow up and BP
medication titration
.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atenolol 100 mg PO DAILY
2. Valsartan Dose is Unknown PO DAILY
3. Amlodipine Dose is Unknown PO DAILY
4. Pantoprazole 40 mg PO DAILY:PRN heartburn
5. Diazepam 5 mg PO Q8H:PRN esophageal spasm
6. Calcium Carbonate 1250 mg PO BID
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal
congestion
8. Acetaminophen Dose is Unknown PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN Pain
2. Amlodipine 5 mg PO DAILY
3. Atenolol 100 mg PO DAILY
4. Diazepam 5 mg PO Q8H:PRN esophageal spasm
5. Indapamide 2.5 mg PO DAILY
6. Pantoprazole 40 mg PO Q24H heartburn
7. Valsartan 80 mg PO DAILY
8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*10 Tablet Refills:*0
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY:PRN nasal
congestion
10. Vitamin D 400 UNIT PO DAILY
11. Calcium Carbonate 1250 mg PO DAILY
please take as you have been prior to the hospitalization
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Pulmonary edema
Non-infectious diarrhea
Low magnesium, potassium and phosphorus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to a blockage in your bile system. This
was releaved with an ERCP. There was concern that you developed
an infection as a result of this blockage and you will complete
a course of antibiotics. You developed fluid in the lungs and
were given diuretics to improve your breathing. An echo was done
which revealed normal heart function. You should follow up with
your PCP and GI physician for consider of removal of your
gallbladder.
.
Medications changes, see list below-No aspirin, plavix, NSAIDS,
coumadin for 5 days
Followup Instructions:
___
|
19783776-DS-18
| 19,783,776 | 25,618,903 |
DS
| 18 |
2130-06-12 00:00:00
|
2130-06-12 11:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / morphine
Attending: ___.
Chief Complaint:
Right ___ toe gangrene
Major Surgical or Invasive Procedure:
___ Treatment of right superficial femoral artery stenosis
with a 5 mm Complete stent.
History of Present Illness:
___ year old female with a history of Afib not on coumadin ___
h/o GI bleed/high bleeding risk) initially presented with R ___
toe pain and erythema of R ___, and ___ toes. The patient
initially had pain and erythema of the above mentioned toes
approximately one week ago and presented to ___-N,
where she was admitted and treated with IV vancomycin. Her son
and daughter note some improvement in her erythema during this
time, however, she was discharged to her assisted living
facility on keflex, on which her children report the erythema
again worsened. The patient's son reported that he received a
call from the patient's visiting nurse reporting that she had
newly found gangrene of the tip of her R ___ toe. Given this new
finding, the patient was taken to ___-N and started on heparin
drip at around 15:30. She was then transferred to ___ for
vascular evaluation. She denied fevers, chills,chest pain, or
shortness of breath.
Past Medical History:
Hypertension
breast cancer
Right lower extremity neuropathy
RA
dementia
afib not on coumadin ___ GI bleed/high risk for bleeding
severe aortic stenosis s/p TAVR ___
CAD
mitral regurgitation
___
hypothyroidism
PSH:
Left carpal tunnel surgery years ago.
Right carpal tunnel surgery ___
Cholecystectomy
Hysterectomy
Surgical removal of a goiter
Low back surgery
Social History:
She resides in assisted living. She was a former smoker, quit
many years ago.
Physical Exam:
On Discharge:
VS: 97.6F HR 65 BP 159/83 RR 16 99%RA
Gen: AAOx2, NAD, then comfortably sleeping
CV: RRR no MRG
Pulm: CTAB
Abd: soft, nttp non distended
RLE palpable femoral/popliteal and ___ pulse; foot warm, well
perfused, mildly red not cellulitic, non tender toe exam; ___
toe tip necrotic
LLE: palpable femora/popliteal/ DP and ___ pulse
R groin: stitch removed; c/d/i with no evidence of hematoma
Pertinent Results:
___ 06:14AM BLOOD WBC-8.8 RBC-3.87* Hgb-11.6* Hct-34.6*
MCV-89 MCH-30.1 MCHC-33.7 RDW-15.5 Plt ___
___ 07:48AM BLOOD ___ PTT-48.7* ___
___ 06:14AM BLOOD Glucose-86 UreaN-9 Creat-0.6 Na-137 K-4.0
Cl-101 HCO3-25 AnGap-15
___ 07:48AM BLOOD Calcium-9.8 Phos-3.2 Mg-2.1
___ 06:14AM BLOOD Vanco-23.8*
___ R foot AP/lat/obl IMPRESSION:Soft tissue swelling of
the right little toe without radiographic evidence of
osteomyelitis.
___ RIGHT CTA AORTA/BIFEM/ILIAC IMPRESSION:
1. Non opacification of the posterior tibial arteries
bilaterally. Two-vessel runoff to the level of the ankles
bilaterally.
2. Moderate atherosclerosis with foci of high-grade stenoses.
Moderate atherosclerosis involves the common iliac arteries.
Left: Moderate stenosis of the left CFA. Moderate amount of
atherosclerosis involves the entirety of the L SFA and
popliteal.
Right: superficial artery pseudoaneurysm has resolved. A
moderate amount of atherosclerosis involves the entirety of the
SFA and popliteal. There is a focal high-grade stenosis in the
upper popliteal artery, however, there is a 2 vessel runoff.
3. Diverticulosis without diverticulitis.
___ CXR IMPRESSION: 1. Mildly prominent interstitial lung
markings, worse at the lung bases are unchanged from ___. 2. Moderate cardiomegaly is unchanged.
___ ABI/PVR IMPRESSION: Severe arterial disease at the
right iliac, SFA, and tibial levels. Mild to moderate left
tibial arterial insufficiency. Left ABI was 0.82, right ABI
could not be obtained due to the lack of vessel compressibility.
Brief Hospital Course:
___ year old female who was admitted to ___ after transfered
from ___ for concern of critical limb ischemia of RLE.
She had experienced a week of increased right ___ toe cellulitis
and had developed gangrene at the ___ toe tip. The heparin drip
started at OSH was continued on a heparin drip from ___ until
her stent placement on ___
#) Limb ischemia: ___ ABI/PVR showed Severe arterial disease at
the right iliac, SFA, and tibial levels. CTA ___ showed no flow
in posterior tibial arteries bilaterally. Two-vessel runoff to
the level of the ankles bilaterally. She underwent angiography
of the RLE with Right SFA stent placement on (___) which showed
good anterior tibial and peroneal artery runoff.
#) cellulitis RLE: She was started on antibiotics on ___ for
the cellulitis (Vancomycin/cipro/flagyl) and these were
continued until her discharge when she was changed to a 7 day PO
agumentin course.
#) Dispo: mild delirium on ___ and request from family kept
from discharge to rehab but was back to baseline on ___ and
discharged to rehab.
At discharge Mrs. ___, was appropriate with back to
pre-operative baseline functioning, she had good pain control
with PO non narcotic medications, and she and her family were
appraised and in agreement with the care plan. She is discharged
on aspirin and plavix with follow up in 1 month.
Medications on Admission:
synthroid ___ daily
Iron slow release 159mg daily
ASA 81mg daily
plavix 75mg daily
colace
donepezil 10mg daily
furosemide 20mg daily
hydroxychloroquine 200mg BID
metoprolol succinate ER 50mg daily
Namenda 10 BID
pravastatin 20mg daily
Premarin 0.625 qMWF
Vitamin D3 1,000units daily
Vitamin C 250mg BID
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Donepezil 10 mg PO QHS
6. Estrogens Conjugated 0.625 mg PO 3X/WEEK (___)
7. Ferrous Sulfate 325 mg PO DAILY
8. Hydroxychloroquine Sulfate 200 mg PO BID
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Memantine 10 mg PO BID
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Pravastatin 20 mg PO QPM
13. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 1 capsule by mouth at bedtime Disp
#*40 Capsule Refills:*1
14. Vitamin D 1000 UNIT PO DAILY
15. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 days,
please discontinue on ___.
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 875 by mouth
twice a day Disp #*20 Tablet Refills:*0
16. Acetaminophen 650 mg PO TID
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth q8hrs Disp #*50 Tablet Refills:*1
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Peripheral arterial disease s/p right superficial femoral artery
stenting on ___.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance, fall risk.
Discharge Instructions:
You were transferred to the Vascular Surgery Service at ___
for concerns about the circulation in your right leg and foot.
You underwent a stenting procedure in your right leg to improve
blood flow to both your right leg and foot. You have done well
since your procedure and we feel that you are ready to go home
with the following instructions:
MEDICATION:
Take Aspirin 81mg (enteric coated) once daily
Take Plavix (Clopidogrel) 75mg once daily for the next month
only
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 (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
Followup Instructions:
___
|
19784083-DS-16
| 19,784,083 | 29,806,503 |
DS
| 16 |
2127-11-26 00:00:00
|
2127-11-26 11:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p colonoscopy 3 days ago presents with 1 day of
worsening pain. He reports sharp cramping pain in the lower
abdomen, worse in the LLQ. It is not relieved by any position.
He
has nausea but no emesis. No fever or chills. He has not been
passing flatus for the last 24 hours. The last BM was prior to
the colonoscopy. He has not been taking POs. He thought it was
constipation and has been taking milk of mag without effect.
Past Medical History:
PMH: HTN, HLD, CAD (MI s/p BMS), chronic constipation
PSH: tonsillectomy
Social History:
___
Family History:
Father had MI at the age of ___. Mother had MI
at the age of ___. Sister had diabetes and coronary artery
disease. He has one daughter.
Physical Exam:
On admission:
Vitals: Temp: 98.4 °F, Pulse: 81, RR: 16, BP: 152/89, O2Sat: 97
Gen: A&O, uncomfortable appearing male
CV: RRR, no M/R/G
Pulm: CTAB
Abd: moderate distension with tympany, he has TTP in the lower
abdomen mostly in the LLQ, no rebound/guarding, no hernia
Ext: w/d, no edema
On discharge:
Vitals: 97.7 56 137/82 16 99% RA
GEN: A&O, NAD
CV: RRR
PILM: CTAB
ABD: Soft, nontender, nondistended.
EXTR: No edema.
Pertinent Results:
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 1:59 AM
IMPRESSION:
1. High-grade small-bowel obstruction with a sharp transition
zone in the left lower quadrant. Small bowel wall thickening,
mesenteric edema, and a large amount of intrapelvic free fluid
is concerning for early ischemic change. There is no
pneumatosis or portal venous gas.
2. No free air.
3. Ill defined subcentimeter hypodensity within the inferior
portion of the liver is nonspecific. This is likely benign,
however, attention on followup examinations, or a followup US
examination, is recommended.
4. 2 mm right lower lobe nodule. Per ___ guidelines, no
followup is necessary if there are no high risk factors;
otherwise a 12 month followup chest CT can be considered.
___ 10:55PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 10:55PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 10:55PM URINE MUCOUS-OCC
___ 10:55PM WBC-10.1 RBC-4.70 HGB-15.9 HCT-46.1 MCV-98
MCH-33.9* MCHC-34.6 RDW-12.4
___ 10:55PM NEUTS-87.1* LYMPHS-9.3* MONOS-3.4 EOS-0.1
BASOS-0.1
___ 10:55PM PLT COUNT-227
___ 10:55PM GLUCOSE-133* UREA N-16 CREAT-1.1 SODIUM-134
POTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-27 ANION GAP-18
___ 10:55PM ALT(SGPT)-36 AST(SGOT)-49* ALK PHOS-76 TOT
BILI-1.0
___ 10:55PM ALBUMIN-5.0
___ 03:13AM ___ PTT-28.9 ___
___ 03:21AM LACTATE-1.2
Brief Hospital Course:
Mr. ___ was admitted on ___ under the Acute Care Surgery
service for management of his small bowel obstruction. A
nasogastric tube was placed and he was kept on bowel rest and
resuscitated with IV fluids. Vital signs were routinely
monitored and remained stable. Serial abdominal exams were
performed and he remained nontender with improving distention
and on ___ his NG tube was removed. He reported passing flatus
and his diet was advanced slowly over 24 hours to regular which
he tolerated without difficulty. On ___ he had two small bowel
movements in which he reported a small amount of blood, which
was unwittnessed. His hematocrit remained stable and a rectal
exam was performed and he was guiac negative. No further blood
was ntoed. A foley catheter had been placed on admission for
urine output monitoring and was removed on ___ at which time he
voided adequate amounts of urine without difficulty.
Of note he was bradycardic intermittently into the 40's with a
stable blood pressure. He was asymptomatic and denied any
symptoms of syncope or presyncope. Per prior cardiology reports
and patient history, this is an ongoing issue for the patient
for which he is closely followed as an outpatient and it has
been determined that a pacemaker is not indicated at this time.
On ___ at discharge he is afebrile with stable vital signs. He
is tolerating a regular diet and voiding adequate amounts of
urine. He is ambualting independently. He is being discharged
home with ___ services for blood pressure and heart rate
monitoring.
Medications on Admission:
ASA 81/325 alternating qod, Zocor 80', Isosorbide mononitrate
30', MVI', Vit B
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Isosorbide Mononitrate 30 mg PO DAILY
3. Simvastatin 80 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Vitamin D 400 UNIT PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Milk of Magnesia 30 mL PO Q6H:PRN constipation
8. Senna 2 TAB PO HS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with a small bowel
obstruction. You were placed on bowel rest and had a nasogastric
tube placed for decompression. Your obstruction resolved with
this management, and you have resumed eating a regular diet and
having bowel function. You are now being discharged home.
Please follow up with your gastroenterologist at the appointment
scheduled for you below. If you have any questions regarding
your recent hospitalization you may contact the Acute Care
Surgery clinic at ___.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication
Followup Instructions:
___
|
19784487-DS-14
| 19,784,487 | 21,502,734 |
DS
| 14 |
2156-04-01 00:00:00
|
2156-04-06 10:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with past medical history significant for kidney stones with
recent lithotripsy and stent placement approximately 6 days ago,
as well as stent placement 6 weeks ago. The patient has been
reporting dysuria since that time, as well as left flank pain.
These have not changed, however yesterday he began having fevers
and shaking rigors. He had a temperature yesterday of 103°F, and
today was 104.2°F. The patient denies any chest pain, cough,
abdominal pain. Endorses 1 episode of nonbloody vomiting prior
to arrival. He was seen at an outside hospital, where he
received 1 g of ceftriaxone. He was transferred for evaluation
by urology.
CT ABD PELVIS
1. Mild increase in perinephric stranding and thickening of the
dura is
fascia, concerning for pyelonephritis, despite interval
placement of a
double-J stent and decompression of the hydronephrosis, now
resolved. Please
correlate with urinalysis.
2. Minimally decreased stone burden on the left.
3. Colonic diverticulosis without diverticulitis.
Past Medical History:
Crohn's Disease s/p two prior resections
Recurrent nephrolithiasis
DVT ___ years prior, without PE
B12 deficiency
Social History:
___
Family History:
No family history of IBD
Father had ___ and CAD s/p CABG
Physical Exam:
NAD
perfused
breathing nonlabored
Abdomen soft
Ext WWP
Pertinent Results:
___ 10:42PM GLUCOSE-103* UREA N-36* CREAT-4.7* SODIUM-142
POTASSIUM-4.7 CHLORIDE-116* TOTAL CO2-16* ANION GAP-15
___ 10:42PM WBC-8.7 RBC-2.13* HGB-7.4* HCT-23.2* MCV-109*
MCH-34.7* MCHC-31.9* RDW-14.6 RDWSD-59.0*
Brief Hospital Course:
Patient was admitted from the ED and continued on
vanc/ceftriaxone. Afebrile throughout his time on the floor,
sent home on levofloxacin. Urine and blood cultures negative.
Potassium was high initially but normalized quickly. Bicarbonate
low throughout admission, consulted renal who recommended
isotonic bicarb drip with transition to PO before discharge,
ultimately sent home with bicarb 19 on PO bicarb.
At time of discharge, he was in a stable condition, tolerating
regular diet, ambulating, sent home with foley. He was
instructed to follow up on ___ with his PCP for repeat lab work,
as well as with nephrology in the next ___ weeks.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Warfarin 7 mg PO DAILY16
2. AzaTHIOprine 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. Levofloxacin 250 mg PO Q48H
RX *levofloxacin 250 mg 1 tablet(s) by mouth every 48 hours Disp
#*5 Tablet Refills:*0
4. Sodium Bicarbonate 650 mg PO BID
5. AzaTHIOprine 50 mg PO DAILY
6. Warfarin 7 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Complete a 10-day course of antibiotics as directed
-Take bicarb twice daily
-Follow up with your PCP on ___ or ___ for
repeat labs to monitor bicarbonate level
-Follow up with your nephrologist in ___ weeks for continued
monitoring
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
The maximum daily Tylenol/Acetaminophen dose is ___ grams FROM
ALL sources.
-Do NOT drive or drink alcohol while taking narcotics and do NOT
operate dangerous machinery.
-Colace has been prescribed to avoid constipation and
constipation related to narcotic pain medication, discontinue if
loose stool or diarrhea develops. Colace is a stool "softener"-
it is NOT a laxative
-Resume your home medications
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest emergency room.
Followup Instructions:
___
|
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