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19784870-DS-21
| 19,784,870 | 25,579,760 |
DS
| 21 |
2185-10-02 00:00:00
|
2185-10-08 09:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Compazine / sulfur dioxide
Attending: ___
Chief Complaint:
right lower quadrant pain
Major Surgical or Invasive Procedure:
___: laparoscopic appendectomy
History of Present Illness:
___ year old female with complaints of right lower abdominal
pain. The patient comes in complaining of RLQ abdominal pain
that has been ongoing
since last night. Sexually active with ___ male partner that
is monogamous without barrier protection.
Past Medical History:
Chronic UTIs
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION: upon admission:
Temp: 98.0 HR: 71 BP: 128/77 Resp: 16 O(2)Sat: 100 Normal
Constitutional: Constitutional: comfortable
Head
/ Eyes: NC/AT
ENT: OP WNL
Resp: CTAB
Cards: RRR. s1,s2. no MRG.
Abd: S/tender in the RLQ/ND
Flank: no CVAT
Skin: no rash
Ext: No c/c/e
Neuro: speech fluent
Psych: normal mood
Pertinent Results:
___ 11:29AM BLOOD WBC-10.0 RBC-4.64 Hgb-13.7 Hct-42.0
MCV-91 MCH-29.5 MCHC-32.6 RDW-12.3 Plt ___
___ 11:29AM BLOOD Neuts-74.5* Lymphs-16.1* Monos-7.6
Eos-1.3 Baso-0.5
___ 09:10AM BLOOD Glucose-143* UreaN-12 Creat-0.8 Na-137
K-4.3 Cl-104 HCO3-25 AnGap-12
___: US of appendix:
Normal pelvic ultrasound with multiple follicules in both
ovaries, showing normal arterial and venous waveforms. No
appendix was seen on scanning the right lower quadrant
___: cat scan of abdomen and pelvis:
Blind ending retrocecal tubular structure in the right lower
quadrant
measuring 11 mm in diameter with equivocal adjacent fat
stranding is
suspicious for acute appendicitis- although the appendiceal base
is not
clearly identified due to paucity of intraabdominal fat.
Correlation with physical exam and possibly ultrasound may help
to clarify the clinical
picture.
Brief Hospital Course:
The patient was admitted to the hospital with right lower
quadrant pain. Upon admission, she was made NPO, given
intravenous fluids and underwent imaging. On cat scan imaging
she was reported to have acute appendicitis. She was taken to
the operating room on HD #1 where she underwent a laparoscopic
appendectomy. The operative course was stable with minimal
blood loss. The patient was extubated after the procedure and
monitored in the recovery room . Her post-operative course has
been stable. She resumed a regular diet. Her pain has been
controlled with oral analgesia. She reported a "sensation" of
tightness in upper extremities and decreased sensation upper
outer left thigh. She reported that this was noted after dental
extraction and resolved spontaneously. Prior to discharge, she
reported that the right upper thigh "tightness" had resolved.
She has been voiding without difficulty and ambulating. Of note,
blood work on admission showed a total bilirubin of 2.0 with
normal liver function tests. A repeat total bilirubin was done
at time of discharge which was 1.3. The patient was discharged
home on POD # 1 in stable condition. An appointment for
follow-up was made to follow-up with Dr. ___ and with her
primary care provider.
Medications on Admission:
Keflex: takes it for empiric treatment of chronic UTIs
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 #*15 Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
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 right lower quadrant
pain. You underwent a cat scan of the abdomen which showed
acute appendictis. You were taken to the operating room where
you had your appendix removed. You are recovering from your
surgery and you are preparing for discharge home with the
following instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19784979-DS-9
| 19,784,979 | 25,654,842 |
DS
| 9 |
2160-08-16 00:00:00
|
2160-08-16 21:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin
Attending: ___.
Chief Complaint:
lower abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with HTN, HLD, CAD s/p PCI in ___ and s/p TURP on ___ at
___ and discharged on ___ who re-presented to ___ today
with lower abdominal pain. In the ___, he was hypoxic and
placed on BiPAP. Per patient report he had not taken his
Symbicort in 2 days. SBP was in the ___ and he was bolused with
IVF. Labs notable for creatinine 1.5, lactate 2.9, and trop-I
0.05. CT A/P showed no acute intra-abdominal process. He
received a total of 3L IVF. The ___ physician discussed his care
with Dr. ___ who noted GNR from urine in the OR.
Zosyn was given due to past resistance to levofloxacin. A Foley
was placed. He then developed a fever. For medications, he
received albuterol nebulizers, 125mg methylprednisolone,
diazepam, zofran, and morphine.
He was transferred to ___ for further management. In our ___,
SBPs were in the ___ on arrival and HR in the 110s. He was 99%
on 4L NC. He was afebrile. A R IJ CVC was placed, CVP was 17,
and he was started on levophed. Inital labs notable for Cr 1.7
(baseline 1.3-1.5), lactate 2.0, WBC 6.2, H/H 11.2/34.9. CXR
showed a right-sided internal jugular central venous lines
of the mid to distal SVC. On exam he had lower abdominal
tenderness. His mental status was normal. Urology was consulted
and recommended starting vancomycin and zosyn and placing a
Foley. He also received an additional 2L NS. Prior to leaving
the ___, levophed was at 0.09 and BP was 110s/80s. HR ___.
On arrival to the ICU, initial VS: 82, 131/66 on 0.06 levo, 20,
95% on RA, CVP 16. He denied chills, chest pain, dyspnea, leg
pain, leg swelling, or back pain. He has had shoulder and knee
pain recently but not currently.
Past Medical History:
- BPH
- Asthma
- Rheumatoid Arthritis (12.5mg prednisone daily for 2 months)
- Hypertension
- Hyperlipidemia
- CAD s/p PCI in ___
- Ventral hernia repair ?___
- S/P left nephrectomy ?___
- S/P TURP ___
Social History:
___
Family History:
Non-contributory in this ___ year old gentleman.
Physical Exam:
On Admission:
Vitals- 82, 131/66 on 0.06 levo, 20, 95% on RA
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, R IJ CVL is dressed and
c/d/i
Lungs: Good effort, non-labored, faint bibasilar rhonchi that
clear with cough, no wheeze or rales
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: foley with dark red urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
___ 08:52AM BLOOD WBC-6.2 RBC-3.71* Hgb-11.2* Hct-34.9*
MCV-94 MCH-30.1 MCHC-32.0 RDW-14.6 Plt ___
___ 03:45PM BLOOD WBC-17.7*# RBC-3.78* Hgb-11.5* Hct-35.8*
MCV-95 MCH-30.3 MCHC-32.0 RDW-15.1 Plt ___
___ 03:54AM BLOOD WBC-20.4* RBC-3.63* Hgb-10.4* Hct-33.6*
MCV-93 MCH-28.6 MCHC-30.8* RDW-15.7* Plt ___
___ 08:52AM BLOOD Glucose-95 UreaN-26* Creat-1.7* Na-146*
K-3.4 Cl-114* HCO3-20* AnGap-15
___ 03:45PM BLOOD Glucose-118* UreaN-26* Creat-1.6* Na-142
K-3.9 Cl-112* HCO3-18* AnGap-16
___ 03:54AM BLOOD Glucose-166* UreaN-31* Creat-1.7* Na-138
K-4.4 Cl-110* HCO3-20* AnGap-12
___ 08:58AM BLOOD Lactate-2.0
___ Urine Culture (___)
Final
Organism 1 ESCHERICHIA COLI
COLONY COUNT: >100,000 CFU/ML
1. ESCHERICHIA COLI
___ M.I.C.
------ ------
AMIKACIN S <=2
AMPICILLIN S <=2
CEFAZOLIN S <=4
CIPROFLOXACIN R >=4
GENTAMICIN S <=1
IMIPENEM S 0.5
LEVOFLOXACIN R >=8
NITROFURANTION R 128
PIPERACILLIN/TAZOBACTAM S <=4
TOBRAMYCIN S <=1
TRIMETHOPRIM/SULFA S <=20
Discharge Labs:
___ 07:00AM BLOOD WBC-12.5* RBC-3.91* Hgb-11.6* Hct-36.1*
MCV-92 MCH-29.7 MCHC-32.1 RDW-15.4 Plt ___
___ 07:00AM BLOOD Glucose-69* UreaN-26* Creat-1.4* Na-144
K-3.8 Cl-110* HCO3-25 AnGap-13
Brief Hospital Course:
This is an ___ male with PMHx asthma, CAD s/p remote
PCI, and is 2 days post-op from TURP presenting with lower
abdominal pain, found to have fevers and hypotension consistent
with septic shock from a urinary source.
# Septic Shock
Hypotensive refractory to 5L IVF requiring pressors. Most likely
source was urinary, given recent instrumentation and E. coli in
urine culture from the OR. On admission to ___ ICU he was
afebrile. He is on chronic steroids for rheumatoid arthritis, so
received stress-dose steroids while on pressors. He initially
required norepinephrine to maintain blood pressures but this was
weaned off in 12 hours. He maintained adequate urine output.
Antibiotics were narrowed to Ceftriaxone with a planned 14 day
course to be completed as an outpatient. A midline was placed on
___. LFT's and a CBC should be checked on ___ at his
PCP ___ appointment.
# Acute Kidney Injury
Creatinine elevated on admission to 1.7 from a presumed baseline
of 1.3. Likely prerenal in the setting of septic shock with a
probable element of ATN. There was no evidence of obstruction on
CT abdomen/pelvis from ___. Cr was 1.4 on the day of
discharge.
# Hypoxia
Upon arrival to ___ was reportedly hypoxic requiring
BiPAP. He denied feeling dyspneic. He received IV solumedrol,
nebullizers, and levofloxacin x 1 for presumed COPD
exacerbation. The patient states he has asthma and not COPD. He
was weaned to nasal cannula on arrival to our ___ and remained on
room air here with no wheezing and good air movement. CXR
without infiltrate. Low suspicion for respiratory infection or
COPD exacerbation. He was not continued on Levofloxacin.
# Rheumatoid Arthritis
After transfer to the general medicine floor the patient began
to complain of worsening bilateral hand, shoulder, and neck
pain. He was seen in consultation by Rheumatology who felt this
to be secondary to an RA flare vs. gout vs. pseudogout. They
recommend obtaining imaging with Xrays of bilateral hands as
well as checking
a uric acid level, at ___ PCP and ___
discretion. His home prednisone was increased to 20mg at the
time of discharge and he was advised to discuss this further
with his physicians.
# Hypernatremia
Felt to be hypovolemic, resolved with IV fluids.
# Constipation
Started on bowel regimen.
# Asthma
Stable respiratory status. Symbicort was substituted for Advair
while hospitalized.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
2. PredniSONE 12.5 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. PredniSONE 12.5 mg PO DAILY
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*15 Tablet
Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. lactobacillus acidophilus 1 tablet oral qd
4. Multivitamins 1 TAB PO DAILY
5. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
6. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 g IV daily Disp #*10 Vial Refills:*0
7. Outpatient Lab Work
Please check a CBC, Chem 7, and LFT's on ___ and send
results to ___ at fax number ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection with sepsis
Rheumatoid Arthritis
Asthma
Chronic kidney insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted to ___ after becoming very ill from a
urinary tract infection. Your blood pressure became very low
and you required special medication to increase your blood
pressure, and you were in the ICU to receive this medication.
You were seen by the infectious disease doctors regarding the
___ and choice of antibiotics for your infection, and they
have advised that you take Ceftriaxone for an additional 10
days. For this reason, a midline was placed. You should have
bloodwork done at your PCP's office on ___.
You also had increased joint pain for which you were seen by
rheumatology. Your prednisone was increased to 20mg. Please
schedule a ___ appointment with your rheumatologist to
discuss this further.
Followup Instructions:
___
|
19785550-DS-4
| 19,785,550 | 26,450,371 |
DS
| 4 |
2167-11-19 00:00:00
|
2167-11-19 10:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
neck pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male who was playing rugby and tackled head first and had
right sided neck pain and 30 seconds or so of right arm
paresthesias that quickly resolved. He denies any further
paresthesias, weakness, or radiculopathy. CT scan showed a
right C6, non-displaced lateral mass fracture.
Past Medical History:
ADHD
Social History:
___
Family History:
N/A
Physical Exam:
T: 97.5 HR: 59 BP:114/73 RR:16 O2 sats:98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA 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.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, propioception and vibration
bilaterally.
Reflexes: B T Br Pa Ac
Right ___ 2 2
Left ___ 2 2
Proprioception intact
Toes down going bilaterally
Rectal exam deferred
Pertinent Results:
Cervical CTA ___
Again seen, is a fracture through the right C6 pedicle,
minimally displaced. Fracture line spares the transverse
foramen. No definite vascular injury identified. There is
apparent irregularity of the right vertebral artery in its
distal V1/proximal V2 portion (series 3, image 96 through 107,
felt to be related to streak artifact and not in association
with the fracture. No flow-limiting stenosis in the cervical
vessels.
Brief Hospital Course:
On ___ the patient presented after sports trauma with right
neck pain and right C6 lateral mass fracture. He was placed in
a ___ collar. CTA was negative for any vertebral artery
injury. He was admitted for observation overnight and given his
lack of neuro symptoms and stable exam an MRI was not indicated.
He was discharged home and will follow up in the office in 4
weeks with cervical XRays.
Medications on Admission:
Adderall
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Cyclobenzaprine 5 mg PO BID:PRN muscle spasm
RX *cyclobenzaprine 5 mg 1 (One) tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right C6 Lateral Mass Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Cervical 6 Right Lateral Mass fracture
Nonsurgical
Activity
*** You must wear your hard cervical collar at all times. You
may remove it briefly for skin care and showering.
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. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
19785633-DS-10
| 19,785,633 | 26,705,692 |
DS
| 10 |
2181-08-26 00:00:00
|
2181-08-26 16:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of
myelodysplastic
syndrome, CKD, and IDDM presenting to the emergency department
as
a transfer from ___ after a fall on ___. The patient was noted to have a T12 and L1 fracture in
their documentation though a disc with images was not sent with
the patient, and he was transferred for orthopedic evaluation.
The patient complained of back pain in the lower T-spine and
upper L-spine. The patient denied bowel or bladder incontinence,
saddle anesthesia, weakness in the lower extremities. The
patient
also has injury to his right great toe from the fall.
Documentation from the previous hospital demonstrates no
fracture, however they were concerned for cellulitis given the
erythema around the injury.
- In the ED, initial vitals were: T 99.6, HR 89, BP 155/65, RR
18, SPO2 97% RA
- Exam was notable for:
"Neuro: Cranial nerves II through XII intact, sensation intact
throughout, muscle strength ___ in all major muscle groups.
Babinski equivocal in bilateral lower extremities. Ambulation
deferred
MSK: pain to palpation of lower T and L spine
Skin: There are Steri-Strips Dermabond and to the right great
toe. There is surrounding erythema of the dorsum of the right
foot tracking up the medial lower extremity up to the knee
without any purulent drainage. The area is warm to the touch."
- Labs were notable for: WBC 5.6, Hgb 8.9, plt 65, Cr 1.3, BUN
27, lactate 1.1
- The patient was given: morphine sulfate 2 mg IV x4
- Ortho-Spine was consulted and recommended outpatient follow
up.
Podiatry was consulted and said no concern for osteomyelitis
based on R foot films.
He was admitted for IV antibiotics, pain control, and ___ eval.
On arrival to the floor, he reports that his back pain is
currently very minimal, but becomes severe if he stands up. He
reports that he fell last ___ when he caught his right toe
on a stair and fell onto his back. He did not lose consciousness
or hit his head. He denies any falls prior to this or subsequent
difficulty walking. He denies leg numbness, weakness, urinary or
fecal incontinence, or urinary retention.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
Myelodysplastic syndrome
IDDM
CKD
HTN
HLD
Memory impairment
Depression
GERD
Gout
Social History:
___
Family History:
Father - died of colon cancer
Daughter - died of malignancy (he cannot recall the type)
Daughter - currently has breast cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ 0215 Temp: 98.1 PO BP: 178/65 L Lying HR: 86
RR:
18 O2 sat: 95% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. Cap refill <2s. Ecchymoses diffusely across upper
extremities. Right great toe with bruising and covered by
Steri-Strips with surrounding erythema streaking up leg to
mid-shin
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHSYCIAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 729)
Temp: 98.3 (Tm 98.9), BP: 133/62 (116-162/61-67), HR: 76
(66-86), RR: 18 (___), O2 sat: 96% (94-98)
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No suprapubic tenderness. No
organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. Right foot lesion with bruising, and surrounding
edema. Non-purulent, no dorsal streaking, or abscess.
SKIN: Warm. Cap refill <2s. Ecchymoses diffusely across upper
extremities. Right great toe with bruising, not visualized on
exam today
NEUROLOGIC: AOx2. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS:
===============
___ 06:10PM BLOOD WBC-5.6 RBC-2.92* Hgb-8.9* Hct-27.3*
MCV-94 MCH-30.5 MCHC-32.6 RDW-18.1* RDWSD-61.2* Plt Ct-65*
___ 06:10PM BLOOD Neuts-69.2 Lymphs-15.1* Monos-14.2*
Eos-0.0* Baso-0.4 Im ___ AbsNeut-3.86 AbsLymp-0.84*
AbsMono-0.79 AbsEos-0.00* AbsBaso-0.02
___ 06:10PM BLOOD ___ PTT-30.8 ___
___ 06:10PM BLOOD Glucose-207* UreaN-27* Creat-1.3* Na-137
K-4.7 Cl-99 HCO3-22 AnGap-16
___ 06:10PM BLOOD Glucose-207* UreaN-27* Creat-1.3* Na-137
K-4.7 Cl-99 HCO3-22 AnGap-16
___ 06:10PM BLOOD Calcium-8.8 Phos-2.8 Mg-1.3*
___ 06:10PM BLOOD CRP-154.1*
___ 06:16PM BLOOD Lactate-1.1
___ 05:39PM URINE Color-Straw Appear-Hazy* Sp ___
___ 05:39PM URINE Blood-SM* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 05:39PM URINE RBC-16* WBC->182* Bacteri-FEW*
Yeast-MANY* Epi-0
___ 05:39PM URINE Mucous-RARE*
DISCHARGE LABS:
===============
___ 06:04AM BLOOD WBC-6.5 RBC-3.24* Hgb-9.7* Hct-29.8*
MCV-92 MCH-29.9 MCHC-32.6 RDW-16.8* RDWSD-55.8* Plt ___
___ 06:04AM BLOOD Glucose-194* UreaN-57* Creat-1.5* Na-138
K-4.6 Cl-102 HCO3-25 AnGap-11
___ 06:04AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.7
MICROBIOLOGY:
=============
___ 5:39 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
Blood cultures all negative throughout admission
IMAGING/REPORTS:
================
___ CT T/L Spine
IMPRESSION:
1. Compression fracture of the L1 vertebral body without
retropulsion. There
is mild prevertebral edema and a trace component of hematoma.
2. There is extension of the fracture into an anterior
osteophyte off of the
inferior endplate of T12. No additional fracture plane is
demonstrated
through the T12 vertebral body.
3. No high level spinal canal narrowing within the limits of
modality.
Multilevel moderate canal narrowing in the lumbar spine below
the level of the
fracture.
4. Focal abdominal ectasia of the heavily calcified abdominal
aorta just above
the bifurcation measuring up to 2.9 cm.
___ R foot X-Ray:
IMPRESSION:
1. Cortical irregularities along the mediolateral aspect of the
base of the
distal phalanx of the first toe. Findings could represent a
fracture, however
if this is the area of the patient's infection, osteomyelitis is
a concern.
No subcutaneous emphysema.
2. Slight lucency of the base of the first digit MTP near the
TMT joint
without cortical irregularity is likely artifactual, however
recommend
correlation with patient's symptoms.
3. No subcutaneous emphysema.
___ Lumbo-Sacral Spine X-Ray
IMPRESSION:
1. Redemonstration of known mild compression deformity of the L1
vertebral
body. Previously seen fracture involving the inferior aspect of
a T12
anterior osteophyte is not visualized on the current exam.
2. Normal alignment.
3. Moderate to severe lumbar spondylosis.
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
======================
Mr. ___ is a ___ male with myelodysplastic syndrome,
CKD, IDDM who was admitted following a fall with R great
toe/foot cellulitis and T12/L1 compression fractures. Patient
was evaluated by orthopedics in the emergency department who
determined that no acute surgical intervention was needed at
this time. Patient will be okay to follow-up in 6 weeks their
clinic. Patient was also evaluated by department and while
hospitalized for injury to right first toe and foot. Initially
there was concern for cellulitis with possible underlying
osteomyelitis in the right foot based on foot x-ray findings and
elevated CRP on lab tests. Ultimately given patient's rapid
clinical improvement and lack of systemic symptoms osteomyelitis
felt to be much less likely and patient was treated as simple
cellulitis. Physical therapy worked with patient while in
hospital. Recommended rehab prior to returning ___. Patient
also became acutely confused on ___. Endorsed visual
hallucinations of ants crawling all over his ceiling, did not
recall earlier conversations with healthcare providers.
Patient's mental status improved with treatment of his pain from
injuries, restarting of his ___ Seroquel. Ultimately altered
mental status was felt to be a combination of delirium, pain,
withholding Seroquel.
TRANSITIONAL ISSUES:
====================
Plan for 7-day course of antibiotics for cellulitis of right
foot. Patient discharged on Keflex to end ___.
Patient will need follow-up at ___ in 5 weeks from
discharge for continued evaluation of vertebral fractures
Patient to wear TLSO brace at all times while out of bed.
ACUTE/ACTIVE ISSUES:
====================
#Right ___ toe cellulitis
Patient presented with R toe erythema which extended up to
mid-shin consistent with felt to be. Nidus for SSTI felt to be
most likely recent trauma from fall. There was no evidence of
purulence/abscess. Strep sp is most
likely given streaking erythema of shin. Right foot x-ray showed
cortical irregularities of mediolateral distal phalanx of first
toe concerning for possible fracture vs osteomyelitis. However
per Podiatry, concern for osteomyelitis is low based on x-ray.
Appearance of patient's foot overall improved on antiviral
therapy prior to leaving the hospital. He had no systemic signs
of infection. While hospitalized patient received 1 day of
Keflex on ___ and was transitioned to vancomycin and
ceftriaxone ___ to ___. He received vancomycin and
ceftazidime ___ out of concern that worsening
encephalopathy was septic in nature, see below. Ultimately
discharged on Keflex to complete 7-day course of antibiotics
ending ___ when concern for osteomyelitis/systemic
infection was alleviated.
#Delirium
___ patient became suddenly altered, could
not recall earlier conversations with healthcare providers and
endorsed visual hallucinations of ants crawling all over his
ceiling. Patient was examined and was without focal neurologic
deficits other than confusion. Initially suspected TME due to
brewing sepsis and antibiotics were broadened. Blood and urine
cultures were obtained at this time, UA was suspicious for
infection with pyuria, large leuk esterase, few bacteria.
However, urine culture ultimately only grew yeast. Patient
remained afebrile and hemodynamically stable throughout. From
initial mental status change to urine culture returning negative
for infection. Antibiotics de-escalated this time to simple
cellulitis coverage with Keflex. Ultimately, patient's delirium
felt to be a combination of sleep in the hospital, pain,
withholding of ___ Seroquel. Seroquel was restarted and pain
medications were uptitrated with improvement in mental status
prior to discharge.
#T12 and L1 compression fractures
CT C/T/L spine shows mild T12 and L1 compression fractures
without retropulsion no significant collapse, no significant
canal stenosis. Patient was neurologically intact with no red
flag symptoms. Ortho-Spine evaluated patient in ED and
recommended outpatient follow up. Patient was given TLSO brace
to wear while out of bed. He worked with patient while admitted,
recommended rehab. Pain control provided with acetaminophen,
low-dose oxycodone when mental status improved as above. He will
need to follow-up in spine clinic 5 weeks of discharge.
CHRONIC/STABLE ISSUES:
======================
# HTN
continued ___ amlodipine and atenolol
# HLD
continued ___ atorvastatin
# Gout
continued ___ allopurinol
# Myelodysplastic syndrome
# Thrombocytopenia
# Normocytic anemia
Follows with Heme/Onc at ___ and a Partners affiliate in
___, last chemotherapy was 1 month ago per patient
report, with no current plan for further chemo.
Anemia/thrombocytopenia chronic iso MDS. ___ iron
supplementation continued
# IDDM
Continued ___ glargine with additional insulin sliding scale
instead of ___ glipizide while hospitalized.
# Memory issues
continued ___ donepezil
# GERD
continued ___ omeprazole
# Depression
continue ___ sertraline, quetiapine
# Dietary supplements
continue ___ cyanocobalamin and MVI, iron
>30 min spent on discharge planning including face to face time
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atenolol 50 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Cyanocobalamin 1000 mcg PO DAILY
7. Diazepam 5 mg PO Q8H:PRN neck pain
8. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN diarrhea
9. Donepezil 10 mg PO QHS
10. Ferrous Sulfate 325 mg PO DAILY
11. GlipiZIDE 5 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
14. Sertraline 100 mg PO DAILY
15. TraMADol 50 mg PO QHS
16. QUEtiapine Fumarate 25 mg PO QHS
17. Multivitamins 1 TAB PO DAILY
18. Glargine 20 Units Bedtime
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Cephalexin 500 mg PO QID
3. Miconazole Powder 2% 1 Appl TP QID
4. Glargine 20 Units Bedtime
5. Allopurinol ___ mg PO DAILY
6. amLODIPine 5 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atenolol 50 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Cyanocobalamin 1000 mcg PO DAILY
11. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN diarrhea
12. Donepezil 10 mg PO QHS
13. Ferrous Sulfate 325 mg PO DAILY
14. GlipiZIDE 5 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Omeprazole 20 mg PO DAILY
17. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
18. QUEtiapine Fumarate 25 mg PO QHS
19. Sertraline 100 mg PO DAILY
20. HELD- Diazepam 5 mg PO Q8H:PRN neck pain This medication
was held. Do not restart Diazepam until you are told to do so by
your physician
21. HELD- TraMADol 50 mg PO QHS This medication was held. Do
not restart TraMADol until you are told to do so by your
physician
___:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
-------
Vertebral Fractures
right foot cellulitis
delirium
Secondary
---------
HTN
HLD
Gout
MDS
___ Anemia
IDDM
Memory Impairment
GERD
Depression
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 privilege taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
===================================
-You are admitted to the hospital because he fell and fractured
some of the vertebrae in your spine and needed a surgical
evaluation.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
==========================================
-There is no indication for surgery you would be safe to wear a
brace while standing and follow-up with them in their clinic.
Physical therapy evaluated you while you are in the hospital
and recommended that you go to rehab before returning ___.
There was concern that you had an infection in the soft tissues
of your foot. This was treated with antibiotics by mouth and by
IV. There is also concern that you had an infection in the
bones of your foot, however, this ultimately was not the case.
You were confused while you were here. This was likely due to
a combination of a condition called delirium, pain, not
receiving one of your ___ medications called Seroquel. Your
confusion improved with better control of your pain and
restarting Seroquel.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
============================================
- Please continue to take all your medications and follow up
with your doctors at your ___ appointments.
We wish you all the best!
Followup Instructions:
___
|
19785715-DS-17
| 19,785,715 | 21,745,141 |
DS
| 17 |
2190-12-13 00:00:00
|
2190-12-13 11:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M w/ PMH of DM, CAD s/p CABG, CVA, HTN, HL, invasive
bladder CA s/p cystectomy, CKD presents with weakness and
confusion in the setting of a ___ 34. Patient awoke this morning
and felt too weak to get out of bed. He may have also had some
transient slurred speech. He pressed his "lifeline button" to
___ and ___ at arrival was 34. He was given 1 amp D50 IV
in the field and brought to the ED. Patient reports no change in
eating habits in the last couple of days and states that he's
taken all medications as prescribed, though missed all
medications this morning. He is on metformin 850 BID, glyburide
10 BID, Januvia 100 daily. States he's felt a little warm with
sweats recently. Denies chest pain/shortness of breath, recent
sickness, headache. Unsure of why glucose was so low.
.
In ED VS were 97.7 80 167/67 18 98% 2L Nasal Cannula. ___ on
arrival to ED 94. Given juice and breakfast, ___ 76. Given cereal
and boxed lunch, ___ 60. Octreotide 150mg SC, 500cc bag of D5 and
___ boxed lunch given. Labs were remarkable for Cr 1.5, K 5.3,
hct 35.4, UA with large leuks, 13 WBCs, few bacteria. Urine
culture sent. Given ceftriaxone in ED for UTI. Patient notes
that he ran out of ileostomy bags ___ days ago, and nurses have
not been able to get replacements. Denies past UTIs.
.
Vitals on transfer were 98.9 rr 18 HR 76 BP 167/69 100% RA. On
arrival to the floor, vitals were 97.4, 194/84, 71, 16, 99%RA ___
370. He feels he is back to his baseline, without weakness,
confusion, SOB, CP.
.
Review of systems:
(+) Per HPI
(-) Denies rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. Denied arthralgias or
myalgias.
Past Medical History:
DM - A1c 7% ___
Asthma, COPD, smoker - PNA in ___
CKD - Cr 1.4
CAD s/p CABG ___, multiple stents to LAD, cath ___, subclavian
bare metal stent, EF 56% by MIBI
Hyperlipid
HTN
H/o small stroke ___ ago: right parietal lobe w/ left arm
affected
Obesity
GERD
Anxiety
Chronic back pain
Partial blindness
Invasive bladder Cancer
Social History:
___
Family History:
Mom with heart attack @ ___, Dad HTN and heart attack at ___.
Physical Exam:
Admission Exam:
VS: 97.4, 194/84, 71, 16, 99%RA ___ 370
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. Bilateral
carotid bruits.
Cards: RRR S1/S2 heard. ___ systolic murmur of LUSB. no
gallops/rubs.
Pulm: wheezes diffusely, no rhonchi or rales. no accessory
muscles used, breathing comfortably
Abd: soft, NT, +BS. no g/rt. neg HSM. ileostomy bag draining
dilute urine, ostomy mucosa pink, healthy.
Extremities: wwp, no edema. PTs 1+.
Skin: sternotomy scar over chest, vertical scar over lower
abdomen
Neuro/Psych: CNs II-XII grossly intact. ___ strength throughout.
sensation intact to LT, temperature, however decreased in feet
b/l.
Discharge Exam:
VS: 98.1/97.0, 150/80 (142-164/64-80), 67 (64-70), 18, 99%RA ___
115, 251, 189, 243, 159, 84
GA: AOx3, NAD, pleasant, interactive
HEENT: MMM. no JVD. Bilateral carotid bruits.
Cards: RRR, S1/S2 nml. ___ systolic murmur of LUSB. no
gallops/rubs.
Pulm: mild wheezes L>R, no rhonchi or rales. no accessory
muscles used, breathing comfortably
Abd: soft, NT, +BS. no g/rt. neg HSM. ileostomy bag draining
clear yellow urine, ostomy mucosa pink, healthy.
Extremities: wwp, no edema. PTs 1+.
Skin: healed sternotomy scar over chest, vertical scar over
lower abdomen
Neuro/Psych: alert and oriented X3
Pertinent Results:
Admission Labs:
___ 10:15AM BLOOD WBC-7.5 RBC-3.81* Hgb-10.9* Hct-35.4*
MCV-93 MCH-28.5# MCHC-30.7* RDW-16.1* Plt ___
___ 10:15AM BLOOD Neuts-80.2* Lymphs-12.9* Monos-4.9
Eos-1.3 Baso-0.5
___ 10:15AM BLOOD Glucose-124* UreaN-27* Creat-1.5* Na-137
K-5.3* Cl-108 HCO3-22 AnGap-12
UA: large Leuks, few bacteria, 13 WBC, no nitrates.
Anemia workup:
___ 07:55AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.7 Iron-44*
___ 07:55AM BLOOD calTIBC-287 Ferritn-28* TRF-221
Microbiology: ___ Urine Culture: GNRs >100,000
Discharge Labs:
___ 05:15AM BLOOD WBC-6.3 RBC-3.68* Hgb-10.3* Hct-33.4*
MCV-91 MCH-28.1 MCHC-30.9* RDW-16.6* Plt ___
___ 05:15AM BLOOD Glucose-91 UreaN-32* Creat-1.5* Na-137
K-4.6 Cl-105 HCO3-26 AnGap-11
___ 05:15AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9
Imaging:
___ CXR: PA and lateral views of the chest were obtained
demonstrating sternotomy wires. The lungs are hyperinflated and
clear. No focal consolidation, effusion, or pneumothorax.
Cardiomediastinal silhouette is normal. Bony structures are
intact. There is no free air below the right hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
___ CT head w/o contrast: 1. No acute intracranial
hemorrhage.
2. Severe progressive chronic microvascular ischemic disease
compared with CT dated ___.
Brief Hospital Course:
___ M w/ PMH of DM, CAD s/p CABG, CVA, HTN, HL, invasive
bladder cancer s/p cystectomy, CKD presented with weakness and
confusion in the setting of a ___ 34.
.
Active Issues:
# Hypoglycemia: On arrival to the floor, ___ 370. Patient feels
back to baseline and is without complaints. The first night of
admission, patient had very fickle glucose control, likely ___
being given the octreotide and complex carbs in the ED, with
very high sugars (critical value) and sugars down to 69. Home
metformin, glyburide, and januvia were held and patient was put
on ISS. The following morning, his sugars were more stable in
the 100s-200s, on standard ISS. Patient denied any devation from
his usual routine and home medication regimen, however notes
significant weight loss recently (120lbs since ___- likely
due to aggresive bladder CA). Given weight loss, it is likley
the his medication regimen is too aggressive for him. He notes a
fasting blood sugar of 60 five times in the past month. HgbA1c
was 7.0 last month. Patient was restarted on glyburide at 5mg
BID (on 10mg BID at home) 2 days prior to discharge. ___ ranged
from 100s-200s, with a fsating ___ of 84 on the morning of
discharge. Home metformin (Cr 1.5) and januvia was held
throughout admission and on discharge.
.
# Asymptomatic UTI: UA with large leuks and few bacteria, GNR
(>100,000) on Urine culture (sensitivities pending). Patient
with UTI in the setting of running out of iliostomy bags (s/p
cystectomy for invasive bladder CA). Patient is without symptoms
and denies ever having a UTI before. He received ceftriaxone X1,
and then switched to ciprofloxacin and is doing well. He will
complete a 7 day course of antibiotics.
.
# Anemia: Patient had baseline in the low ___ prior to ___.
Since cystectomy (___), hct has been 33-35. Patient denies
changes in bowel habits. MCV in ___. RDW slightly elevated ___
throughout admission, but normal in previous months with hct of
33. No evidence of active bleeding. B12 in ___ was
low-normal (278). Iron and ferritin low on this admission.
Likely iron deficiency anemia +/- B12 deficiency. Patient was
started on iron supplements. Can consider additionally giving
B12 supplementation as an outpatient.
.
# Hyperkalemia: Patient with hyperkalemia ranging from 5.3-6.0
during the first two days of admission. ECGs unchanged, without
peaked Twaves. Given Kayexalate. K+ has been 4.5, 4.6 in the
last day.
.
Chronic Issues:
# CKD: Cr stable throughout admission at 1.5, baseline around
1.4.
.
# HTN: continued home losartan and metoprolol. Patient's SBPs
ranged in the mid ___ on admission. Can consider advancing
home regimen as an outpatient.
.
# COPD/ASTHMA: Patient has been consistently wheezy on exam,
however feels asymptomatic. Continued home albuterol,
ipratropium, fluticasone. Written for prn nebs.
.
# CAD: continued home ASA, plavix, simvastatin.
.
# Depression: continued home citalopram.
.
# GERD: continued home ranitidine.
.
# Back pain: continued home percocet.
.
Transitional Issues: Patient has close follow up with his PCP
___ ___. He will need further management
of his diabetes medications as his weight fluctuates. He may
additionally need to increase his antihypertensive regimen, as
his SBPs ranged from 140s-160s during admission. Can consider
starting patient on B12 supplementation, in addition to iron
supplementation for his anemia. Neurology recommends f/u with
Dr. ___ in clinic given patient's bilateral carotid bruits (no
imaging since ___. Finally, patient is having some issues
with his ___ service, as they do not appear to be ordering his
iliostomy bags in time and patient is going ___ days at a time
without iliostomy bags and is now coming in with a UTI.
Medications on Admission:
Albuterol 2 puffs Q4h
citalopram 20mg daily
ASA 81'
Plavix 75
Fluticasone
Furosemide 20mg PO Qam as needed
glyburide 10mg BID
ipratropium-albuterol nebs q4 prn SOB
Lactulose 15mg prn constipation
losartan 50 daily
Metformin 850mg BID
Toprol XL 50mg
NTG PRN
oxazepam 10mg prn for anxiety
ranitidine 150mg BID
simvastatin 40mg daily
Januvia 100mg daily
tamsulosin ER 0.4mg daily
Percocet ___ tabs q4 prn for back pain
Discharge Medications:
1. glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours).
3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
6. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily) as needed for constipation.
7. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
every four (4) hours as needed for back pain.
14. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) nebulization Inhalation every four
(4) hours as needed for shortness of breath or wheezing.
15. oxazepam 10 mg Capsule Sig: One (1) Capsule PO once a day as
needed: for anxiety.
16. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual once a day as needed for chest pain: as needed for
chest pain. may repeat every 5 minutes X3 doses for relief.
17. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days: Take until tablets run out.
Disp:*9 Tablet(s)* Refills:*0*
18. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: hypoglycemia
Secondary Diagnosis:
DM - A1c 7% ___
Asthma, COPD, smoker - PNA in ___
CKD - Cr 1.4
CAD s/p CABG ___, multiple stents to LAD, cath ___, subclavian
bare metal stent, EF 56% by MIBI
Hyperlipid
HTN
H/O small stroke ___ y ago - right parietal lobe with left arm
affected
Obesity
GERD
Anxiety
Chronic back pain
Partial blindness
Invasive bladder Ca
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for low blood sugars and
weakness. You were given juice, food and a medication called
octreotide to increase your blood sugar. Imaging of your head
and chest did not show any acute problems. Your low blood
sugars are likely because you have lost a lot of weight in the
last several months and are no longer requiring all the oral
diabete medications that you are on. In the hospital we
stabilized your blood sugars and blood pressure. You are safe
for discharge home. We are discharging you on fewer oral
diabetic medications and you should follow up with your primary
care doctor for further managment of this. Additionally, you
were found to have a urinary tract infection and you are being
treated with ciprofloxacin for a total of 7 days.
Please make the following changes to you medications:
START Ciprofloxacin 500mg by mouth twice daily for 5 days (last
dose on ___
TAKE Glyburide 5mg by mouth twice daily (half the dose you were
taking prior to admission)
STOP Metformin
STOP Januvia
START taking iron (ferrous sulfate) supplements 300mg by mouth
twice daily
* Should you become constipated from the iron supplements,
please take your previously prescribed lactulose as needed.
Continue all other home medications as previously prescribed.
Followup Instructions:
___
|
19785715-DS-18
| 19,785,715 | 22,312,433 |
DS
| 18 |
2191-01-19 00:00:00
|
2191-01-19 15:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Confusion, Poor PO intake, ___, Hyperkalemia, UTI
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ gentleman with a pmhx. significant
for IDDM, bladder cancer s/p cystectomy with ileal conduit
creation in ___, COPD, HTN, and hyperlipidemia who presents to
the ED after his daughter found him confused and hallucinating
at home.
.
According to patient, he has felt "not-himself" for the past 3
weeks. During this time, he complains of erratic blood sugars,
increased pain in his back, and worsening infection of his feet.
He has also started falling during this time: the most recent
episode was the day before admission while he was taking
communion. Patient states that when he falls, he doesn't feel
lightheaded or dizzy, but his legs just "give out." He denies
any head trauma with these episodes. According to the patient's
daughter, she is worried that Mr. ___ isn't taking care of
himself anymore at home. Daughter found patient at home acting
strangely, and called ___ to complain of erratic behavior;
daughter was told to bring patient into the ED. Of note,
patient has had multiple admissions for hypoglycemia. However,
his sugars have been running high over the past few days (in the
400s), and he was told by his PCP to increase insulin dosage
from 12 to 15 units/day. He uses a pre-filled pen for
injections.
.
In the ED, initial VS were: 97.4 104 115/53 20 96%. UA was
positive and he was given Cipro 400mg IV x1. Vanc also given for
? cellulitis in lower extremity. His blood sugar was 511 with
anion gap 14, so DKA diagnosed and insulin gtt started. His K+
was 6.6, with peaked T waves on EKG; he was given calcium
gluconate and kayexalate in addition to the insulin gtt. He was
also given 1 liter of normal saline. Upon admission to the
MICU, vitals were: afebrile, BP: 140/74, HR: 69, SP02 100% on
RA. C-collar was removed as no evidence of fracture on CT.
Insulin drip was continued and labs were rechecked.
Past Medical History:
DM - A1c 7% ___
Asthma, COPD, smoker - PNA in ___
CKD - Cr 1.4
CAD s/p CABG ___, multiple stents to LAD, cath ___, subclavian
bare metal stent, EF 56% by MIBI
Hyperlipid
HTN
H/o small stroke ___ ago: right parietal lobe w/ left arm
affected
Obesity
GERD
Anxiety
Chronic back pain
Partial blindness
Invasive bladder Cancer
Social History:
___
Family History:
Mom with heart attack @ ___, Dad HTN and heart attack at ___.
Physical Exam:
Admission exam
Vitals: T: 97 BP: 138/45 P: 69 R: 16 SPO2: 100% on RA
GENERAL: Alert , oriented, no acute distress (but thought that
this ___ was ___s ___)
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Wheezes on exhale, no dullness or consolidation
Abdomen: soft, non-tender, non-distended, bowel sounds present,
ileal conduit in place, ?puss in bag
GU: no foley
EXT: Erythema bilaterally, no ulcerations
Discharge exam
Pertinent Results:
Admission labs
___ 01:40PM BLOOD WBC-9.1 RBC-3.92* Hgb-10.9* Hct-33.8*
MCV-86 MCH-27.7 MCHC-32.1 RDW-16.3* Plt ___
___ 01:40PM BLOOD Neuts-86.1* Lymphs-7.7* Monos-5.0 Eos-1.0
Baso-0.3
___ 01:40PM BLOOD ___ PTT-24.9* ___
___ 01:40PM BLOOD Glucose-511* UreaN-89* Creat-2.5* Na-125*
K-6.6* Cl-98 HCO3-13* AnGap-21*
___ 01:40PM BLOOD ALT-14 AST-9 LD(LDH)-147 AlkPhos-157*
TotBili-0.2
___ 06:00PM BLOOD CK-MB-3 cTropnT-0.02*
___ 01:40PM BLOOD Albumin-3.6 Calcium-9.4 Phos-3.7 Mg-1.8
___ 06:00PM BLOOD VitB12-385 Folate-10.9
___ 06:00PM BLOOD TSH-0.92
___ 01:40PM BLOOD ASA-NEG Acetmnp-NEG
___ 02:01PM BLOOD Glucose-494* Lactate-2.2* Na-127* K-6.0*
Cl-101 calHCO3-16*
.
Discharge labs
___ 06:20AM BLOOD WBC-6.2 RBC-3.57* Hgb-10.0* Hct-30.4*
MCV-85 MCH-28.0 MCHC-32.8 RDW-16.7* Plt ___
___ 06:20AM BLOOD Glucose-128* UreaN-42* Creat-1.6* Na-133
K-5.0 Cl-105 HCO3-18* AnGap-15
___ 06:20AM BLOOD Calcium-9.2 Phos-2.8 Mg-1.8
.
URINE STUDIES
___ 03:00PM URINE Color-Straw Appear-Hazy Sp ___
___ 03:00PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 03:00PM URINE RBC-11* WBC-127* Bacteri-FEW Yeast-FEW
Epi-<1
___ 03:49PM URINE Hours-RANDOM UreaN-459 Creat-82 Na-34
K-29 Cl-10
___ 03:49PM URINE Osmolal-356
.
MICROBIOLOGY
___ Blood cultures pending x 2- No growth to date
.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
.
EKG
The underlying rhythm is likely sinus with intra-atrial
conduction abnormality. Low QRS voltage in the limb leads.
Compared to the previous tracing of ___ R wave progression
has improved in the precordial leads and the rate is faster
.
HEAD CT WITHOUT INTRAVENOUS CONTRAST: No intra- or extra-axial
hemorrhage, mass effect, or shift of midline structures is
demonstrated. Confluent periventricular and subcortical white
matter hypodensities are again demonstrated in the cerebral
hemispheres bilaterally most likely compatible with chronic
microvascular infarction. Punctate hypodensities within the
basal ganglia bilaterally likely reflect chronic lacunar
infarcts as well as within the right caudate head. Widening of
the ventricles and sulci bilaterally is compatible with
age-appropriate involutional change. Opacification of the right
mastoid air cells suggests an ongoing inflammatory process.
Minimal opacification of an inferior mastoid air cell on the
left is also noted. The paranasal sinuses are clear. Surrounding
osseous and soft tissue structures are otherwise unremarkable.
IMPRESSION: No acute intracranial hemorrhage or mass effect.
.
CT OF THE CERVICAL SPINE WITHOUT INTRAVENOUS CONTRAST: No
fracture, change in alignment, or prevertebral soft tissue
swelling is demonstrated. There are multilevel degenerative
changes identified, worst at C6/7 where posterior osteophyte
results in moderate canal narrowing. There is bilateral moderate
to severe neural foraminal narrowing present at this level as
well. Mild grade 1 retrolisthesis of C5 on C6 is unchanged.
Ossification of the nuchal ligament is noted posterior to C6.
Carotid vascular calcifications are most pronounced at the
bifurcations bilaterally. Surrounding soft tissue structures
otherwise are unremarkable. A vascular stent is noted within the
proximal right subclavian artery, and is partially imaged.
Severe emphysematous changes are noted within the lung apices.
Ossification of the right mastoid air cell suggests ongoing
inflammation.
.
IMPRESSION: No acute fracture or subluxation. Moderate cervical
spondylosis, worst at C6/7 with moderate central canal narrowing
and moderate to severe bilateral neural foraminal narrowing.
Emphysema within the lung apices.
.
PA AND LATERAL VIEWS OF THE CHEST: Patient is status post median
sternotomy and CABG. Vascular stent is noted within the right
subclavian artery. Heart size is normal. Coronary arterial
vascular stent is also demonstrated. The mediastinal and hilar
contours are unchanged. The pulmonary vascularity is normal.
There is hyperinflation of the lungs with attenuation of the
pulmonary vascular markings towards the apices, compatible with
emphysema. Minimal interstitial opacities are seen predominantly
within the lung bases, likely reflecting chronic changes. No
focal consolidation, pleural effusion or pneumothorax is
present. There are mild degenerative changes of the thoracic
spine. Degenerative spurring is also noted within the right
acromioclavicular joint.
IMPRESSION: Emphysema with chronic interstitial changes, but no
evidence for pneumonia or congestive heart failure.
Brief Hospital Course:
Mr ___ is a ___ gentleman with a past medical history
of of IDDM, CAD s/p CABG, CVA, HTN, HL, invasive bladder CA s/p
cystectomy, and CKD, who presents with anion gap, falls,
confusion, poor PO intake, ___, Hyperkalemia, and UTI.
.
# ANION GAP: Patient with anion gap of 15 in the setting of
elevated blood sugar and lactate of 2.2. No ketones in urine to
suggest overt DKA. Likely combination of dehydration and renal
failure. He has had substantial N/V for abotu 1 week. He was
briefly in the MICU after admission. Gap closed quickly with
fluid and insulin (only 2units/hour on drip). Lactate trended
down to normal quickly with IVF. He was called out to the floor
where he continued to do well and was ultimately discharged to a
___ on ___.
.
# HYPERGLYCEMIA: Potentially HONK, with precipitant being
possible infection (cellulitis), dehydration and renal failure
(patient unable to excrete glucose). Patient is an elderly type
II diabetic, presenting with dehydration and change in mental
status. He improved with minimal insulin (per above), and mostly
with IVF. He was initially restarted on his home dose of
insulin. ___ was consulted and recommended decreasing lantus
to 8 units at night and intiating a humalog sliding scale with
meals and at bed time. Blood glucose control improved and FSG
were in the 100-200s at the time of discharge. The patient will
follow-up with ___ as an outpatient.
Underlying infection was treated per below.
.
# CONFUSION: Likely a combination of infection, dehydration,
and hyperglycemia superimposed on ?more chronic memory decline.
Head CT unrevealing, but only prelim report. Underlying issues
were treated per respective paragraphs. TSH, B12, and folate
were checked and were normal. Mental status improved with
correction of acidosis and hydration. The patient may benefit
from neurocognitive testing as an outpatient to evaluate for
underlying dementia.
.
# HYPERKALEMIA: Likely secondary to ___ and acidosis. EKG with
peaked T's on admission, given calcium gluconate, kayexalate,
and insulin drip. K+ lowered to 5.0 in MICU. Losartan was held.
On the floor potassium remained stable at around 5.0. Losartan
was restarted at the time of discharge.
.
# UTI: On admission, urine with blood, leuks, and WBC clumps.
Evidence of pus in urine bag. Last urine culture with
klebsiella sensitive to ciprofloxacin. It was unclear if this
was represntative of a true UTI as the patient has an iliostomy
especially as urine culture showed mixed bacterial flora. He was
started bactrim ___s below.
.
# CELLULITIS: Patient with bilateral erythema of his feet. No
evidence of blisters or pustules that would suggest a MRSA
infection. Patient was given a dose of vancomycin in the ED. He
was initally strated on bactrim/keflex and then narrowed to
bactrim alone for a planned 7 day course (3 more days). Erythema
and pain were noted to improve. The patient was afebrile with a
noraml white blood cell count throughout this admission.
.
# ACUTE ON CHRONIC RENAL FAILURE: Likely pre-renal in setting
of severe volume depletion secondary to DKA. Urine lytes show
FeNA of 0.8%. He was given IVF and with improvement in his
creatinine
.
# FREQUENT FALLS: Likely reflective of mechanical instability
exacerbated in the setting of dehydration. History was not
consistent with a syncopal event, there was no nausea,
lightheadedness to suggest vaso-vagal episode. Troponin were
negative. There were no signs of arrythmia on tele. The
development of falls coincides with patient's overall decline
since ___. The patient was evaluated by ___ who recommended
acute rehab as above.
.
# Non gap acidosis: Patient contined to have persistently low
bicarb despite correction of hyperglycemia and gap acidosis.
This was felt to be possibly resultant from iliostomy, although
worsening of renal function may also be contributing.
Bicarbonate was noted to increase over the course of the
admission
.
# HTN: The patients home losartan was held in setting of
hyperkalemia. He was continued on his home metoprolol succinate
50mg daily at home.
.
# COPD/ASTHMA: Continued home Advair, albuterol, ipratropium
.
# CAD: Continued home ASA, plavix, simvastatin.
.
# DEPRESSION: Continued home citalopram.
.
# GERD: Continued ranitadine, renally dosed.
.
# BACK PAIN: Continued tylenol, oxycodone
===============================
Transitional issues
- Blood culures were pending at the time of discharge
- Patient was full code throughout this admission
- Patient will follow-up with ___ regarding management of his
insulin regimen
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
(Two) puffs(s) inhaled every four (4) hours
CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth once a day for
depressed
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider: Dr.
___ - 75 mg Tablet - 1 Tablet(s) by mouth once a day
currently not taking -- last dose of plavix ___.
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 (One) puff inhaled twice a day
FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth qam as needed
for for edema
INSULIN GLARGINE [LANTUS SOLOSTAR] - 100 unit/mL (3 mL) Insulin
Pen - 12 units once a day
IPRATROPIUM-ALBUTEROL - 0.5 mg-2.5 mg/3 mL Solution for
Nebulization - 3 cc q4 as needed for shortness of breatth use
with nebulizer
LACTULOSE [CONSTULOSE] - 10 gram/15 mL Solution - 15 ml by mouth
once a day as needed for for constipation
LOSARTAN - 50 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1
(One) Tablet(s) by mouth once a day
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 sublingually as
needed for chest pain
OXAZEPAM - 10 mg Capsule - 1 Capsule(s) by mouth once a day as
needed for anxiety
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 or 2 Tablet(s)
by mouth q4 as needed for back pain do not exceed 8 tablets in
one day
RANITIDINE HCL - 150 mg Capsule - 1 (One) Capsule(s) by mouth
twice a day
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by
mouth Daily
UREA - 40 % Cream - apply twice a day
Medications - OTC
ASPIRIN - (OTC; Dose adjustment - no new Rx) - 81 mg Tablet,
Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - use
as
directed to test blood sugar
BLOOD-GLUCOSE METER [FREESTYLE LITE METER] - Kit - use as
directed to check blood sugar up to three times a day.
FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by
mouth once a day
INSULIN NEEDLES (DISPOSABLE) [PEN NEEDLE] - 29 gauge X ___
Needle - use as directed qd
LANCETS [LANCETS,THIN] - Misc - use as directed three times a
day
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
5. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
9. urea 40 % Cream Sig: One (1) application Topical twice a day.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
12. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) nebulizer Inhalation every six (6)
hours as needed for shortness of breath or wheezing.
13. lactulose 10 gram/15 mL (15 mL) Solution Sig: Fifteen (15)
mL PO once a day as needed for constipation.
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
16. insulin glargine 100 unit/mL Solution Sig: Eight (8) units
Subcutaneous at bedtime.
17. Humalog 100 unit/mL Solution Sig: see below Subcutaneous
four times a day: see sliding scale .
18. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
every four (4) hours as needed for back pain: hold for RR < 12.
19. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
20. oxazepam 10 mg Capsule Sig: One (1) Capsule PO once a day as
needed for anxiety.
21. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tab
Sublingual As Needed as needed for chest pain.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Hyperglycemia
Dehydration
Cellulitis
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___
___ was a pleasure participating in your care while you were
admitted to ___. As you know
you were admitted due to confusion. This was most likely caused
by several factors including high blood sugar, dehydration, and
pain medications. You were given fluids and insulin and your
mental status improved. The diabetes doctors started ___ on
insulin with your meals which you will need to continue. You
will need to follow up at ___. You were seen
by our physical therapist who felt you would benefit from
___ rehab. You were therefore discharged to a rehab
facility
We made the following changes to your medications
1. START humalog insulin according to sliding scale
2. DECREASE lantus to 8 units at night
3. HOLD losartan until instructed to restart this medication by
Dr. ___
4. START Bactrim for 3 more days
You should continue to take all other mediations as instructed.
Please feel
Followup Instructions:
___
|
19785715-DS-19
| 19,785,715 | 28,052,102 |
DS
| 19 |
2192-05-04 00:00:00
|
2192-05-15 07:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___
Chief Complaint:
substernal chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
This is a ___ yo Male with a history of CAD and bladder cancer
s/p urostomy presents with substernal chest pain starting this
morning. The pateint states he had a cough for the last 2 days
which he thought was similar to his COPD, he took albuterol neb
and then had crushing substernal chest pain which felt like
something heavy was sitting on his chest. This pain was ___.
This pain was similar to his previous heart attack pain. He took
nitroglycerin and the pain improved, he called EMS, who gave him
another 3 nitroglycerin and a full dose of aspirin. With
resolution of chest pain.
In the ED, initial vitals were 111 156/82 23 98%. He reported
that his pain had resolved. He denied any chest pain or
shortness of breath and states he feels no discomfort. He denies
any abdominal pain, nausea, vomiting, changes in his bowel or
bladder habits. Initial labs, revealed a negative trop. A chem 7
reveal a BUN/Cr of 52/2.2, other electrolytes (initially
hemolyzed) were normal. proBNP was 2183. CBC revealed macrocytic
anemia of Hct of 37.4, normal WBC and plt count. Coag wnl. CXR
was obtained an final read was pending. He was started on
heparin gtt and admitted for r/o ACS.
On review of systems, he reports a prior TIA, but denies deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, 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:
DM - A1c 7% ___
Asthma, COPD, smoker - PNA in ___
CKD - Cr 1.4
CAD s/p CABG ___, multiple stents to LAD, cath ___, subclavian
bare metal stent, EF 56% by MIBI
Hyperlipid
HTN
H/o small stroke ___ ago: right parietal lobe w/ left arm
affected
Obesity
GERD
Anxiety
Chronic back pain
Partial blindness
Invasive bladder Cancer
Social History:
___
Family History:
Mom with heart attack @ ___, Dad HTN and heart attack at 36.
Physical Exam:
Admission Exam:
VS: T=97.9 BP=168/78 HR=73 RR=20 O2 sat= 98%
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. No xanthelasma.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. systolic murmur heard along sternum. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits. urostomy in place,
C/D/I
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge Exam:
vitals: 66 110/63 18 97% RA
unchanged.
Pertinent Results:
Admission Labs:
___ 11:40AM BLOOD WBC-8.4 RBC-3.76* Hgb-12.9*# Hct-37.4*
MCV-100*# MCH-34.2*# MCHC-34.4# RDW-14.9 Plt ___
___ 11:40AM BLOOD ___ PTT-30.7 ___
___ 11:40AM BLOOD Glucose-184* UreaN-52* Creat-2.2* Na-136
K-6.1* Cl-108 HCO3-16* AnGap-18
___ 11:40AM BLOOD cTropnT-0.01
___ 07:05PM BLOOD CK-MB-11* MB Indx-8.3 cTropnT-0.24*
___ 07:10AM BLOOD CK-MB-10 MB Indx-4.3 cTropnT-0.22*
___ 11:40AM BLOOD proBNP-2183*
Discharge labs:
___ 06:55AM BLOOD WBC-7.7 RBC-4.07* Hgb-13.6* Hct-41.3
MCV-102* MCH-33.4* MCHC-32.9 RDW-14.9 Plt ___
___ 06:55AM BLOOD Glucose-80 UreaN-38* Creat-2.0* Na-138
K-4.8 Cl-106 HCO3-20* AnGap-17
Cath Report:
Coronary angiography: LEFT dominant
LMCA: The LMCA was short but patent.
LAD: The LAD tended to be selectively engaged with the JL4 and
AL2 catheters with significant pressure dampening. Views with
the
AL2 in the LMCA showed a 40-50% near-ostial stenosis. There was
a
50% stenosis in the proximal LAD prior to the first diagonal
branch that appeared similar to the appearance in the prior
angiogram from ___. The proximal LAD was calcified. D1 was of
moderate caliber with a proximal 50% stenosis. A larger D2 had a
moderate origin stenosis, a proximal 50% stenosis and diffuse
plaquing throughout; its small medial pole had a significant
origin stenosis (also seen on the prior angiogram). The major
distal D3 ran parallel to the distal/apical LAD. The apical LAD
either wrapped around the apex or supplied a modest caliber
collateral to the LPDA.
LCX: The LCX had a proximal 30% stenosis after a high modest
OM1 followed by a large atrial branch. There was a large
branching OM2 with mild plaquing throughout that arose from a
35%
stenosis in the AV groove CX. The AV groove CX was severely
narrowed just after OM2 and then totally occluded prior to the
several stents seen in the mid-distal AV groove CX (without
contrast filling). The atrial branch provided faint collaterals
to the posterolateral wall.
RCA: The RCA could not be engaged selectively with the JR4.
Non-selective angiography confirmed the proximal tapering and
proximal-mid vessel diffuse occlusion seen on the prior
angiogram
with delayed filling of a small caliber long RV branch.
SVG-LPDA: The SVG proper was patent with minimal luminal
irregularities. There was a 40% stenosis in the LPDA distal
(antegrade) from the anastomosis. The LPDA gave off several
laterally oriented sidebranches. There was retrograde perfusion
of several LPL branches. There was also a tortuous apical
collateral to the RV.
Assessment & Recommendations
1. Three vessel native coronary artery disease with moderate
LAD
stenoses unlikely to cause rest angina, but continued small
vessel disease too small for PCI.
2. Patent SVG-LPDA with mild distal native disease.
3. Severe, poorly controlled systemic systolic arterial
hypertension suggestive of malignant hypertension in the setting
of acute NSTEMI.
4. No hemodynamic evidence of significant right subclavian
artery in-stent restenosis.
5. No lesions conducive to PCI.
6. Suggest aggressive secondary preventative measures against
CAD, hypertension, NSTEMI, and LV diastolic dysfunction,
including continued clopidogrel for ___ year for post-MI secondary
prevention, addition of amlodipine or other dihydropyridine
calcium channel blocker, maximal statin therapy, and referral to
outpatient cardiac rehabilitation.
Brief Hospital Course:
This is a ___ yo M with h/o COPD, 2 vessal CAD (RCA, LCx), s/p
BMS to R subclavian artery, and CVA presenting with severe
crushing substernal chest pain.
#. NSTEMI/Demand Ischemia - The patient presented with
substernal chest pain similar to his prior MI. He was given
aspirin, plavix load, and started on heparing gtt. Serial
cardiac enzymes revealed an increase in both CK-MB and troponin,
which peaked at 0.24. On the second day of hospitalization he
under went a cath that demonstrated three vesseal CAD, however
the stenosises were too small to explain the patient's troponin
evalation/symptoms and was grossly unchanged from the prior cath
in ___. Moreover, the patient was hypertensive with SBP's in
180's, which ___ thought to cause demand ischemia, leading to
elevated cardiac enzymes/chest pain. The patient was coninued
on his home aspirin, plavix, and statin. He was encouraged to
follow up with his cardiologist and PCP for further ___.
After discharge, his PCP or cardiologist should consider
disconinuing plavix since it is not need for the cardiac stent.
Moreover, the patient was encouraged to participate in cardiac
rehab.
#. HTN- The patient was started on an increased dose of
meoprolol (100, up from 50mg daily) and started on amlodipine
5mg daily. These interventions improved his blood pressure. He
was discharged with SBP in the 110-140's. He was also continued
on is home dose of tamsulosin.
Chronic Issues:
#. COPD- former smoker. He's advair was continued and he was
given albuterol nebs prn.
#. Type 2 DM We continued home glargin, start HISS
#. HL- Continued home statin.
Transition Issues:
- f/u with PCP, ___, and cardiac rehab
- consider discontinuing plavix
- monito blood pressure and titrate medications prn
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Docusate Sodium 100 mg PO TID:PRN constipation
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Glargine 20 Units Dinner
8. Multivitamins 1 TAB PO DAILY
9. Ranitidine 150 mg PO BID
10. Rosuvastatin Calcium 40 mg PO DAILY
11. sodium chloride *NF* 5 % OD qHS
12. Tamsulosin 0.4 mg PO HS
13. Zinc Sulfate 220 mg PO DAILY
14. Acyclovir 400 mg PO BID
15. ammonium lactate *NF* 12 % Topical BID prn dry skin
16. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation QID prn SOB
17. HYDROcodone-acetaminophen *NF* 7.5-750 mg Oral q8 prn pain
18. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
19. Nitroglycerin SL 0.4 mg SL PRN chest pain
20. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
21. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation QID prn SOB
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___
___. You were admitted for chest pain, which we
found to be related to your heart. You underwent a cardiac
catheterization, which revealed that the blood vessel that
supply oxygen to your heart are unchanged from ___. It is very
important to control your blood pressure to prevent this type of
chest pain in the future. We have started a new medication and
increase an already existing medication to better control your
blood pressure. (see below for details)
Please follow up with Dr. ___ to re-establish care with
him. Please also follow up with ___ clinic (see
below for details). Please also follow up with your
cardiologist (see below, they will call with an appointment),
kidney/bladder doctor.
Medication Changes:
Start taking amlodipine 5mg daily
Increase metoprolol XL to 100mg daily
Followup Instructions:
___
|
19786059-DS-5
| 19,786,059 | 24,017,882 |
DS
| 5 |
2171-03-06 00:00:00
|
2171-03-06 13:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia on pre-op testing
Major Surgical or Invasive Procedure:
___ EGD with BIOPSIES
History of Present Illness:
___ yo female with a history of hip arthritis with plans for
total hip replacement, who was found to have microcytic anemia
on pre-op labs.
She Presented to the ED 1 week ago for anemia, and had been
taking high dose ibuprofen at that time. Vital signs were
stable, she was asymptomatic, and had no evidence of active
bleeding, so she was instructed to stop ibuprofen, increase
omeprazole to BID, start PO iron, and discharged with plans for
outpatient endoscopy. She presented for her outpatient
endoscopy today and was found have persistent anemia, so she was
referred to the ED once again.
She denies abdominal pain, melena, hematochezia, nausea,
vomiting, or bloating. Her last colonoscopy was performed ___
at ___ and revealed diverticulosis and colon polyps. Reports
she had an upper EGD in the past as well, but no history of
ulcers, GI bleed, or transfusions in the past. Denies
dizziness, lightheadedness, chest pain, shortness of breath, or
fatigue. Father was diagnosed with stomach cancer in his ___,
otherwise no history of GI malignancies.
In the ED, rectal exam was notable for hard, guaiac negative
stools. She was given normal saline (1L), morphine for hip
pain, and admitted to medicine.
Past Medical History:
Diabetes mellitus
Hypertension
Hyperlipidemia
Hypothyroidism
Hip arthritis
Social History:
___
Family History:
Father had gastric cancer, no other GI malignancies
Physical Exam:
DISCHARGE PHYSICAL EXAM
GEN: Alert, pleasant, comfortable
HEENT: NCAT, anicteric sclera, mild conjunctival pallor
CV: Normal S1, S2, no murmurs
RESP: Good air entry, no rales or wheezes
ABD: Normal bowel sounds, soft, non-tender, non-distended, no
rebound/guarding;
EXTR: No edema. Intact pulses.
DERM: No rash.
NEURO: Face symmetric, speech fluent, non-focal
PSYCH: Calm, cooperative
Pertinent Results:
ADMISSION LABS
___ 11:00AM BLOOD WBC-8.9 RBC-3.46* Hgb-7.2* Hct-25.3*
MCV-73* MCH-20.8* MCHC-28.5* RDW-21.2* RDWSD-54.5* Plt ___
___ 12:12PM BLOOD WBC-8.9 RBC-3.18* Hgb-6.7* Hct-23.2*
MCV-73* MCH-21.1* MCHC-28.9* RDW-21.1* RDWSD-54.5* Plt ___
___ 11:00AM BLOOD Glucose-98 UreaN-18 Creat-0.9 Na-140
K-4.2 Cl-102 HCO3-25 AnGap-17
___ 12:12PM BLOOD ALT-10 AST-15 LD(LDH)-158 AlkPhos-62
TotBili-0.2
DISCHARGE LABS
___ 06:40AM BLOOD WBC-8.2 RBC-3.44* Hgb-7.6* Hct-26.6*
MCV-77* MCH-22.1* MCHC-28.6* RDW-23.3* RDWSD-58.6* Plt ___
___ 06:40AM BLOOD Glucose-82 UreaN-16 Creat-1.1 Na-139
K-4.1 Cl-103 HCO3-28 AnGap-12
___ 06:40AM BLOOD Calcium-9.7 Phos-4.8* Mg-1.9
OTHER RELEVANT LABS
___ 12:12PM BLOOD calTIBC-385 Ferritn-158* TRF-296
___ 12:12PM BLOOD TSH-29*
IMAGING / STUDIES
___ EGD:
Impression: Food in the stomach
Non-bleeding clean based ulceration of the pylorus was noted,
particularly on the side of the duodenal bulb. .
2cm area of clean-based friable ulceration was noted in the
distal duodenal bulb, entering the sweep.
Multiple clean-based nonbleeding ulcers were noted in D2 varying
in size from 4-6mm. (biopsy)
Distorted anatomy of D1 and D2 that merits further evaluation
with cross-sectional imaging of the abdomen.
Otherwise normal EGD to third part of the duodenum
Recommendations: Multiple clean-based ulcerations in the
pylorus, distal duodenal bulb and D2 are the likely, but not
definitive cause of patient's anemia. Distorted anatomy of D1
and D2 merits further evaluation with cross-sectional imaging of
the abdomen.
Avoid NSAIDS.
Continue high dose oral PPI BID for 8 weeks, daily thereafter.
Follow-up duodenal biopsy.
Please send H. Pylori stool antigen and treat if positive.
___ CT ABD/PELVIS
1. Duodenal diverticulum measuring up to 4.5 cm. There is
circumferential
wall thickening of the first/ second portion of the duodenum
which may be
related to ulcer history.
2. Cholelithiasis.
3. Diverticulosis.
HISTORICAL EXAM:
___ COLONOSCOPY:
3 mm sessile polyp. Polypectomy performed with cold biopsy
forceps. Polyp retrieved.
3 mm sessile polyp. Polypectomy performed with cold snare. Polyp
could not be retrieved due to stool
4 mm sessile polyp in sigmoid colon. Polypectomy performed with
cold biopsy forceps. Polyp retrieved.
5 mm sessile polyp in rectum. Polypectomy performed with cold
snare. Polyp retrieved.
Diffuse diverticulosis
3 mm sessile polyp in rectum. Polypectomy performed with cold
biopsy forceps. Polyp retrieved.
ENDOSCOPIC DIAGNOSIS
Colon polyp(s).
Diverticulosis
Brief Hospital Course:
# Iron deficiency anemia due to blood loss, subacute:
# Duodenal ulcers
Patient presented with significant microcytic anemia noted on
pre-operative lab testing with stable vital signs, no overt
symptoms of severe anemia, and no clinically apparent bleeding.
Colonoscopy ___ was notable for numerous polyps and
diverticulosis. Hemolysis labs unremarkable.
EGD ___ revealed multiple duodenal ulcers which were
biopsied. This is the probable source of her slow GI losses. A
CT abdomen was obtained at the recommendation of the
endoscopists, to evaluate causes of her distorted duodenal
architecture - she was found to have redundant colon causing
this distortion, without pancreatic or duodenal masses.
She was transfused 1U PRBCs on ___, continued of PO iron
supplementation. She is to continue taking high dose PPI BID
for at least 8 weeks and avoid NSAIDs indefinitely.
- TTG/IgA were sent to evaluate for celiac disease
- H. pylori testing recommended (unable to provide stool sample
during this hospitalization)
# Hip arthritis: Plan for elective hip replacement once anemia
stabilizes
# Diabetes mellitus: Held metformin and maintained on SSI while
inpatient
# Hypertension: Held lisinopril given concern for ongoing
bleeding, restarted upon discharge
# Hyperlipidemia: Cont home statin
# Depression: Cont home wellbutrin
[x]Pt is medically stable for discharge.
[]Time spent coordinating discharge: > 30 minutes.
TRANSITIONAL ISSUES
- Please ensure H. pylori testing and treatment if positive
- TTG/IgA pending
- Repeat endoscopy in 8 weeks; if anemia persists, consider
colonoscopy and/or capsule study
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO TID
2. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Levothyroxine Sodium 100 mcg PO 4X/WEEK (___)
5. Levothyroxine Sodium 125 mcg PO 3X/WEEK (___)
6. Lisinopril 20 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Rosuvastatin Calcium 20 mg PO QPM
9. Omeprazole 20 mg PO BID
10. trospium 20 mg oral BID
Discharge Medications:
1. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. Ferrous Sulfate 325 mg PO TID
4. Levothyroxine Sodium 100 mcg PO 4X/WEEK (___)
5. Levothyroxine Sodium 125 mcg PO 3X/WEEK (___)
6. Rosuvastatin Calcium 20 mg PO QPM
7. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*1
8. Lisinopril 20 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. trospium 20 mg oral BID
Discharge Disposition:
Home
Discharge Diagnosis:
Peptic ulcer disease
GI bleed
Blood loss 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:
You were hospitalized for evaluation of anemia (low blood
counts). You received a blood transfusion. You underwent
endoscopy, which revealed multiple duodenal ulcers. Please
continue to take pantoprazole for at least 8 weeks. Please
avoid NSAID medications (ibuprofen, naproxen) as these
medications can cause ulcers. Please follow-up with your
gastroenterologist and PCP.
Your thyroid tests were abnormal (your TSH was high at 29).
This test should be repeated at your PCP office as you may
require an adjustment to your thyroid supplementation. Please
separate your levothyroxine doses from your iron doses by at
least 4 hours for optimal absorption.
Followup Instructions:
___
|
19786108-DS-14
| 19,786,108 | 24,187,156 |
DS
| 14 |
2187-11-24 00:00:00
|
2187-11-30 16:31:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
fevers and strep viridans bacteremia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ h/o afib not on AC, hypothyroidism, p/w fevers to 102 x3
weeks. She would develop fevers periodically throughout the day.
She reports general malaise, but denied any localizing symptoms
including chest pain, cough, odynophagia, abd pain, dysuria,
neck pain. She reports having had a transient head ache
localized over her front sinus although this is resolved. She
reports having had a dental cleaning ~4 weeks ago. She went to
her PCP who documented ___ fever and thought she had Lyme and was
started on doxycycline empirically. BCx were drawn as were Lyme
titers. Lyme titers were negative, but BCx grew out strep
viridans (although initially mis-reported as G+ rods) in ___
bottles. She was contacted by her PCP who urged her to go to the
ED for admission.
In the ED, initial vitals were: 99.6 94 103/67 18 100% RA. She
was given a dose of vancomycin and gentamicin and promptly
admitted to medicine.
On the floor, the pt's VS were 98.2 105/59 73 16 98% RA. She
has no complaints. She says she felt feverish earlier today but
denies any current fevers. Denies any chest pain, palpitations,
dyspnea, abd pain, n/v, hematuria, arthralgias.
Past Medical History:
hypothyroidism 2'/2 ablation
osteoporosis
Atrial fibrillation from toxic goiter
DCIS s/p excision
Parotid Malignancy s/p removal
HLD
Social History:
___
Family History:
mother - healthy - did have bladder ca deceased multiple myeloma
father - deceased lung cancer
sibs -healthy
no breast, uterine, ovarian, colon cancer
Physical Exam:
ADMISSION
Vitals: 98.2 102/59 73 16 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, no
palatal petchiae
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no ___ lesions, no ___ nodes
Neuro: CNII-XII intact
DISCHARGE
PHYSICAL EXAM:
Vitals: T: 97.5 BP: 90-103/48-64 P: ___ R: 16 O2: 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear. Fundus exam
limited by non-dilated pupils, no hemorrhages seen.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1, split S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: finger and toe nails covered w/ nail ___.
Pertinent Results:
LABS ON ADMISSION
___ 09:13AM BLOOD WBC-8.9 RBC-4.21 Hgb-13.4 Hct-39.3 MCV-93
MCH-31.7 MCHC-34.0 RDW-13.4 Plt ___
___ 09:13AM BLOOD Neuts-76.6* ___ Monos-3.9 Eos-0.6
Baso-0.4
___ 09:13AM BLOOD Glucose-125* UreaN-14 Creat-0.8 Na-139
K-4.4 Cl-100 HCO3-25 AnGap-18
___ 09:13AM BLOOD Glucose-125* UreaN-14 Creat-0.8 Na-139
K-4.4 Cl-100 HCO3-25 AnGap-18
___ 09:44AM BLOOD Lactate-1.2
LABS ON DISCHARGE
___ 07:50AM BLOOD WBC-7.1 RBC-4.05* Hgb-12.7 Hct-38.8
MCV-96 MCH-31.3 MCHC-32.7 RDW-13.5 Plt ___
___ 09:17AM BLOOD Neuts-67.5 ___ Monos-4.4 Eos-1.2
Baso-0.5
___ 07:50AM BLOOD Glucose-176* UreaN-11 Creat-0.8 Na-139
K-4.0 Cl-100 HCO3-26 AnGap-17
___ 09:17AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.3
___ 09:17AM BLOOD CRP-11.3*
STUDIES
Cardiovascular Report ECG Study Date of ___ 6:02:16 ___
Sinus rhythm. Normal ECG. No previous tracing available for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
65 146 86 ___ 41
TRANSTHORACIC ECHO ___
The left atrium is dilated. 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. Tricuspid annular plane systolic excursion is normal
(1.9 cm; nl>1.6cm) consistent with normal right ventricular
systolic function. 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. There
is a small (0.4 cm diameter, clip 33) vegetation on the aortic
valve. Trace aortic regurgitation is seen. There is mild
posterior leaflet mitral valve prolapse. No mass or vegetation
is seen on the mitral valve. No masses or vegetations are seen
on the tricuspid valve, but cannot be fully excluded due to
suboptimal image quality. The pulmonary artery systolic pressure
could not be determined. There is a very small pericardial
effusion.
IMPRESSION: Small undulating structure at the ventricular side
of the aortic valve consistent with endocardits. Trace aortic
regurgitation.
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a follow-up echocardiogram is suggested in ___ year; if
previously known and stable, a follow-up echocardiogram is
suggested in ___ years.
Compared with the prior study (images reviewed) of ___,
the aortic valve vegetation is new.
Cardiovascular Report ECG Study Date of ___ 8:51:02 AM
Sinus rhythm. Low QRS voltage in the limb leads. Otherwise,
within normal
limits. Compared to the previous tracing of ___ there is no
significant
change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
62 156 96 ___ 50
CXR ___
IMPRESSION:
As compared to the previous radiograph, the patient has received
a right-sided PICC line. The course of the line is unremarkable,
the tip of the line projects over the mid to lower parts of the
SVC. No pneumothorax or other complications. Severe scoliosis
with asymmetry of the ribcage. Borderline size of the cardiac
silhouette. No pleural effusions. No pulmonary edema. No
pneumonia.
Brief Hospital Course:
___ with 3 weeks of objective fevers after dental cleaning now
with strep viridans bacteremia and vegetation on aortic valve
consistent with strep viridans bacterial endocarditis.
ACTIVE ISSUES:
#SBE: S viridans bacteremia confirmed w/ 2 seperate culture. A
TTE was positive for a vegetation on the aortic valve. Pt was
initially treated with ceftriaxone, which was then changed to
penicillin G 3 million units q 4hr per ID and discharged with
PICC and home infusion. Has follow up with OPAT program, plan
for 4 week coruse. An EKG did not show any PR prolongation.
Physical exam revealed no evidence of emboli, limited retinal
exam without hemorrhages.
CHRONIC ISSUES:
# Atrial Fibrillation: CHADSVASc=1, not on systemic
anticoagulation. Continued atenolol 25 mg PO qday and aspirin 81
mg PO qday.
# Hypothyroidism: Continued levothyroxine 75 mcg PO qday.
# HLD: Continue rosuvastatin 5mg PO qday.
# Osteoporosis: Continue alendronate 70mg qweek.
TRANSITIONAL ISSUES:
# Strep viridans endocarditis: Plan for 4 weeks of home PCN
infusion (3 million units q 4hr). Has follow up with ID on ___, and home infusion with weekly labs on ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lorazepam 1 mg PO HS:PRN insomnia
2. Alendronate Sodium 70 mg PO Frequency is Unknown
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Rosuvastatin Calcium 5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Doxycycline Hyclate 100 mg PO Q12H
9. Atenolol 25 mg PO DAILY
Discharge Medications:
1. Penicillin G Potassium 3 Million Units IV Q4H Duration: 24
Days
RX *penicillin G pot in dextrose 3 million unit/50 mL 3 million
units IV every four (4) hours Disp #*144 Intravenous Bag
Refills:*0
2. pump
Please dispense one continuous infusion pump
3. Alendronate Sodium 70 mg PO QSUN
4. Aspirin 81 mg PO DAILY
5. Atenolol 25 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Lorazepam 1 mg PO HS:PRN insomnia
8. Multivitamins 1 TAB PO DAILY
9. Rosuvastatin Calcium 5 mg PO DAILY
10. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subacute Bacterial Endocarditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___:
You were admitted to ___ due to your 3 week history of fevers
and blood cultures positive for strep viridans, possibly due to
your recent dental procedure. An echocardiogram revealed a
vegetation on your aortic valve. You were diagnosed with
endocarditis. You were treated with penicillin and will continue
it for a four week course.
Please follow up with your PCP ___ ___ weeks to update them about
your recent diagnosis and hospitalization. Please follow up
with the ___ clinic (Outpatient Parenteral Antibiotic Clinic)
as scheduled (see below for details). They will be following
your labs drawn by the home ___ team.
Thank you for choosing ___! All the best for the future!
Sincerely,
___ Treatment Team
Followup Instructions:
___
|
19786179-DS-14
| 19,786,179 | 26,698,008 |
DS
| 14 |
2112-08-17 00:00:00
|
2112-08-17 18:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure like events
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old woman w/ no significant PMH who
presents with reported seizures
History per chart review, from patient, patient's sister and
mother
Patient's sister reports that patient's roommate called sister
around 11pm last night to let her know they were at ___.
Roommate stated she witnessed a seizure, with the following
description: Her head kept falling, and she was saying head hurt
and she felt dizzy. She then laid down, and some type of
convulsive activity occurred. The patient reported hitting head
hard against ground, but roommate reported it was only a very
light head strike. Her roommate says this lasted maybe 10
minutes, but sister thinks estimate probably inaccurate. She had
been drinking alcohol, apparently more than she typically does
when she does drink.
She presented to ___ yesterday night/this morning. Per
their note it stated she had a history of "pseudoseizure" and
was
reported to have movements c/w PNES per EMS. Although this does
not seem to be documented anywhere else in the ___ or
___
records and family not familiar with this diagnosis. She was
intoxicated at that point. Chem7, LFTs, CBC Ca, Hcg wnl. EtOH
level 199 at 2355 ___. No lactate done. She had reported alcohol
use, denied other drug use. She had denied fall at that point.
She was noted to have witnessed what was felt to be PNES
activity
per ___ note, "talking during writhing movements and answering
questions. She was monitored, as activity had stopped and
sobriety had improved, so was discharged home around 0500. She
had told the ___ there that she frequently had episodes like
this.
around 5 am after returning to school, with her sister and
father
accompanying her she had several more seizure like events. The
next event occurred in the elevator, with sister and father
witnessing, she said that she felt like seizure was going ot
happen, fell to floor, dad grabbed her, making the fall very
slow, she then was convulsing in arms and legs, making choking
noises, lasted less than a minute. Was very lethargic after
this,
would nod to some questions. Then shortly afterwards event with
same description occurred. ___ 1 minute separated them. sister
states it appeared that it looked like arms were limp and then
jolting up occasionally like it had been zapped with
electricity.
She remained very sleepy after this, was able to stand, but
needed assistance to stretcher. Able to answer questions. Stated
she recognized paramedics that came (it was the same EMS team
that had brought her to ___ earlier in the night), and
remembers being in elevator. Knew where she was, did not recall
the event. no bowel/bladder incontinence. No known tongue bites.
Her father said it ___ look like her sister's seizures (her
sister's being tense arms and legs with some rhythmic jerking).
She had an additional ___ event of the night) when EMS arrived
and she was being put in ambulance. Not witnessed by family.
There were a total of 4 events since last night sister and dad
witnessed 2 seizures
She family reports that she had a seizure ___ year ago, in
___. Occurred at school, thought she bad bumped her head
possibly. Had HA, and some concussions from volleyball. had some
sort of jerking activity, went to ___. They do not have
much of the details. ___ records patient "was
drinking alcohol tonight and fell back and struck her head on a
corner of a thermostat. she reports a brief loss of
consciousness. She states she remembers her friend calling her
name but could not speak and she was shaking. Her friend states
that her eyes rolled back and they were concerned she may have
had a seizure. There was no tongue biting or incontinence.
patient states she was alert this entire time. She was not
confused after" CT head no bleed. She did not have this
evaluated
as an outpatient.
Currently family feels like she is not quite at baseline, mostly
seems more tired, but otherwise ok.
Received 500 mg keppra in the ___ here.
Did receive 1 dose of ativan in the ___ at ___, unclear what
this was given for exactly.
She denies rising sensation, abdominal pain, jamais ___, odd
smell. endorses occasional ___.
Regarding stressors, the family notes that patient's grandfather
passed away recently and funeral was last ___.
Has been previously seen in Neurology clinic with Dr. ___
headaches. This was felt to likely be complicated migraine.
She had R sided pounding mild headache ___, worse during
menses for some time. At college, she noted the headaches
started
to change, began having dizziness with this as well, nausea,
vomiting, some tingling as well. She was started on topiramate
and propanolol, but stopped taking this after HA resolved. She
had a MRI brain done with her PCP. Report impression below. At
her last visit in ___ this year with Dr. ___ reported
no symptoms.
Past Medical History:
Headaches
Social History:
___
Family History:
Mother with lupus
Sister with epilepsy since ___, stopped having seizures in college
and weaned off meds. Was told it was adolescent epilepsy.
trileptal monotherapy. GTC had 2 in ___ grade, 1 when she was ___
and 1 when ___, medication controlled.
no other family history of seizures
MGF w/ MI
PGM thyroid cancer
Physical Exam:
PHYSICAL EXAM (SAME ON ADMISSION AND DISCHARGE)
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Language
is
fluent with intact comprehension. Able to follow both midline
and
appendicular commands. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic
exam performed, revealed crisp disc margins with no papilledema,
exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.No adventitious movements, such as tremor, noted. No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 ___ 5 ___ 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5
-Sensory: No deficits to light touch, cold sensation
-DTRs:
___ Tri ___ Pat Ach
L 2 - 2 2 1
R 2 - 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Normal steady gait, no ataxia
Pertinent Results:
LABS
=====
___ 04:15AM BLOOD WBC-4.7 RBC-4.42 Hgb-12.5 Hct-38.4 MCV-87
MCH-28.3 MCHC-32.6 RDW-12.4 RDWSD-39.7 Plt ___
___ 04:15AM BLOOD Plt ___
___ 04:15AM BLOOD Glucose-82 UreaN-15 Creat-0.9 Na-140
K-4.5 Cl-104 HCO3-24 AnGap-12
___ 08:31AM BLOOD ALT-18 AST-21 AlkPhos-81 TotBili-0.4
___ 04:15AM BLOOD Calcium-9.7 Phos-4.5 Mg-2.1
___ 08:31AM BLOOD ASA-NEG Ethanol-27* Acetmnp-NEG
Tricycl-NEG
CXR
===
Hyperexpanded lungs with no acute radiographic cardiopulmonary
abnormality.
ECG
===
Normal
Brief Hospital Course:
___ year old woman w/ no significant PMH who presented with four
seizure-like events in the day prior to admission. Events are
characterized by LOC, head dropping and falling to the ground,
occasionally with some shaking preceded by pre-syncope symptoms.
No definite postictal period (able to answer orientation
questions almost immediately after). By history events do not
sound clearly like typical epileptic seizures and are more
consistent with non epileptic seizures or convulsive or
vasovagal syncope. They occurred in the setting of stressor of
death in the family and heavy alcohol use. She was monitored on
EEG for 48 hours and no episodes were captured. Her interictal
EEG background was normal. There was no suggestion of a
predisposition for seizures. She also received ibuprofen and
Tylenol for headache. She was briefly on levetiracetam, but
this was not continued after the loading dose in the ER.
Medications on Admission:
Depo provera
Discharge Medications:
Depo provera
Discharge Disposition:
Home
Discharge Diagnosis:
Non epileptic seizures (nonepileptic psychogenic events)
Syncope
Conversion disorder
Migraine headaches
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 Epilepsy service at ___ after having
multiple events where you lost consciousness and fell. We
monitoring you with an electroencephalogram (EEG). You did not
have any episodes during the hospitalization but we were able to
assess your baseline brain wave activity and it was normal. It
did not show that you are at risk for having seizures. While
this cannot say for sure that the events you had weren't
seizures, it is unlikely that they were. More likely they were
"non-epileptic seizures" which are events that look like
seizures that often occur when people are stressed. They do not
originate from abnormal brain activity. The treatment for this
involves stress management and sometimes cognitive behavioral
therapy to help control these events. Seizure medicines do no
help. Since you lost consciousness recently, we recommend that
you take precautions such as not swimming along, taking showers
instead of baths, and not driving for at least 6 months (this is
___ law). You will be scheduled for follow-up
with our Neurology clinic to monitor these events.
Sincerely, ___ Neurology
Followup Instructions:
___
|
19786784-DS-10
| 19,786,784 | 28,900,650 |
DS
| 10 |
2149-08-12 00:00:00
|
2149-08-12 23:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / cefazolin
Attending: ___.
Chief Complaint:
Right abdominal pain, nausea, vomiting, increased urinary
frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a PMH of SLE, DM, and nephrolithiasis
who presents with abdominal pain.
Her pain started 6 hours prior to admission. Patient states that
she was at home when she developed sudden onset of sharp right
sided abd pn. Pain is constant and rated as a ___. She also
endorses chills, nausea and 3 episodes of non-bloody emesis.
Pain not related to food. Denies fevers, dysuria, hematuria,
diarrhea, chest pain, sob.
Past Medical History:
Lupus
Kidney stones
Nonalcoholic fatty liver disease (per patient, "scars" in liver)
DMII
Asthma
AVN of L wrist c/b nec fasc. s/p surgery in ___
L5 laminectomy/discectomy ___ (with residual left sided
weakness, walks with cane/walker at baseline)
Cholecystectomy
Social History:
___
Family History:
1. Mother had 15 strokes before she passed away. CAD, HTN.
2. Father passed with leukemia.
Physical Exam:
ADMISSION EXAM
**************
VS: 98.1 104/51 74 16 98 RA
GEN: Alert, lying in bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-distended, RLQ tenderness, pressure-induced pain
radiates to RUQ, right flank and back.
MSK: Costovertebral angle tenderness.
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE EXAM
**************
VS: 98.6 T max, 98.3, 121/56, 58, 18, 100 RA
I/Os: - 480 (1120/1600)
GEN: Alert, lying in bed, writing in bed in moderate distress
holding her right side
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: CTAB
COR: Bibasilar crackles in lower lung bases. RRR (+)S1/S2 no
m/r/g
ABD: Soft, non-distended, continues to have R CVA tenderness, no
L CVA tenderness, mild RLQ tenderness.
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
Admission Labs
--------------
___ 12:35AM BLOOD WBC-5.8 RBC-4.30 Hgb-11.8 Hct-37.3 MCV-87
MCH-27.4 MCHC-31.6* RDW-15.9* RDWSD-50.2* Plt ___
___ 12:35AM BLOOD Neuts-77.1* Lymphs-13.8* Monos-8.5
Eos-0.2* Baso-0.2 Im ___ AbsNeut-4.46 AbsLymp-0.80*
AbsMono-0.49 AbsEos-0.01* AbsBaso-0.01
___ 12:35AM BLOOD Plt ___
___ 12:35AM BLOOD Glucose-90 UreaN-9 Creat-0.7 Na-136 K-3.7
Cl-99 HCO3-26 AnGap-15
___ 12:35AM BLOOD ALT-56* AST-88* AlkPhos-179* TotBili-0.7
___ 12:35AM BLOOD Albumin-3.5
___ 12:35AM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:35AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-LG
___ 12:35AM URINE RBC-26* WBC-9* Bacteri-NONE Yeast-NONE
Epi-7
___ 12:35AM URINE Mucous-FEW
Pertinent Labs
--------------
___ 12:35AM URINE UCG-NEGATIVE
Discharge Labs:
---------------
___ 05:15AM BLOOD WBC-3.7* RBC-4.03 Hgb-11.0* Hct-35.5
MCV-88# MCH-27.3 MCHC-31.0* RDW-15.9* RDWSD-51.3* Plt ___
___ 05:15AM BLOOD Plt ___
___ 06:05AM BLOOD Glucose-94 UreaN-10 Creat-0.6 Na-141
K-4.0 Cl-105 HCO3-28 AnGap-12
___ 06:05AM BLOOD ALT-47* AST-74* AlkPhos-154* TotBili-0.3
___ 06:05AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.9
Imaging:
--------
___: CT non-contrast abd/pelvis:
1. No acute process in the abdomen or pelvis.
2. There is a 4 mm nonobstructing stone in the interpolar right
kidney.
3. Splenomegaly.1. No acute process in the abdomen or pelvis.
2. There is a 4 mm nonobstructing stone in the interpolar right
kidney.
3. Splenomegaly.
___: CTU (Abd/Pelvis)w and w/o contrast
1. Unchanged 4 mm right interpolar renal stone without
hydronephrosis. No
new CT findings to explain the patient's right sided abdominal
pain.
2. Splenomegaly.
3. Small fat containing umbilical hernia.
Microbiology:
-------------
___ 12:35AM URINE Hours-RANDOM
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Pathology:
----------
none
Brief Hospital Course:
___ with PMH of SLE, DM2, and nephrolithiasis who presented with
abdominal pain, nausea and non-bloody emesis likely ___
nephrolithiasis visualized on CT (4 mm stone in right kidney).
ACTIVE ISSUES:
--------------
# Nausea/Vomiting/Abdominal pain: Etiology felt to be recurrent
nephrolithiasis. UA revealed microscopic hematuria, no bacturia,
trace pyuria without WBC casts that was consistent with
nephrolithiasis. Non-contrast CT of abd/pelvis also showed a 4
mm radio-opaque calculus. Pain was managed with IV and PO meds
(morphine, oxycodone, tylenol, and ibuprofen) and Zofran for
nausea. She continued to have right flank pain on a combination
of this regimen on day 5 of hospitalization so a repeat CT
Abd/Pelvis was ordered to evaluate for other intra-abdominal
process. CT was unchanged from admission and did not show any
concerning obstruction. She was tolerating PO/fluids and was
given a 2-day course of oxycodone on discharge for continued
pain management.
CHRONIC ISSUES:
---------------
# Lupus: She was continued on home dose of 5mg of prednisone.
# Asthma: She was continued on home Fluticasone-Salmeterol
Diskus inhaler.
# T2DM: She had no insulin requirement during this admission
with serum glucose levels in ___ to 100s. On talking to the
patient further, she mentions that she takes Humalog at home and
her sugars are in the ___ to 100s. We scheduled a f/u
appointment at her ___ office to discuss this T2DM diagnosis
further.
# NASH: LFTs at baseline
Transitional ISSUES:
--------------------
Medication additions:
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Disp #*15 Capsule Refills:*0
Please follow-up with PCP:
#Nephrolithiasis: Consider urine Ca2+/oxalate measurement i/s/o
recurrent stone formation. Thiazide prophylactic therapy could
be considered if urinary calcium is elevated. At this
hospitalization, her serum Ca2+ was low (8.4) and did not
suggest the secondary cause of PTH, however elevations in serum
Ca2+ can be transient.
#T2DM: Of note, her serum glucose was wnl (90s) during this
admission and did not require any insulin. She is also not on
any home insulin or oral glycemic agents. Her most recent HgA1C
was 5.8 in ___ and she is due for follow-up HgA1C and screening
lipid panel; recommend re-addressing this diagnosis as
outpatient.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. PredniSONE 5 mg PO DAILY
Tapered dose - DOWN
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Zonisamide 50 mg PO QHS
4. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
5. TraMADol 50 mg PO BID:PRN Pain - Moderate
6. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH DAILY
7. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
8. Sumatriptan Succinate 25 mg PO ONCE MR1 headache
Discharge Medications:
1. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth every 8 hours PRN Disp
#*9 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth every 4 hours as needed
Disp #*15 Capsule Refills:*0
3. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*7
Capsule Refills:*0
4. Ibuprofen 800 mg PO Q8H nephrolithiasis pain
Take for as short a time as possible until the stone passes (the
next few days)
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
7. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH DAILY
8. PredniSONE 5 mg PO DAILY
Tapered dose - DOWN
9. Sumatriptan Succinate 25 mg PO ONCE MR1 headache Duration: 1
Dose
10. Zonisamide 50 mg PO QHS
11. HELD- TraMADol 50 mg PO BID:PRN Pain - Moderate This
medication was held. Do not restart TraMADol until you finish
the oxycodone
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Nephrolithiasis
Secondary diagnoses:
Lupus
Asthma
Type 2 Diabetes
Nonalcoholic steatohepatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for abdominal pain, nausea,
vomiting, and increased urinary frequency. This was felt to be
due to a kidney stone, which you have had before, based on
imaging and lab studies. We notified your primary care doctor,
___ you were admitted to the hospital and
recommend you follow-up with her in clinic to discuss ways to
prevent future formation of kidney stones.
Thank you for seeking your care here,
Your ___ medical team
Followup Instructions:
___
|
19786784-DS-11
| 19,786,784 | 27,140,018 |
DS
| 11 |
2149-08-19 00:00:00
|
2149-08-20 07:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / cefazolin
Attending: ___.
Chief Complaint:
R Flank Pain, abdominal pain, nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o woman with a PMH of chronic lower
back pain, SLE, T2DM, NAFLD, and asthma, recently discharged
from ___ ___ after admission for abdominal pain, nausea, and
vomiting thought to be secondary to nephrolithiasis, who now
presents with sub-acute onset of severe R flank pain, abdominal
pain, nausea, and vomiting. During her previous admission, she
was managed conservatively with morphine, oxycodone, Tylenol
ibuprofen, Zofran and fluids, and sent home with 2 days of
oxycodone on ___ after her pain and nausea were controlled. She
began having increasing abdominal pain in the last 3 days,
acutely much worse today which led the patient to come to the
ED. Review of systems was notable for chills, rigors, right
flank pain radiating to the groin.
In the ED, initial vitals were:
T 98.8F P 87 BP 120/78 mmHg RR 20 O2 100% RA
Exam notable for R CVA tenderness, abdomen tender, no rebound
tenderness, non-distended, soft.
Labs notable for
CHEMISTRIES:
137 / 103 / 8
-------------< 86
4.0 / 24 / 0.5
Lactate:1.2
UCG: Neg
CBC:
11.2
4.2 >-----< 122
36.0
DIFF:
N:76.9 L:13.0 M:9.0 E:0.7 Bas:0.2 ___: 0.2 Absneut: 3.26
Abslymp: 0.55 Absmono: 0.38 Abseos: 0.03 Absbaso: 0.01
LFTs:
ALT: 67
AST: 110
AP: 187
Tbili: 0.5
Alb: 3.4
UA: mod leuks, neg nitrites, 1 WBC, few bact
Imaging notable for RUQ ultrasound with grossly normal hepatic
parenchyma without intrahepatic biliary ductal dilatation with 4
mm nonobstructive right upper pole renal stone.
Patient was given:
___ 13:31 IV Morphine Sulfate 4 mg
___ 13:31 IVF 1000 mL NS 1000 mL
___ 13:31 IV Ondansetron 4 mg
___ 20:25 IV Morphine Sulfate 4 mg
Decision was made to admit for pain management and possible
MRCP.
Vitals prior to transfer: T 98.6F BP 134/75 mmHg P 75 RR 20 O2
98% RA
On the floor, she reported that her pain was a 6 when she was
discharged; the pain was manageable on ___ and ___,
but then on ___ she started to experience more nausea,
vomiting, and abdominal pain. The pain starts on the right side
of her abdomen and radiates toward the back. The pain is now an
8. She says that she disposed of all of her pain medications on
___ because she was nauseous and could not hold them down.
She also endorses chills and dizziness. Otherwise, she denies
fevers, chest pain, shortness of breath, hematuria, dysuria,
hematochezia, or melena.
ROS:
- as above, otherwise negative
Past Medical History:
- SLE
- nephrolithiasis
- T2DM
- NAFLD
- asthma
- AVN of L wrist c/b necrotizing fasciitis s/p debridement
(___)
- L5 laminectomy/discectomy (___) w/ residual left-sided
weakness uses cane/walker at baseline)
- s/p cholecystectomy
Social History:
___
Family History:
- mother with reported history of "15 strokes"
- father died of leukemia
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VS: T 98.8F BP 145/73 mmHg P 78 RR 20 O2 99% RA
General: Seated comfortable in bed, NAD.
HEENT: EOMs intact; anicteric sclerae. MMM, OP clear.
Neck: Supple, no JVD.
CV: RRR, no MRGs; normal S1/S2.
Pulm: CTA b/l; no wheezes, rhonchi, or rales.
Back: +R CVA tenderness. No spinal tenderness to palpation.
Abd: Obese, soft, tender to palpation in RUQ and RLQ, without
rebound or guarding. Large hematoma present in R suprapubic
region with area of firm induration. NABS.
Ext: Warm and well-perfused; no edema. Well-healed surgical
scars on L arm and R hand.
Neuro: A&Ox3.
DISCHARGE PHYSICAL EXAM
VS: 98.2 115 / 51 61 16 100
General: awake, alert, in NAD
CV: RRR
Pulm: No increased work of breathing
Back: +R CVA tenderness. No spinal tenderness to palpation.
Abd: Obese, soft, tender to palpation in RUQ, RLQ and R flank,
without rebound or guarding. Large hematoma present in R
suprapubic region with area of firm induration.
Ext: Warm and well-perfused; no edema. Well-healed surgical
scars on L arm and R hand.
Pertinent Results:
ADMISSION LABS:
___ 01:42PM BLOOD WBC-4.2 RBC-4.13 Hgb-11.2 Hct-36.0 MCV-87
MCH-27.1 MCHC-31.1* RDW-15.9* RDWSD-50.4* Plt ___
___ 01:42PM BLOOD Neuts-76.9* Lymphs-13.0* Monos-9.0
Eos-0.7* Baso-0.2 Im ___ AbsNeut-3.26 AbsLymp-0.55*
AbsMono-0.38 AbsEos-0.03* AbsBaso-0.01
___ 05:16AM BLOOD ___ PTT-36.4 ___
___ 01:42PM BLOOD Glucose-86 UreaN-8 Creat-0.5 Na-137 K-4.0
Cl-103 HCO3-24 AnGap-14
___ 01:42PM BLOOD ALT-67* AST-110* AlkPhos-187* TotBili-0.5
___ 01:42PM BLOOD Lipase-25
___ 05:16AM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.7 Mg-1.7
___ 01:42PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 01:42PM BLOOD HCV Ab-Negative
___ 01:56PM BLOOD Lactate-1.2
___ 01:56PM URINE Color-Straw Appear-Clear Sp ___
___ 01:56PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD
___ 01:56PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-2
___ 01:56PM URINE UCG-NEG
INTERVAL LABS:
___ 05:16AM BLOOD dsDNA-NEGATIVE
___ 05:16AM BLOOD C3-97 C4-18
DISCHARGE LABS:
___ 05:10AM BLOOD WBC-3.0* RBC-3.60* Hgb-9.8* Hct-31.9*
MCV-89 MCH-27.2 MCHC-30.7* RDW-15.9* RDWSD-51.5* Plt ___
___ 05:10AM BLOOD Glucose-69* UreaN-11 Creat-0.6 Na-139
K-3.9 Cl-105 HCO3-24 AnGap-14
___ 05:16AM BLOOD ALT-53* AST-88* LD(LDH)-189 AlkPhos-188*
TotBili-0.4
___ 05:10AM BLOOD Calcium-7.7* Phos-3.3 Mg-1.7
IMAGING:
___ Abdominal US
1. Mildly limited examination due to patient body habitus.
2. Grossly normal hepatic parenchyma without intrahepatic
biliary ductal
dilatation.
3. 4 mm nonobstructing right upper pole renal stone. The
kidneys are
otherwise unremarkable.
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with a PMH of chronic
lower back pain, SLE, T2DM, NAFLD, and asthma, recently
discharged from ___ ___ after admission for abdominal pain,
nausea, and vomiting thought to be secondary to nephrolithiasis,
who now presents with sub-acute onset of severe R abdominal and
flank pain.
# Right Abdominal/Flank pain: Patient recently treated for
abdominal pain last admission in the same distribution of right
flank and right sided abdominal pain. Thought potentially due to
nephrolithiasis of a right 4mm stone in the renal pelvis.
However, US on this admission showed that stone had not moved in
position, making this unlikely to be cause of pain. CTU on
previous admission showed no other etiology of pain. LFTs
unchanged from prior, has known NAFLD. Lipase normal and is s/p
cholecystectomy. Lupus labs were negative for active flare.
Patient was treated initially with oxycodone 5mg q4h but then
weaned and transitioned to tramadol 50mg q6h (home dose is 50mg
BID). Upon review of ___, patient has received 41 Rxs for
pain medication from 14 different providers in the last year. In
addition, there is a report that patient was discharged from ___
___ clinic because her husband was abusive toward staff
regarding narcotics. Given some of these red flags, it was
decided that she would be discharged with a temporary Rx for
tramadol 50mg q6h to make it to her PCP apt with the
anticipation that either a narcotic contract could be agreed
upon with proper monitoring of her narcotic use or that an
alternative pain management plan could be decided upon.
# Nephrolithiasis. On prior admission, this had been thought to
be contributing to her pain, although it is a 4 mm
nonobstructing right upper pole stone and had not yet passed
into the ureter. Urology consulted and given imaging did not
feel 4mm stone was the cause of her pain. Kept on tamsulosin 0.4
mg qhs.
CHRONIC ISSUES:
# SLE: continued prednisone 5 mg daily.
# T2DM: covered with ISS.
# Asthma: continued home fluticasone-salmeterol and albuterol
TRANSITIONAL ISSUES:
#Chronic Pain: See above for full details. Patient should either
have narcotics contract at next visit or alternative plan for
chronic pain.
#Patient required no insulin while admitted with glucose ranging
from 90-130. Given large amount of insulin with meals (20u with
breakfast and 22u with dinner), concern for causing hypoglycemia
at home so patient was instructed to not take insulin, but to
continue monitoring blood sugar. Consider an oral agent if
insulin is deemed too risky for hypoglycemia.
CORE MEASURES:
# CODE: FULL
# CONTACT: ___: Sister ___
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH DAILY
3. PredniSONE 5 mg PO DAILY
Tapered dose - DOWN
4. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
5. Ibuprofen 800 mg PO Q8H nephrolithiasis pain
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Tamsulosin 0.4 mg PO QHS
8. TraMADol 50 mg PO BID:PRN Pain - Moderate
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
10. Humalog 20 Units Breakfast
Humalog 22 Units Bedtime
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY:PRN constipatoin
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
4. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours Disp #*4
Tablet Refills:*0
5. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
6. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH DAILY
7. PredniSONE 5 mg PO DAILY
Tapered dose - DOWN
8. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic 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 ___ because you had pain along your right
side with nausea and vomiting. We did an extensive workup to see
if your pain was caused by a lupus flare, an infection, or a
problem with your liver, pancreas, bowels, or kidney, but none
of these things seemed to be a cause of your pain. We think this
is likely a presentation of your chronic pain.
You have an appointment with your PCP tomorrow to further
discuss management options for your chronic pain. Please see
instructions for your follow up below.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19786784-DS-12
| 19,786,784 | 20,385,221 |
DS
| 12 |
2150-08-19 00:00:00
|
2150-08-19 19:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / cefazolin
Attending: ___.
Chief Complaint:
Leg ulceration and pain
Major Surgical or Invasive Procedure:
Skin biopsy on ___
History of Present Illness:
___ is a ___ with a history of Lupus (on 2.5 mg
prednisone), RA, obesity, NIDDM, and NASH who presents with
bilateral ___ ulcers. She was in her usual state of health until
approximately 2 weeks ago when she developed pain over her shins
and what appeared to be pimples. The lesions soon ulcerated and
began to have drainage, some of which has been purulent
appearing. Her legs developed new edema and have been very
painful. She has no lesions elsewhere on her body and have never
had anything like this before. She has had no fevers but has had
chills over the past week. She has no joint pain, joint
swelling,
or other rashes. She denies any trauma or bug bites.
In the past her lupus flares have largely consisted of malar
rash. She also gets joint pain chronically although also has
erosive RA for which she had previously been on etanercept
although says she is no longer taking this.
In the ED, initial VS were: 8 97.5 102 154/77 16 100% RA
Labs showed:
Lactate:1.1
Trop-T: <0.01
proBNP: 144
Na 141
K 4.0
BUN 12/ Cr 0.4
ALT: 34 AP: 157 Tbili: 0.6 Alb: 2.5
AST: 77
___: 12.9 PTT: 37.9 INR: 1.2
Imaging showed:
Bilateral LENIs: No DVT though evaluation in the upper calf
limited due to large body habitus.
Chest X ray:
1. Linear opacities in right lower lobe likely represents
subsegmental
atelectasis.
2. No focal consolidation.
3. No evidence of pulmonary edema.
Patient received:
___ 21:00 IV Piperacillin-Tazobactam 4.5 g
___:46 IVF NS 500 mL ___ Stopped (1h ___
___ 22:39 PO OxyCODONE (Immediate Release) 5 mg
___ 22:39 PO Acetaminophen 1000 mg ___
___ 00:06 PO OxyCODONE (Immediate Release) 5 mg
___ 00:28 IV Vancomycin 1500 mg
Transfer VS were: 8 91 132/74 19 100% RA
On arrival to the floor, patient reports ongoing pain in her ___
when they are touched or when she moves them. They also feel
"tight" and swollen. No CP, dyspnea, orthopnea, palpitations,
abd
pain, n/v/d. Otherwise as above.
Past Medical History:
- Lupus diagnosed in ___
- RA
- kidney stones
- diskectomy ___ in the lumbar spine
- liver biopsy showing nonalcoholic fatty liver disease
- diabetes diagnosed in ___
- sciatic nerve damage
- cholecystectomy
- asthma.
- AVN of the wrist complicated by nec fasc
Social History:
___
Family History:
Very significant for lupus including
two brothers. The patient describes that her youngest brother
has
not sought treatment for his lupus and that it is "eating his
face" sounds consistent with discoid lupus. Her sister has lupus
as well and has problems with low blood counts. Her daughter has
lupus, which she reports the fact that the lungs. Leukemia also
runs in the family and a paternal grandmother and her father
died
from leukemia at age ___. Paternal aunts have had breast cancer.
Physical Exam:
ADMISSION EXAM
==================
VS: 97.8 144/87 83 18 98 RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, conjunctivae noninjected and
without lesions, MMM, no oral lesions
NECK: unable to assess JVP secondary to body habitus
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft, nontender in all quadrants, no rebound/guarding
EXTREMITIES: anterior shins bilaterally with a few scattered
ulcers (largest 1.5 cm) with some purulence at edge and serous
drainage; skin warm and erythematous surrounding ulcers; 2+
pitting edema to knees bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: few 2-3 mm erythematous nodules on arms that patient says
are chronic, otherwise no other rashes other than those
described
above
DISCHARGE EXAM
===================
Vitals: 98.0, 136/82, HR 88, RR 20, 97 RA
General: alert, oriented, no acute distress, resting in bed
HEENT: sclera anicteric
Pulm: clear to auscultation bilaterally, no wheezes, normal WOB
CV: regular rate and rhythm, normal S1 + S2
Abdomen: soft, non-tender
Skin: anterior shins bilaterally with a few scattered
ulcers (largest 1.5 cm) with some purulence at edge and serous
drainage; skin warm and erythematous surrounding ulcers;
bilateral edema noted as well
Neuro: A+Ox3, MAE, answers questions appropriately
Pertinent Results:
ADMISSION LABS
===============
___ 08:32PM LACTATE-1.1
___ 08:26PM GLUCOSE-99 UREA N-12 CREAT-0.4 SODIUM-141
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-28 ANION GAP-10
___ 08:26PM ALT(SGPT)-34 AST(SGOT)-77* ALK PHOS-157* TOT
BILI-0.6
___ 08:26PM cTropnT-<0.01
___ 08:26PM proBNP-144
___ 08:26PM ALBUMIN-2.5*
___ 08:26PM ___ PTT-37.9* ___
DISCHARGE LABS
================
___ 07:10AM BLOOD WBC-4.2 RBC-3.29* Hgb-9.1* Hct-28.5*
MCV-87 MCH-27.7 MCHC-31.9* RDW-16.7* RDWSD-52.0* Plt ___
___ 07:10AM BLOOD ___ PTT-42.2* ___
___ 07:10AM BLOOD Glucose-73 UreaN-11 Creat-0.6 Na-139
K-4.1 Cl-104 HCO3-25 AnGap-10
___ 07:10AM BLOOD ALT-33 AST-84* AlkPhos-153* TotBili-0.5
___ 07:10AM BLOOD Calcium-8.5 Phos-4.2 Mg-1.7
___ 12:40PM BLOOD Cryoglb-NO CRYOGLO
___ 06:40AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 06:40AM BLOOD ANCA-NEGATIVE B
___ 06:40AM BLOOD dsDNA-NEGATIVE
___ 07:10AM BLOOD CRP-75.1*
___ 06:40AM BLOOD C3-82* C4-13
___ 06:40AM BLOOD HCV Ab-NEG
REPORTS
================
Bilateral ___ US ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. Please note, evaluation of the posterior tibial and
peroneal veins of
the bilateral upper calf is limited due to body habitus.
CXR ___. Allowing for hypoinflated lungs, no evidence of pulmonary
edema..
2. No focal consolidation.
PATHOLOGY
===============
***pending at time of discharge***
MICROBIOLOGY
================
WOUND CULTURE
SERRATIA MARCESCENS
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S <=0.5 S
LEVOFLOXACIN---------- 0.5 S
MEROPENEM-------------<=0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
Brief Hospital Course:
This is a ___ with a history of Lupus (on 2.5 mg prednisone),
RA, obesity, NIDDM, and NASH who presents with bilateral ___
ulcers with surrounding erythema concerning for cellulitis vs.
vasculitic rash. During her hospital stay she complained of pain
bilaterally L>R requiring tramadol, APAP, ibuprofen, and
initiation of gabapentin. We consulted rheumatology and
dermatology.
# Painful skin ulceration with possible cellulitis: Presented
with several days of skin ulceration, cellulitis vs vasculitis.
Initial biopsy was inconclusive, repeat was done ___ and
pending at time of discharge. DDx: cellulitis, vasculitis
lesion, pyoderma. She had pain and persistence of redness at the
time of discharge. Cultures were taken of the wound, showing
growth of Serratia and Staph aureus, but unclear if this was
truly infectious or a contaminant. She was initially treated
with Vancomycin, then Bactrim, ultimately changed to Doxycycline
given propensity of Bactrim to worsen SLE. Skin biopsy final
results pending at time of discharge, results to be followed up
as outpatient with visits to Derm and Rheum. However, per
preliminary report at 5pm on day of discharge, showing
inflammatory process (not infectious). Thus, she was started on
a steroid cream per Dermatology, called in to her pharmacy.
She will finish 7 day course of antibiotics, last day of
Doxycycline 100mg BID on ___.
# SLE: On presentation, there was suspition for increase SLE
activity, possibly vasculitis as cause of rash. Biopsy of skin
was taken x2, as above. Home Prednisone 2.5mg daily was
continued. Lupus Anticoagulant, Beta-2 Glycoprotein, Cardiolipin
were pending at time of discharge. Anti-dsDNA was negative.
# Transaminitis: HBV and HCV negative. Likely a manifestation of
SLE and/or NASH
# Pancytopenia: Likely related to autoimmune disease, as above.
Stable, should be monitored as outpatient.
# Pain control: Initiated Gabapentin this admission, continued
home regimen otherwise.
Transitional issues:
============================
[] Patient to follow up with Rheumatology and Dermatology to
discuss final results of skin biopsy, and consideration of
treatment for vasculitis (if found)
[] Preliminary skin biopsy results showing an inflammatory
process, rather than infectious. Thus, started on topical
steroid per Dermatology, Betamethasone BID. This was called in
to the patient's pharmacy, given the recommendation given at 5pm
on day of discharge.
[] Skin biopsy final results pending at time of discharge
[] Complete 7 day course of Antibiotics as outpatient.
Doxycycline 100mg BID, last day ___.
[] Initiated on Gabapentin 200mg TID for pain control while
inpatient. Please uptitrate/adjust as needed after discharge.
[] The patient had a skin biopsy with placement of a
nonabsorbable stitch. Please remove the stitch in ~10 days,
___.
[] Patient was found to have pancytopenia likely secondary to
her lupus. Please follow-up with a CBC in 1 week to ensure
stability.
[] Labs pending at time of discharge: Lupus Anticoagulant,
Beta-2 Glycoprotein, Cardiolipin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO DAILY:PRN Pain - Mild
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. PredniSONE 2.5 mg PO DAILY
6. TraMADol 50 mg PO QHS:PRN Pain - Moderate
7. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
Last day ___
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice daily
Disp #*5 Tablet Refills:*0
2. Gabapentin 200 mg PO TID
RX *gabapentin 100 mg 2 capsule(s) by mouth three times daily
Disp #*84 Capsule Refills:*0
3. Acetaminophen 650 mg PO DAILY:PRN Pain - Mild
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of breath
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
7. MetFORMIN (Glucophage) 500 mg PO BID
8. PredniSONE 2.5 mg PO DAILY
9. TraMADol 50 mg PO QHS:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth nightly Disp #*14 Tablet
Refills:*0
10. betamethasone dipropionate 0.05 % topical cream, apply to
leg wound twice daily
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Rash
SLE
Transaminitis
Pancytopenia
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at the ___
___.
You were admitted because of a skin rash on your legs. You were
treated with antibiotics for this for infection (called
"cellulitis"), and will completethese after discharge.
During her hospital stay you were evaluated by the dermatology
team who collected a skin biopsy from your legs. The skin
sample is still pending at time of discharge. You were also
seen by the rheumatology team. You will follow up with these
specialists next week to discuss the results and the next steps.
The Rheumatology department is working on getting you an
appointment even sooner, next week, to discuss your plan more.
They will call you in the next day with the scheduling. If you
do not hear from them by the end of the day on ___, call
___.
You were also started on a medication called Gabapentin to help
with pain.
In case of worsening pain fever worsening redness in your legs
inability to walk or move your joints or any other symptom that
concerns you please reach out to your primary care provider or
present to the nearest emergency room for medical evaluation.
Again, it was a pleasure taking care of you at the ___
___. We wish you all the best
- Your ___ team
Followup Instructions:
___
|
19786784-DS-7
| 19,786,784 | 28,705,952 |
DS
| 7 |
2148-07-15 00:00:00
|
2148-07-16 13:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / cefazolin
Attending: ___.
Chief Complaint:
headache; nausea/vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with a PMH notable for type 2 diabetes mellitus, lupus (on
prednisone), chronic headaches, and recently diagnosed possible
pituitary adenoma, presenting with 2 days of worsening headache,
nausea, vomiting, and vision changes.
The patient was in her usual state of health until ___
___, when she started to experience a slight headache and
nausea/vomiting (yellow/green, non-bloody). These symptoms
worsened on ___ and she presented to the ED on
___, with continued N/V and worsening headache.
The patient reports that her HA is ___ in intensity ("feels
like head is going to explode"), constant, and left sided with
radiation down her left arm. Denies photophobia/phonophobia. She
also reports diplopia on her left side which she first noticed
on ___. Associated symptoms have included vertigo,
lightheadedness, and epistaxis over past several days.
Endorses ~1 month of weakness, decreased appetite. She denies
any fevers/chest pain/sob/abd pain, bowel or bladder changes
(last BM on ___ was nl), amenorrhea (LMP ___, irregular
periods, and galactorrhea.
Of note, she was seen at ___ in ___ for headaches that
were similar in quality to her current headaches, and subsequent
brain MRI showed "questionable 4 mm focus of hypodensity within
the superior aspect of the gland at the base of the pituitary
stalk of uncertain clinical significance." Workup for pituitary
adenoma at ___ in ___ included mild hyperprolactinemia
(PRL of 45 on ___, repeat PRL of 61.3 on ___ and mildly
elevated TSH (7.3) with nl T3/T4; FSH and LH were wnl, and if
cortisol and ACTH were checked we are unable to access these
results.
In the ED, initial vitals were: 21:51 10 97.8 110 145/83 19 100%
RA
- Labs were significant for unremarkable chem10
- Neurology was consulted and recommended admit to medicine with
neurosurgery consult to further ___, pain control,
and orthostatics.
- Imaging revealed CT head that was negative for any bleed
- The patient was given 30mg IV ketorolac, 1L NS, and 1g tylenol
Vitals prior to transfer were: ___, 04:41: 0 88 145/91 18 100%
RA
Upon arrival to the floor, she was in no acute distress,
complaining primarily of headache (___). She received toradol
at 9am with some relief (from ___ to ___.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, night sweats, recent weight loss or gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies diarrhea, constipation or abdominal pain.
No recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
Lupus
Kidney stones
Nonalcoholic fatty liver disease (per patient, "scars" in liver)
DMII
Asthma
AVN of L wrist c/b nec fasc. s/p surgery in ___
L5 laminectomy/discectomy ___ (with residual left sided
weakness, walks with cane/walker at baseline)
Cholecystectomy
Social History:
___
Family History:
1. Mother had 15 strokes before she passed away. CAD, HTN.
2. Father passed with leukemia.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: 98.4 131/83 66 16 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact; confrontational visual fields intact;
___ strength upper/lower extremities, grossly normal sensation,
2+ reflexes bilaterally, gait deferred.
DISCHARGE PHYSICAL EXAM
========================
Vitals: 98.7 98.1 ___ 50-60 ___ 98-100%RA
General: Alert, oriented, no acute distress, resting in bed
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, except for decreased hearing in left
ear. No horizontal, vertical or rotational nystagmus. Visual
fields are fully intact. She has monocular horizontal diplopia
when her right eye is covered. Strength is ___ in all
extremities.
Pertinent Results:
ADMISSION LABS
==============
___ 11:32PM BLOOD WBC-6.5 RBC-4.12 Hgb-11.1* Hct-35.8
MCV-87 MCH-26.9 MCHC-31.0* RDW-15.2 RDWSD-48.6* Plt ___
___ 11:32PM BLOOD Neuts-70.4 Lymphs-18.4* Monos-9.3 Eos-1.1
Baso-0.5 Im ___ AbsNeut-4.56 AbsLymp-1.19* AbsMono-0.60
AbsEos-0.07 AbsBaso-0.03
___ 11:32PM BLOOD Glucose-107* UreaN-15 Creat-0.7 Na-139
K-3.8 Cl-105 HCO3-24 AnGap-14
___ 03:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:03AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:03AM URINE RBC-0 WBC-0 Bacteri-FEW Yeast-NONE Epi-7
___ 09:03AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 09:03AM URINE UCG-NEGATIVE
DISCHARGE LABS
==============
___ 05:35AM BLOOD WBC-6.3 RBC-3.91 Hgb-10.9* Hct-34.2
MCV-88 MCH-27.9 MCHC-31.9* RDW-15.5 RDWSD-49.1* Plt ___
___ 05:35AM BLOOD Plt ___
___ 05:35AM BLOOD Glucose-101* UreaN-9 Creat-0.7 Na-140
K-4.1 Cl-106 HCO3-26 AnGap-12
___ 05:35AM BLOOD Calcium-8.3* Phos-4.0 Mg-1.8
___ 05:20AM BLOOD Prolact-52* TSH-1.1
___ 05:20AM BLOOD Cortsol-7.5
___ 05:20AM BLOOD CRP-23.7*
___ 05:20AM BLOOD SED 48*
Brief Hospital Course:
___ is a ___ yo woman with PMH notable for type 2
diabetes mellitus, lupus (on prednisone), and chronic headaches
presenting for evaluation of headache and dizziness in the
setting of a presumed pituitary adenoma identified on imaging at
___ in ___.
# Headache:
Initial differential for her presenation included migraine
without aura (most likely), medication overuse headache (note
that she has been filling frequent prescriptions for oxycodone),
elevated ICP ___ pituitary adenoma, temporal arteritis, large
vessel vasculitis, and venous sinus thrombosis. CT was obtained
on admission and showed no acute intracranial process or
hemorrhage at the sella. Additional workup included MRA/MRV of
the head and neck, which showed no evidence
for venous sinus thrombosis or vessel dissection, and temporal
artery ultrasounds which were negative. Most likely etiology of
headache is migraine. Pain was controlled with tramadol,
toradol, compazine, and topamax. Tylenol was limited to 2g/day
given patient's history of possible cirrhosis.
# Dizziness:
Patient described a feeling that the room was spinning with
change in position, concerning for vertigo vs orthostatic
hypotension. Orthostatics were obtained and showed stable blood
pressures and HR in lying, sitting, and standing positions. If
vertigo continues would likely benefit from ___ rehab
# Adenoma:
Dedicated MRI of the pituitary was obtained, and showed a
top-normal size in the gland. Workup notable for a normal AM
cortisol of 7.5, a slightly elevated prolactin of 52, and normal
TSH of 1.1.
CHRONIC PROBLEMS
================
# Lupus
Continued prednisone 2.5 po QD
# Diabetes (type II)
Continued home NPH 26 units AM 22 units ___, with insuling
sliding scale
# Asthma
Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID.
TRANSITIONAL ISSUES
===================
- Pituitary measured 10 mm was found on previous MRI and
in-patient pituitary labs showed normal TSH, normal cortisol,
and elevated prolactin.
- adjust insulin regimen, patient had lower blood sugars while
in house and was discharged on lower NPH regimen
- Patient to establish care with new PCP at ___
- Patient was on Topamax this admission but did not tolerate ___
lethargy during the day
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) Dose is Unknown IH
BID
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea / wheezing
3. PredniSONE 2.5 mg PO DAILY
4. NPH 26 Units Breakfast; NPH 22 Units Bedtime
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. NPH 20 Units Breakfast
NPH 20 Units Bedtime
3. PredniSONE 2.5 mg PO DAILY
4. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth q8hrs Disp #*30 Tablet
Refills:*0
5. Albuterol Inhaler 1 PUFF IH Q6H:PRN dyspnea / wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Headache
Vertigo
Secondary:
Systemic lupus erythematosus
Diabetes mellitus type II
Nephrolithiasis
Nonalcoholic fatty liver disease
Asthma
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
worsening headache, nausea, vomiting, and dizziness. During your
admission, we attempted to find the cause of your symptoms by
performing blood tests and imaging studies. We conducted imaging
of your head, which was overall normal, but your pituitary gland
is on the large side of normal. We tested for the level of the
hormones made by this gland, and their levels were normal. To
help rule out more concerning causes of your headache and
dizziness, we consulted the neurology team, who recommended that
we obtain an ultrasound study of the arteries in your face. This
study showed was normal.
We gave you medications to help control your headache,
nausea/vomiting, and dizziness, and you showed improvement with
these medications during your stay.
While you were in the hospital, we noticed that your blood
sugars were lower than normal at times. We recommend that you
decrease your insulin dose to 20u in the morning and 20u at
night. Please record your blood sugars and bring the numbers to
your primary care doctor appointment so adjustments can be made.
For your headache, we are discharging you on a new medication
called Tramadol. You will see a headache specialist as an
outpatient who may make further recommendations.
If you have any questions, please do not hesitate to seek
medical attention. Best of wishes from your care team at ___
___!
Followup Instructions:
___
|
19786784-DS-9
| 19,786,784 | 25,944,405 |
DS
| 9 |
2149-01-05 00:00:00
|
2149-01-05 16:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / cefazolin
Attending: ___.
Chief Complaint:
Nausea, wrist pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of SLE and bilateral wrist deformity with ongoing
severe wrist arthritis s/p right wrist fusion on ___ now
with worsening pain over the past 24 hours associated with
nausea and vomiting. She vomited when trying to drink water. No
sick contacts. She denies any other symptoms including pain,
diarrhea, fevers. She has no headaches. No vision changes. She
notes vomiting started suddenly two days prior on ___. She
could not keep any medications down. She was sent home with a
two week course of Bactrim to be finished on ___.
Of note ___ has concerned in her OMR regarding possible
opiate abuse. She also has notably stable top normal pituitary
size on head imaging.
In the Emergency Department:
Initial Vitals: 97.3 109 127/81 16 100% RA
Labs: WBC 7.7, H/H 10.9/34.1, Plts 161, Chem7 WNL, AST 106, ALT
60, Alk phos 211, lipase 56, Bili 0.6, lactate 1.1. CRP 36.6
Studies:
Consults: Plastic surgery was consulted and said that her hand
films look ok, and her physical exam is improved compared to her
last presentation. That she was ok to discharge from a hand
surgery standpoint. They also recommended a ___ volar splint
and xeroform dressing over the bullae.
Pt was given: 1L D51/2NS, 2L NS, Zofran x4, oxycodone x5,
ibuprofen, gabapentin, dilaudid, tylenol, scopolamine, insulin,
reglan, Ativan
ED Course: DISPO: She was to be discharged if she could tolerate
POs, but she could not tolerate POs. She was initially OBS'd for
IV fluids and antiemetics. She continued to have nausea and
vomiting. She did not have diarrhea and no abdominal pain. It
was thought she her medications were inducing her nausea, so she
was trialed on gabapentin and dilaudid and continue to have
vomiting. She was then given a scopolamine patch, and reglan.
She continued to have nausea nad vomiting. It was decided to
admit her as she could not tolerate POs.
Vitals on transfer: 97.7 69 120/72 16 100% RA.
On arrival to the floor, ___ looks well, has no complaints.
Past Medical History:
Lupus
Kidney stones
Nonalcoholic fatty liver disease (per ___, "scars" in liver)
DMII
Asthma
AVN of L wrist c/b nec fasc. s/p surgery in ___
L5 laminectomy/discectomy ___ (with residual left sided
weakness, walks with cane/walker at baseline)
Cholecystectomy
Social History:
___
Family History:
1. Mother had 15 strokes before she passed away. CAD, HTN.
2. Father passed with leukemia.
Physical Exam:
ADMISSION EXAM
==============
VS: 98.4 ___ ___ 18 98%RA
Weight: 130.4kg
General: well appearing, obese
HEENT: MMM
Neck: no LAD
CV: RRR no murmurs
Lungs: CTAB/L no w/r/r
Abdomen: obese, soft, nontender, nondistended
GU: no foley
Ext: R arm in splint, left arm with longitudinal scar
Neuro: MAE
Skin: no rashes
DISCHARGE EXAM
===============
VS: 97.8 140/82, 65, 18, 98%RA
General: well appearing, obese, sitting up comfortably in bed
HEENT: MMM, PERRL, EOMI, oropharynx clear
Neck: supple, no LAD
CV: RRR no murmurs
Lungs: CTAB no w/r/r
Abdomen: +BS, obese, soft, nontender, nondistended, no rebound
or guarding
GU: no foley
Ext: R arm in splint, left arm with longitudinal scar
Neuro: AOx3, grossly non focal, gait not assessed
Skin: no rashes
Pertinent Results:
ADMISSION LABS
==============
___ 02:53PM ___
___
___ 02:53PM ___
___ IM ___
___
___ 02:53PM PLT ___
___ 02:53PM ___
___ 02:53PM ___ UREA ___
___ TOTAL ___ ANION ___
DISCHARGE LABS
==============
___ 05:10AM BLOOD ___
___ Plt ___
___ 05:10AM BLOOD ___
___
___ 05:10AM BLOOD ___
STUDIES
=======
Wrist Xray- Right ___
Stable postsurgical appearance of the right wrist. No evidence
of hardware related complication. Improved right wrist soft
tissue swelling.
Brief Hospital Course:
___ with PMH of SLE and bilateral wrist deformity with ongoing
severe wrist arthritis s/p right wrist fusion on ___ now
with worsening pain over the past 24 hours associated with
nausea and vomiting.
ACTIVE ISSUES
=============
# Nausea. She was initially observation in the ED, however, she
was unable to tolerate PO intake without nausea/vomiting despite
being given scpolomine, Zofran, Ativan, and reglan so she was
admitted. She did not have any abdominal pain, fevers, or
leukocytosis to suggest infectious etiology. The etiology was
thought likely ___ to pain or medications or constipation.
Nausea improved with increasing oxycodone and having a bowel
movement. Her Bactrim was switched to Doxycycline to improve
tolerance. Her electrolytes were within normal limits and she
did not appear dehydrated. She tolerated PO intake the morning
on ___ without nausea/vomiting and was discharged to home with
Zofran to be taken prn for nausea. She has PCP ___ tomorrow,
___.
# Wrist pain s/p R posterior interosseous nerve neurectomy,
radioscapholunate arthrodesis, and excision of triquetrum on
___ by Dr. ___. She was evaluated by Plastics surgery in
the ED. Her wound dressing was replaced and was improved. She
will follow up in outpatient on ___ as planned. She was
continued on oxycodone and given ibuprofen for additional pain
control. ___ antibiotics were changed from Bactrim to
Doxycycline, to complete ___s planned on ___.
CHRONIC ISSUES
==============
# Lupus. She was continued on home dose of prednisone 2.5mg for
her lupus. She did not exhibit s/s current flare.
# NASH. Her LFTs were at her baseline.
TRANSITIONAL ISSUES
===================
Medication Changes
-___ antibiotics (Start ___, End ___ Bactrim
switched to Doxycycline (to aid with nausea). Continue
Doxycycline for 3 days to end ___.
- Bowel regimen: Senna and Docusate
- Zofran ODT
- Oxycodone 10mg q8hrs prn
- Ibuprofen 600mg q6h prn
PCP ___ states that she takes NPH 26 units qAM and 20 units
qPM. Blood sugars during admission were ___. She was not
discharged on insulin. Recommend readdressing in outpatient
follow up based on home blood sugar monitoring.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
3. PredniSONE 2.5 mg PO DAILY
4. Acetaminophen 500 mg PO Q6H
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H
2. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth q8h:prn Disp #*15
Tablet Refills:*0
3. PredniSONE 2.5 mg PO DAILY
4. Doxycycline Hyclate 100 mg PO Q12H
Stop taking on ___
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*7 Tablet Refills:*0
5. Zofran ODT (ondansetron) 4 mg oral Q8H:PRN nausea Duration:
3 Days
RX *ondansetron [Zofran ODT] 4 mg 1 tablet(s) by mouth every 8
hours Disp #*9 Tablet Refills:*0
6. Ibuprofen 600 mg PO Q8H:PRN pain Duration: 7 Days
For ___ use only.
RX *ibuprofen 600 mg 1 tablet(s) by mouth q8h:prn Disp #*21
Tablet Refills:*0
7. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Nausea
Wrist pain
Lupus
___
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. Briefly, you were hospitalized with nausea and
vomiting that did not improve with medications. You also had
hand pain. You were evaluated by the hand surgeons and you
should follow up with them in clinic at your appointment on
___ at 10:10 AM.
Your nausea improved and you were able to tolerate food. You
were discharged to home.
We wish you the best,
Your ___ Treatment Team
Followup Instructions:
___
|
19787146-DS-2
| 19,787,146 | 27,677,042 |
DS
| 2 |
2139-08-29 00:00:00
|
2139-08-29 22:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bladder rupture
Major Surgical or Invasive Procedure:
Repair of intraperitoneal bladder rupture
History of Present Illness:
___ s/p car vs. tree MVC on ___ at 3 AM. Patient reports
that car was totaled, denies LOC, airbags were not deployed and
patient denies any abdominal injury at that time. He was taken
home by the police after medical examination at the scene. He
reported to his local ED during the day on ___ with crampy
abdominal pain and was sent home with diagnosis of
musculoskeletal pains. Patient re-presented to his local ED on
___ with frequency, abdominal distention and hematuria. CT
scan demonstrated bladder perforation with intraperitoneal
free-fluid and Cr of 5.4. He was transferred to ___ for
further evaluation.
Past Medical History:
none
Family History:
non-contributory
Physical Exam:
NAD
Abdomen soft, NT, ND
Incisions c/d/i staples
Foley draining clear yellow urine
Pertinent Results:
___ 07:46PM GLUCOSE-104* UREA N-52* CREAT-6.3* SODIUM-135
POTASSIUM-4.9 CHLORIDE-94* TOTAL CO2-26 ANION GAP-20
___ 07:46PM estGFR-Using this
___ 07:46PM ALT(SGPT)-35 AST(SGOT)-25 ALK PHOS-113 TOT
BILI-0.5
___ 07:46PM LIPASE-18
___ 07:46PM ALBUMIN-4.9
___ 07:46PM WBC-7.5 RBC-5.66 HGB-17.0 HCT-51.0 MCV-90
MCH-30.0 MCHC-33.3 RDW-13.2
___ 07:46PM NEUTS-55.7 ___ MONOS-5.6 EOS-1.9
BASOS-0.6
___ 07:46PM PLT COUNT-226
___ 07:46PM ___ PTT-31.5 ___
Brief Hospital Course:
Patient was admitted to urology service after undergoing repair
of intraperitoneal bladder rupture. Please see operative note
for details. Patient's pain was well controlled. Diet was
advanced. His creatinine had returned to baseline of 1.0, and
JP creatinine was checked which was same as serum, so it was
removed prior to discharge. He was discharged home with foley
catheter with plans for cystogram in ___ days.
Medications on Admission:
none
Discharge Medications:
1. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO every ___ hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
3. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO once a
day for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Intraperitoneal bladder rupture
Discharge Condition:
Stable
Discharge Instructions:
-You may shower but do not bathe, swim or immerse your incision.
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthough pain >4.
Replace Tylenol with narcotic pain medication. Max daily
Tylenol dose is 4gm, note that narcotic pain medication also
contains Tylenol (acetaminophen)
-Do not drive or drink alcohol while taking narcotics
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication,
discontinue if loose stool or diarrhea develops.
-Resume all of your home medications, except hold NSAID
(aspirin, and ibuprofen containing products such as advil &
motrin,) until you see your urologist in follow-up
-Call your Urologist's office today to schedule/confirm your
follow-up appointment in 3 weeks AND if you have any questions.
-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 ER
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids
Followup Instructions:
___
|
19787494-DS-17
| 19,787,494 | 28,120,585 |
DS
| 17 |
2162-05-17 00:00:00
|
2162-05-17 20:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___
Chief Complaint:
flank pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M with HIV (CD4 > 500), nephrolithiasis present with
intermittent diarrhea x 2 weeks and left flank pain x 1 day.
Patient complains of intermittent cramping lower abdominal pain
and diarrhea x 2 weeks. Stools were nonbloody, occurred both at
night and during the day, approximately ___ episodes/day. Denies
any associated nausea/ vomiting, fevers but + chills. The day
prior to presentation, patient had onset of dull aching left
flank pain but no dysuria/ hematuria or urinary frequency. He
denies any recent travel, unusual foods/ seafood or sick
contacts. Of note, he did recently complete a 3 week course of
augmentin for sinusitis and works as a ___.
In the ED, initial VS: 97.9 82 138/91 20 99%. UA was + RBC 66,
WBC 104, large leuk, few bacteria. CT abd/pelvis did not show
nephrolithiasis or hydronephrosis. He received 4mg morphine, 1 L
of IVF and 1g of CTX.
REVIEW OF SYSTEMS:
pertinent +: per HPI
pertinent -: Denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, nausea, vomiting, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- HIV+
- horseshoe kidney
- history of kidney stones
- history of sinusitis
- history of asthma
- history of HSV-1, ___
Social History:
___
Family History:
brother: type 2 DM
Physical Exam:
VS - Temp 97.7 RR 18 HR 87 BP 121/77 SaO2 98%RA
GENERAL - well-appearing in NAD, appears in moderate discomfort
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, LAD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, generalized tenderness to palpation, +
left flank tenderness, 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, cerebellar exam intact, gait not assessed
Pertinent Results:
Admission Labs:
___ 12:00AM WBC-3.8* RBC-4.42* HGB-13.0* HCT-38.4* MCV-87
MCH-29.3 MCHC-33.8 RDW-12.8
___ 12:00AM NEUTS-62.9 ___ MONOS-7.8 EOS-2.3
BASOS-0.7
___ 12:00AM PLT COUNT-250
___ 12:00AM GLUCOSE-113* UREA N-19 CREAT-1.1 SODIUM-135
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-29 ANION GAP-9
___ 12:00AM ALT(SGPT)-18 AST(SGOT)-20 ALK PHOS-111
___ 12:00AM LIPASE-17
___ 12:00AM CALCIUM-9.5 PHOSPHATE-3.2 MAGNESIUM-2.0
___ 12:01AM LACTATE-1.1
___ 01:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
___ 01:30AM URINE RBC-66* WBC-104* BACTERIA-FEW YEAST-NONE
EPI-0
___ 01:30AM URINE MUCOUS-RARE
Discharge Labs:
___ 06:15AM BLOOD WBC-3.4* RBC-4.71 Hgb-13.7* Hct-41.1
MCV-87 MCH-29.1 MCHC-33.4 RDW-12.6 Plt ___
___ 06:15AM BLOOD Glucose-86 UreaN-16 Creat-1.0 Na-136
K-4.7 Cl-100 HCO3-30 AnGap-11
Microbology:
blood cx: ___: gram positive rods
blood cx: ___: no growth to date
urine culture: ___: no growth
stool ___ CAMPYLOBACTER, R/O E.COLI 0157:H7
(Pending):
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___: Feces
negative for C.difficile toxin A & B by EIA.
Imaging:
CT abdomen/ pelvis:
No evidence of nephrolithiasis. No acute CT findings to account
for patient's clinical presentation. Likely duplicated system of
the left kidney with prominent collecting system of the lower
moiety and cortical thinning representing sequela of chronic
reflux.
Brief Hospital Course:
___ yo M with HIV (CD4 > 500), nephrolithiasis admitted with
diarrhea and flank pain
1. abdominal pain: Etiology was felt to be secondary to
pyelonephritis given positive urinalysis and flank pain. CT
scan abdomen/ pelvis showed no intraabdominal process or
nephrolithiasis. Stool studies were negative for cdiff, other
bacterial pathogens such as ecoli were still pending at time of
discharge. Patient was started empirically on ciprofloxacin
while awaiting culture results. Coverage was expanded to
cipro/flagyl once blood cx returned with prelim GPR (see below).
Initially pain was controlled with morphine, toradol and
acetaminophen but symptoms quickly resolved. Patient was
discharged home to complete a 7 day course of antibiotics for
presumed pyelonephritis. Of note, following discharge, urine
culture returned with no growth.
2. positive blood culture: Anaerobic blood culture on ___
grew gram positive rods. Based on prelim results the microbial
differential includes corynebacterium (usually a contaminant),
clostridium species or listeria. Patient's clinical status was
improving with ciprofloxacin alone. Flagyl was added for
clostridium species given history of diarrhea. Patient will
need to follow up closely with his primary care physician
regarding final speciation to ensure that he received adequate
treatment.
3. asymptomatic HIV: CD4 > 500, viral load undetectable. Well
controlled with no evidence of opportunistic infections.
Patient continued on outpatient regimen of truvada, reyetaz,
ritonavir
4. chronic sinusitis: stable; cont home singulair, fluticasone.
Zyrtec was held as it is non-formulary
Transitional Issues:
Follow up final speciation of blood cultures from ___ which
has preliminarily identified as GPR
Medications on Admission:
- Truvada
- reyetaz
- ritonavir
- singulair
- zyrtec
- nasal spray
Discharge Medications:
1. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
2. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 6 days: do not take with alcohol.
Disp:*18 Tablet(s)* Refills:*0*
7. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
pyelonephritis
diarrhea
positive blood culture
Secondary Diagnosis:
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital with diarrhea and flank pain
which was likely due to pyelonephritis, or an infection of the
kidney. You were placed on antibiotics and your symptoms
improved. Of note, you were found to have bacteria in a blood
culture. This may be a contaminant or it may be a result of your
infection. It is very important for you to follow up with your
primary care physician to ensure that you are improving.
Please make the following changes to your medication regimen:
START ciprofloxacin 500mg twice daily for 5 additional days
START flagyl 800mg three times daily for 6 additional days.
Please do not drink alcohol with this medication as it can lead
to an uncomfortable interaction with nausea/ vomiting.
Please continue to take your other medications as previously
prescribed
It was a pleasure taking care of you during this hospital stay
Followup Instructions:
___
|
19787509-DS-6
| 19,787,509 | 27,421,515 |
DS
| 6 |
2167-08-15 00:00:00
|
2167-08-15 14:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUE weakness
Major Surgical or Invasive Procedure:
1. Anterior cervical diskectomy and arthrodesis C4-5.
2. Application of interbody cage, machined allograft C4-5.
3. Arthrodesis C4-5.
4. Anterior instrumentation C4-5 with a plate.
History of Present Illness:
Patient is a ___ w four days of RUE weakness and neck pain. She
has a 6 month history of intermittent neck pain, but it had
recently become worse and the weakness is a new finding. She is
otherwise well. She has no bowel or bladder sx, she does state
she has had clumsiness in her RUE intermittently.
Past Medical History:
HTN
Social History:
No tobacoo, etoh, ___ speaking.
Physical Exam:
Physical Exam Per Ortho Spine Admission Note dated ___-
NAD
Normal chest rise
Motor key
0 - Flaccid
1 - Voluntary twitch
2 - Voluntary mvmt cannot overcome gravity
3 - Can overcome gravity only
4 - Voluntary can overcome some resistance
5 - Normal strength
Sensation key
0 - Insensate
1 - Altered sensation
2 - Normal sensation
Upper Motor Upper Sensation
R L R L
C5 5 5 Elbow flexor ___
C6 3+ 5 Wrist extensor ___
C7 4- 5 Elbow extensor ___
C8 4+ 5 Finger flexor ___
T1 3+ 5 Finger abduction ___
Lower Motor Lower Sensation
R L R L
L2 5 5 Hip adductor L2 2 1
L3 5 5 Knee extensor L3 2 1
L4 5 5 Ankle DF L4 2 2
L5 5 5 ___ L5 2 2
S1 5 5 Ankle PF S1 2 2
Midline pain: TTP right side of cervical spine and shoulder
Rectal sensation: intact
Rectal tone: intact
Babinski:equivocal
___: negative
Clonus: none
Quality of exam: excellent
Upper extremity reflexes symmetric.
Pertinent Results:
___ 05:00AM BLOOD WBC-13.8* RBC-4.01* Hgb-11.2* Hct-35.3*
MCV-88 MCH-28.0 MCHC-31.8 RDW-12.9 Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD Glucose-142* UreaN-9 Creat-0.7 Na-142
K-4.2 Cl-106 HCO3-26 AnGap-14
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2. Physical therapy
and Occupational Therapy was consulted for mobilization OOB to
ambulate and functional status. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain or fever
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*45 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Please do not operate heavy machinery, drink alcohol, or drive
RX *oxycodone [Oxecta] 5 mg ___ tablet, oral only(s) by mouth
every four (4) hours Disp #*75 Tablet Refills:*0
4. Amlodipine 10 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO BID Duration: 3 Days
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Cervical disk herniation C4-5.
2. Cervical right upper extremity radicular symptoms with
weakness.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
ACDF:
You have undergone the following operation: Anterior Cervical
Decompression and Fusion
Immediately after the operation:
Activity: You should not lift anything greater
than 10 lbs for 2 weeks. You will be more comfortable if you do
not sit in a car or chair for more than ~45 minutes without
getting up and walking around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk
for ___ minutes as part of your recovery. You can walk as
much as you can tolerate.
___ Isometric Extension Exercise in the
collar: 2x/day x ___xercises as
instructed.
Swallowing: Difficulty swallowing is not
uncommon after this type of surgery. This should resolve over
time. Please take small bites and eat slowly. Removing the
collar while eating can be helpful however, please limit your
movement of your neck if you remove your collar while eating.
Cervical Collar / Neck Brace: You have been
given a soft collar for comfort. You may remove the collar to
take a shower or eat. Limit your motion of your neck while the
collar is off. You should wear the collar when walking,
especially in public
Wound Care: Remove the dressing in 2 days. If
the incision is draining cover it with a new sterile dressing.
If it is dry then you can leave the incision open to the air.
Once the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain. Please allow 72 hours for refill of
narcotic prescriptions, so plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___ 2. We are not allowed to call in narcotic (oxycontin,
oxycodone, percocet) prescriptions to the pharmacy. In
addition, we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline x rays and answer any questions.
___ We will then see you at 6 weeks from the
day of the operation. At that time we will most likely obtain
Flexion/Extension X-rays and often able to place you in a soft
collar which you will wean out of over 1 week.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
Followup Instructions:
___
|
19787519-DS-7
| 19,787,519 | 20,127,337 |
DS
| 7 |
2120-05-05 00:00:00
|
2120-05-05 20:47:00
|
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 upper quadrant pain
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
___ healthy male p/w acute onset RUQ abdominal pain. His pain
acutely started at 4am, which woke him up from sleep. He
described the pain as sharp and it was associated with one
episode of nausea and bilious emesis. He reports having a
particularly fatty meal yesterday. Of note, he has not had any
similar episodes in the past. Denies fevers, chills, changes in
bowel habits.
Past Medical History:
HTN
Social History:
___
Family History:
siblings with cholecystitis and eye problems
Physical Exam:
Vitals: 98.5 67 110/60 18 97% RA
Gen: NAD, A&Ox3
CV: RRR, S1S2, no m/r/g
Pulm: CTAB
Abd: soft, no peritoneal signs, no guarding or rebound, has
laparoscopic incision closed not draining. Tolerating PO diet
well.
___: WWP, no edema
Pertinent Results:
___ 03:05PM PLT COUNT-222
___ 03:05PM NEUTS-88.0* LYMPHS-9.4* MONOS-2.2 EOS-0.1
BASOS-0.3
___ 03:05PM WBC-9.5 RBC-4.57* HGB-13.8* HCT-38.4* MCV-84
MCH-30.2 MCHC-35.9* RDW-13.6
___ 03:05PM ALBUMIN-4.2
___ 03:05PM LIPASE-20
___ 03:05PM ALT(SGPT)-15 AST(SGOT)-23 ALK PHOS-104 TOT
BILI-1.2
___ 03:05PM estGFR-Using this
___ 03:05PM GLUCOSE-118* UREA N-13 CREAT-0.7 SODIUM-135
POTASSIUM-2.9* CHLORIDE-100 TOTAL CO2-23 ANION GAP-15
___ 03:29PM LACTATE-1.6
___ 07:55PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:55PM URINE GR HOLD-HOLD
___ 07:55PM URINE HOURS-RANDOM
___ 08:42PM ___ PTT-29.7 ___
Brief Hospital Course:
Mr. ___ was admitted on ___ under the acute care
surgery service for management of her acute cholecystitis. He
was taken to the operating room and underwent a laparoscopic
cholecystectomy. Please see operative report for details of this
procedure. He tolerated the procedure well and was extubated
upon completion. He we subsequently taken to the PACU for
recovery.
he was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and she 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 ___, he was discharged home with scheduled follow up in
___ clinic in ___ weeks.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth every eight (8) hours Disp #*30
Tablet Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg ___ tablet, oral only(s) by mouth
every four (4) hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis status post laparoscopic cholecystectomy
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 cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19787679-DS-7
| 19,787,679 | 21,201,856 |
DS
| 7 |
2144-08-08 00:00:00
|
2144-08-10 18:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
hyponatremia
Major Surgical or Invasive Procedure:
Paracentesis ___
Paracentesis ___
History of Present Illness:
___ woman with a history of alcohol
abuse, seizure disorder, and recent admission at ___ for lower
GI bleed and new hepatic failure referred in from ___ due to
hyponatremia and hypokalemia on outpatient labs.
Briefly summarized ___ d/c summary from ___
hospitalization (which is scanned into At___ records):
- ___ had persistent BRBPR, presented to ___
with Hgb of 5. Also with jaundice, abdominal pain for several
weeks in the setting of ___ drinks of vodka daily. Also w/ ___
colonoscopy w/ hemorrhoids. EGD with diffuse candidadis, portal
hypertensive gastropathy in fundus. Transferred to ___ on ___.
At ___:
#GIB: CTA A/P without source of bleed but with rectal/splenic
varices, splenomegaly, hepatomegaly, mild ascites. Bedside
flex-sig showing large internal hemorrhoid thought to be culprit
lesion, surgery declined to intervene. Improved on octreotide
gtt
x5d and IV PPI.
#Acute on Chronic Liver Failure: Jaundiced and A&Ox0 on
admission, ___ 103.5, MELD 35. Abdominal US w/o dilation.
Paracentesis negative for SBP on ___, given levaquin the cipro
___ for ?ppx and discharged on cipro ppx. Mental status
improved w/ lactulose and rifaximine but still waxing/waning.
Also started on Lasix 40mg and Aldactone 100mg. Of note, unclear
if given prednisolone or pentoxyfyline.
#EtOH, Hx DTs: Initially on phenobarb gtt, d/c'd due to HypoTN,
AMS and switched to Ativan w/ good response. On thamine, folate,
MVI, iron at d/c.
#Refeeding Syndrome: NG tube thru ___, PO diet afterwards,
discharged on standing repletion of phos, K and Mg.
#Chronic Respiratory Alkalosis w/ metabolic compensation:
baseline bicarb 14
#Thrombocytopenia: attributed to splenomegaly, chronic etOH,
liver failure, possible med side effect. D/c w/ 50 platelets.
#Systolic murmur: TTE w/ EF 55-60%, trace MR, TR, AR.
#Esophageal candidiasis s/p 2wk fluconazole ___.
#Trichomoniasis: incidentally found, treated with flagyl 2g x1
#Lung nodules: dx in ___, RUL and LUL sub-centimenter
DISCHARGE LABS NOTABLE FOR:
Sodium 132, K 3.7, Cl 112, CO2 14, BUN 9, Cr 0.7, Ca 7.0
AP 105 | ALT 26 | AST 92 | Tbili 24.3
Hgb 6.8/Hct 19.9 | WBC 9.7 | INR 2.7 | Plt 50
She was discharged on ___ to rehab and then ___ to home with
___. At rehab she received ___ and OT and ambulates with a walker
but did not use it much at home. She did not feel like she
progressed much at rehab. She says her appetite improved after
leaving rehab. She was feeling overall better at home.
Symptoms notable for 1 episode BRBPR since leaving rehab, N/V
sometimes especially after taking many of her medicine. She says
her confusion has improved. She came in because of screening
labs. She is highly anxious about a repeat hospitalization.
She denies alcohol use for 35 days and says, "If I survive this,
I am done with it forever."
In the ED, initial VS were 98.1 | 75 | 87/46 | 16 | 100% RA
Exam notable for diffuse jaundice, Scant yellow guaiac positive
stool in vault, no asterixis. She did trigger for vital sign
criteria at one point.
Labs showed
___ 07:40PM BLOOD WBC:10.4* RBC:1.98* Hgb:6.1* Hct:17.6*
MCV:89 MCH:30.8 MCHC:34.7 RDW:19.0* RDWSD:60.6* Plt Ct:66*
___ 07:40PM BLOOD Neuts:81* Bands:3 Lymphs:7* Monos:5 Eos:1
Baso:0 ___ Metas:2* Myelos:1* AbsNeut:8.74* AbsLymp:0.73*
AbsMono:0.52 AbsEos:0.10 AbsBaso:0.00*
___ 07:40PM BLOOD ___ PTT:56.4* ___
___ 07:40PM BLOOD Plt Smr:VERY LOW* Plt Ct:66*
___ 07:40PM BLOOD Glucose:83 UreaN:16 Creat:0.9 Na:126*
K:3.5 Cl:96 HCO3:16* AnGap:18
___ 07:40PM BLOOD ALT:28 AST:97* AlkPhos:148* TotBili:24.8*
___ 07:40PM BLOOD Albumin:1.8* Calcium:6.8* Phos:3.1
Mg:1.5*
___ 07:40PM BLOOD ASA:NEG Ethanol:NEG Acetmnp:NEG
Bnzodzp:NEG Barbitr:NEG Tricycl:NEG
___ 07:44PM BLOOD Lactate:1.4
___ 01:58AM BLOOD Hgb:7.8* calcHCT:23
Imaging was a bedside ultrasound without tappable pocket.
Received:
- 1000mg PO keppra
- lactulose 30mL q2h
- Pantoprazole 40mg IV x1
- Magnesium sulfate 2g IV x1
Hepatology was consulted and recommended labs, lactulose and
rifaximin, IV PPI, infectious workup, and q8h CBC in addition to
workup labs d/t concern for alcoholic hepatitis.
Transfer VS were 97.9 | 84 | 93/50 | 18 | 100% RA
On arrival to the floor, patient confirms interval history since
discharge. She also endorses significant right hand pain at site
of IV as well as anxiety and itchiness.
REVIEW OF SYSTEMS: (+)PER HPI. No rash, ___ swelling, dyspnea.
No
abdominal pain since prior paracentesis.
Past Medical History:
-acute on chronic liver failure
-ETOH use disorder
-lung nodule
-seizure disorder
-early menopause
Social History:
___
Family History:
___
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.1 | 88/44 | 78 | 22 | 100%Ra
GENERAL: Cachectic, nontoxic, diffusely jaundiced
HEENT: icteric sclerae, moist mucous membranes
NECK: supple, no LAD, no JVD
HEART: RRR, holosystolic flow murmur heard best at LUSB
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: distened but not tense. Nontender in all quadrants
except on deep LUQ palpation. Liver edge palpated and percussed
4
finger breadths below ribs.
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: Alert, oriented to date, month, year, ___, city,
clinical scenario. No asterixis. Moving all 4 extremities with
purpose
SKIN: diffusely jaundiced. Warm and well perfused, no
excoriations or lesions, no rashes
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 99.1 104/43 100 16 97 RA
General: Severe jaundice, NAD
CV: IV/VI systolic ejection murmur
Pulm: CTAB without wheezes or rales
Abd: Soft, distended, positive fluid wave, non-tender
Ext: No ___ edema, WWP
Pertinent Results:
ADMISSION LABS:
===============
___ 07:40PM BLOOD WBC-10.4* RBC-1.98* Hgb-6.1* Hct-17.6*
MCV-89 MCH-30.8 MCHC-34.7 RDW-19.0* RDWSD-60.6* Plt Ct-66*
___ 07:40PM BLOOD Neuts-81* Bands-3 Lymphs-7* Monos-5 Eos-1
Baso-0 ___ Metas-2* Myelos-1* AbsNeut-8.74* AbsLymp-0.73*
AbsMono-0.52 AbsEos-0.10 AbsBaso-0.00*
___ 07:40PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-2+* Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-NORMAL
Ovalocy-OCCASIONAL Target-OCCASIONAL Schisto-1+* Burr-1+*
Stipple-OCCASIONAL Acantho-1+*
___ 07:40PM BLOOD ___ PTT-56.4* ___
___ 07:40PM BLOOD Glucose-83 UreaN-16 Creat-0.9 Na-126*
K-3.5 Cl-96 HCO3-16* AnGap-18
___ 07:40PM BLOOD ALT-28 AST-97* AlkPhos-148* TotBili-24.8*
___ 07:40PM BLOOD Albumin-1.8* Calcium-6.8* Phos-3.1
Mg-1.5*
RELEVANT LABS:
==============
___ 07:40AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:10PM BLOOD HIV Ab-NEG
___ 07:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:25PM URINE bnzodzp-NEG barbitr-POS* opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 08:25PM URINE UCG-NEGATIVE Osmolal-305
___ 08:25PM URINE Hours-RANDOM UreaN-196 Na-88
RELEVANT IMAGING/STUDIES:
========================
KUB ___:
IMPRESSION:
No evidence of obstruction.
Mildly distended cecum.
___ (PA & LAT)
IMPRESSION:
No previous images. Cardiac silhouette is within normal limits
and there is no vascular congestion, pleural effusion, or acute
focal pneumonia. Mild atelectatic changes are seen at the left
base.
___ DOPP ABD/PEL
IMPRESSION:
1. Patent hepatic vasculature with appropriate flow directions.
2. 2.1 cm echogenic lesion within the right hepatic lobe is
statistically likely a hemangioma, however, given background of
liver disease and suggestion of cirrhosis, followup MRI in 3
months is recommended to reassess the lesion and compare for any
size change.
3. Mild splenomegaly.
4. Mild ascites.
MICRO:
======
___ C diff- NEGATIVE
___ URINE CULTURE- NEGATIVE
___ Blood Culture, Routine-PENDING
___ Blood Culture, Routine-PENDING
DISCHARGE LABS:
===============
___ 06:10AM BLOOD WBC-10.5* RBC-2.43* Hgb-7.7* Hct-22.4*
MCV-92 MCH-31.7 MCHC-34.4 RDW-20.0* RDWSD-51.3* Plt Ct-90*
___ 06:10AM BLOOD ___ PTT-82.0* ___
___ 06:10AM BLOOD Glucose-117* UreaN-32* Creat-0.8 Na-132*
K-4.4 Cl-100 HCO3-20* AnGap-12
___ 06:10AM BLOOD ALT-37 AST-60* LD(LDH)-203 AlkPhos-212*
TotBili-19.0*
___ 06:10AM BLOOD Albumin-2.3* Calcium-7.6* Phos-3.0
Brief Hospital Course:
Patient summary: ___ woman with history of alcoholic cirrhosis
presents with hyponatremia and hypokalemia on outpatient labs,
admitted with anemia.
=========================
ACUTE ISSUES:
=========================
#ETOH USE DISORDER
#ACUTE ON CHRONIC LIVER FAILURE:
#Leukocytosis:
MELD 34 on admission (52.6% 3-month mortality). Initially had
uptrending LFTs, though now stable. Due to recurrent
leukocytosis and intermittent episodes of severe abdominal pain,
diagnostic paracentesis was performed twice due to concern for
SBP ___ and ___. Both diagnostic paracenteses were
negative for SBP. Urine cultures and blood cultures were pending
on discharge, but UA had been negative. There were no focal
symptoms for infection. She was also treated with rifaximin and
lactulose. Lactulose dosing was titrated to ___ bowel movements
daily. Her diuretics were held due to persistent hypotension.
Additionally, she began treatment with prednisone for acute
alcoholic hepatitis once infection had been ruled out.
#ANEMIA: During this hospital stay, the patient required 4 units
pRBCs (non-consecutive.)On ___, due to an inappropriate rise in
Hgb after transfusion, she received an additional unit. The
question remains as to why she continues to drop her Hgb -- she
has been evaluated for intraperitoneal bleed with CT abd/pelv,
which showed no evidence of bleed. She has no melena or
hematochezia. Anemia of chronic disease certainly playing a role
but would not result in the intermittent acute drops seen in
this patient. Retics elevated, haptoglobin 33 at lower limit of
normal, elevated bili would be masked by current liver
dysfunction; therefore, hemolysis could not be completely ruled
out. She received one unit pRBCs on the day of discharge.
#THROMBOCYTOPNEIA: As per ___ w/u, likely splenomegaly,
chronic EtOH use, and likely due to liver disease.
#ABDOMINAL PAIN: She underwent diagnostic paracentesis on ___,
which was negative for SBP. She was also tested on ___ for C
diff, which was negative. Several days later, on ___, due to
rising WBC (7->12->15.8), increasing abdominal pain, and some
loose stools, infection was considered(C diff, cholecystitis
given RUQ tenderness) but testing and imaging including CT
abdomen/pelvis was negative. Her abdomen was never peritoneal so
it was felt unlikely to be a perforation and she continued to
have BMs so no concern for obstruction. Lactate was normal 1.9,
so there was not concern for mesenteric ischemia. Ultimately,
her abdominal pain was felt to be related to severe gas or GI
hypermotility in the setting of lactulose/rifaximin. Lactulose
was therefore appropriately titrated.
======================
CHRONIC ISSUES:
======================
#HX SEIZURE D/O:
- continue home keppra 500mg BID
======================
Transitional Issues:
======================
[ ]1uRBC transfused prior to discharge. Hgb at 7.7 prior to
transfusion. This should be followed with weekly labs and
evaluated at her next outpatient appointment. A stool guaiac
should be performed, as well.
[ ] Weekly lab monitoring should include: LFTs including
bilirubin, CBC, complete metabolic panel, and coags ___, PTT,
INR).
[ ] The patient was discharged with an NJ tube for enteric
feeding due to nutritional requirements. She will have ___
services for nightly cycled feeds.
[ ] 40mg daily prednisone (___) was started during this
admission for acute alcoholic hepatitis, and should be continued
as an outpatient. Please check lille score to monitor
effectiveness of prednisone. If prednisone found beneficial,
please add Bactrim, PPI, vitamin D and calcium to her regimen
for steroid prophylaxis.
[ ] Prior to admission, the patient was taking spironolactone
and furosemide. Due to persistent hypotension and hyponatremia,
both of these medications were held during the admission and
should not be restarted.
[ ] Platelets remained low while inpatient. Please continue to
monitor thrombocytopenia as an outpatient. Plt: 90 on ___
[ ] 2.1 cm echogenic lesion within the right hepatic lobe is
statistically likely a hemangioma, however, given background of
liver disease and suggestion of cirrhosis, followup MRI in 3
months is recommended to reassess the lesion and compare for any
size change.
- Of note EGD done this admission ___ with 4 cords of grade
I varices were seen in the lower third of the esophagus. Patient
is not on nadolol or ciprofloxacin.
- Discharge MELD 27, CP C
- Consider restarting ciprofloxacin for primary prophylaxis
given ascites. Tested twice while in house with negative
results.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. K-Phos Original (potassium phosphate, monobasic) 500 mg oral
DAILY
2. K-Tab (potassium chloride) 20 mEq oral DAILY
3. MagOx (magnesium oxide) 400 mg oral DAILY
4. Ciprofloxacin HCl 250 mg PO Q24H
5. Lactulose 30 mL PO TID
6. Rifaximin 550 mg PO DAILY
7. Spironolactone 100 mg PO DAILY
8. Furosemide 40 mg PO DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. LevETIRAcetam 500 mg PO BID
12. Thiamine 100 mg PO DAILY
Discharge Medications:
1. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth every day Disp #*60
Tablet Refills:*0
2. Ursodiol 300 mg PO BID
RX *ursodiol 300 mg 1 capsule(s) by mouth every 12 hours Disp
#*60 Capsule Refills:*0
3. Lactulose 15 mL PO BID
RX *lactulose 10 gram/15 mL (15 mL) 15 ml by mouth every 12
hours Refills:*0
4. FoLIC Acid 1 mg PO DAILY
5. LevETIRAcetam 500 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Rifaximin 550 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. HELD- Ciprofloxacin HCl 250 mg PO Q24H This medication was
held. Do not restart Ciprofloxacin HCl until you speak to your
liver doctor
10.Outpatient Lab Work
Weekly labs: ___- CBC, LFT with tbili,
INR, CHEM 10
Dx:___
ATTN: Dr. ___
___: ___
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary:
Anemia
Hyponatremia
Cirrhosis
Secondary:
Seizure disorder
Thrombocytopenia
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 here at ___.
You were admitted to the hospital because of a low sodium and
likely worsening of your liver disease. We restricted your
fluid intake to try to increase the sodium level. We also
checked for infection by looking at your lungs, fluid in your
abdomen, and urine, we found that there were no signs of
infection.
Your sodium improved to 132 on discharge. Please make sure to
keep all of your appointments and take all your medications.
Please continue to eat all of your meals, this will help your
liver disease.
We are happy to see you feeling better.
-Your ___ Team
Followup Instructions:
___
|
19787679-DS-8
| 19,787,679 | 27,332,038 |
DS
| 8 |
2144-09-03 00:00:00
|
2144-09-03 18:17:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Ear Pain
Major Surgical or Invasive Procedure:
Paracentesis: ___
History of Present Illness:
___ F with hx of EtOH cirrhosis decompensated by ascites
currently on spironolactone/lasix, recent admission for
alcoholic
hepatitis discharged on steroids, seizure disorder, who
presented
to the ___ ED with left ear pain and fevers, concerning for
ear
infection.
Patient reports that she has left ear pain, decreased hearing,
and fevers for four days. She reports that she has had pain in
area of left mastoid and left neck as well a the L side of her
throat, without ear discharge. No shortness of breath. Of note,
the patient had recent BRBPR, thought to be attributed to
internal hemorrhoid, denies current lower GI bleed. Patient
also reports increasing abdominal distension and discomfort.
Patient denies having drank in months. She spoke to her PCP who
sent her to ED for evaluation for ear pain and possible need for
paracentesis.
Of note, the patient was discharged on ___ on steroids for
acute alcoholic hepatitis, and the steroids course ended on
___. NJ tube was placed prior to discharge and the patient
is
currently receiving 1600cc enteric feeding nightly.
In the ED, initial vitals: 99.5 96 126/69 16 100% RA
- Exam notable for:
Con: +jaundiced, acute pain from left ear
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact; left auditory
canal erythematous w/ dull TM, +TTP at left mastoid and in left
cervical neck
Resp: Clear to auscultation
CV: Regular rate and rhythm, normal ___ and ___ heart sounds,
no
___ heart sound, no JVD, +pedal edema, 2+ distal upper extremity
and lower extremity pulses. Capillary refill less than 2
seconds.
Abd: Soft, Nontender, +significantly distended with caput
medusa
and umbilical hernia, reducible
GU: No costovertebral angle tenderness
MSK: 3+ pitting edema in legs bilaterally to mid calves
Skin: No rash, Warm and dry, No petechiae
Neuro: Cranial nerves II Through XII intact, 5+ strength in all
extremities, sensation intact in all extremities
Psych: Normal mood/mentation
- Labs notable for:
+ WBC 4.9, H/H 7.5/23.5
+ ___ 21.0, PTT 35.0, INR 1.9
+ ALT/AST 58/68 (downtrending as compared to , Alk phos 202,
Tbili 13.4, Albumin 2.3
+ Peritoneal fluid: WBC 161, Polys 8% RBC 3632,
- Imaging notable for:
- Chest x-ray ___: Left basilar opacity may represent left
pleural effusion and pneumonia in the appropriate clinical
context.
- Pt given:
- Vancomycin IV
- Pip-Tazo 4.5 g IV
- Morphine sulfate 4 mg IV
- Vitals prior to transfer: 99.0 94 117/62 18 100% RA
On the floor, the patient reports continued L ear pain that is
severe and intermittent. She reports that the morphine injection
she received in the ED helped for a short time but the pain has
returned to an ___. She corroborates the above, and reports
that
she has never had such a pain before. She reports that the pain
has been severe for the last day. She denies any new rashes or
history of shingles or herpes infection.
REVIEW OF SYSTEMS: Per HPI
Past Medical History:
-acute on chronic liver failure
-ETOH use disorder
-lung nodule
-seizure disorder
-early menopause
Social History:
___
Family History:
___
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
VITALS: 98.6 PO 130 / 81 82 16 100 Ra
General: Lying in bed, cooperative and mostly comfortable with
intermittent episodes of extreme discomfort from L ear pain.
HEENT: Sclerae icteric, no oropharyngeal lesions. Pharynx
without any obvious erythema or exudates. Tender LAD in cervical
chain. L ear canal with small bumps concerning for small
vesicles
on anterior portion with erythema throughout canal. No
effusions.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Distended with dullness to percussion. Tender to deep
palpation. Normal BS
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 2+ b/l pedal edema up to
mid calf
Skin: Telangectasias over upper chest, face.
Neuro: CNII-XII intact, no asterixis.
========================
DISCHARGE PHYSICAL EXAM
========================
VITALS: 98.1, 120-130s/80s, 80-100s, ___, 100% RA
General: Alert, oriented, laying in bed, comfortable-appearing.
HEENT: +Sclerae icteric, no oropharyngeal lesions. Pharynx
without any obvious erythema or exudates. L ear canal without
erythema, effusions, or vesicles noted. +partially erythematous
TM.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, +Distended. No longer tender to palpation. Normal
BS.
Ext: Warm, well perfused, 2+ BLE edema up to thigh
Skin: Telangectasias over upper chest, face.
Neuro: Grossly intact
Pertinent Results:
___ 04:19PM WBC-4.9# RBC-2.22* HGB-7.5* HCT-23.5*
MCV-106* MCH-33.8* MCHC-31.9* RDW-25.1* RDWSD-94.6*
___ 04:19PM NEUTS-64 BANDS-6* ___ MONOS-8 EOS-0
BASOS-0 ___ METAS-2* MYELOS-0 AbsNeut-3.43 AbsLymp-0.98*
AbsMono-0.39 AbsEos-0.00* AbsBaso-0.00*
___ 04:19PM PLT SMR-LOW* PLT COUNT-87*
___ 04:19PM GLUCOSE-117* UREA N-11 CREAT-0.5 SODIUM-135
POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-22 ANION GAP-11
___ 04:31PM LACTATE-1.2
___ 04:19PM ALT(SGPT)-58* AST(SGOT)-68* ALK PHOS-202* TOT
BILI-13.4*
___ 04:19PM LIPASE-70*
___ 07:03PM ASCITES TNC-161* RBC-3632* POLYS-8* LYMPHS-37*
MONOS-0 EOS-1* PLASMA-1* MESOTHELI-17* MACROPHAG-36* OTHER-0
___ 10:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD* UROBILNGN-NEG PH-8.0
LEUK-NEG
Brief Hospital Course:
Patient Summary: Ms. ___ is a ___ F with hx of EtOH
cirrhosis decompensated by ascites, recent admission for
alcoholic hepatitis, and seizure disorder who presented to the
___ ED with left ear pain, subjective fevers, and initial ear
exam concerning for vesicles, admitted for concern for
Ramsay-Hunt Syndrome.
============
Acute Issues
============
#Otalgia: Given recent one month course of steroids, infection
is likely, especially given ear pain and subjective fevers. CT
scan showed no evidence of mastoiditis. On initial exam, patient
had erythema and small vesicles vs. papules on the anterior ear
canal concerning for early signs of a VZV vs. HSV infection
(including ___ syndrome). On repeat exam no vesicles
visualized, however mildly erythematous TM on ___. We started
Valacyclovir 1g TID x7 days ___, to end on ___. We did
not prescribe steroids due to concern for possible other
infectious cause, however since her ear pain bettered with
Valacyclovir we did not start antibiotics. We obtained HSV/VZV
IgG/IgM, which were still pending on discharge. We also started
Gabapentin 100mg TID for neuropathic pain that can be associated
with Zoster.
#Decompensated EtOH cirrhosis: MELD 24 on admission. Child's
Class C. Decompensated by large ascites. Diagnostic paracentesis
in the ED without SBP. Large volume paracentesis ___ with 4L
fluid removal, with associated symptomatic improvement. We held
Lasix/spironolactone in the setting of infection.
#Macrocytic Anemia: During the previous hospital stay, the
patient required 4 units pRBCs (non-consecutive.) During that
admission she had no melena or hematochezia. Concern for slow
bleeding vs. anemia of chronic disease vs. anemia ___ cirrhosis
with poor production and mild hemolysis. Currently Hgb at 7.5 ->
8.0, slightly reduced from last discharge (mid-___).
Reticulocyte 8.5%. Iron studies - elevated ferritin, normal
iron, low TIBC - suggestive of AoCD. Hgb was 7.1 on day of
discharge, possibly due to fluid shifts after large volume
paracentesis on ___. Plan to recheck labs at PCP appointment
the following week.
#Alcoholic hepatitis:
#Cirhosis:
Home diuretics Lasix and spironolactone held initially in the
setting of infection, restarted on discharge. As above, steroids
were not continued this admission after being stopped as
outpatient.
========================
CHRONIC/STABLE PROBLEMS
========================
# HX SEIZURE D/O: Continued home keppra 500mg BID
#THROMBOCYTOPNEIA: As per ___ workup, likely splenomegaly,
chronic EtOH use, and likely due to liver disease. Monitored
with daily CBCs, did not significantly decrease.
====================
Transitional issues:
====================
-Obtain CBC/BMP/LFTs on ___ at ___ appointment -- note that
Hgb was 7.1 on day of discharge, monitor for resolution; also
evaluate renal function as held diuretics in-house but restarted
on discharge
-F/u with Hepatology (Dr. ___ time of appointment pending
-F/u on VZV/HSV IgG/IgM results
-Incidental finding: 2.1 cm echogenic lesion within the right
hepatic lobe is statistically likely a hemangioma, however,
given background of liver disease and suggestion of cirrhosis,
followup MRI in 3 months is recommended to reassess the lesion
and compare for any size change.
-Incidental Finding: Multiple lung nodules measuring up to 6mm
found on CT. Recommend follow-up CT in ___ months.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. LevETIRAcetam 500 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
5. Ursodiol 300 mg PO BID
6. Ciprofloxacin HCl 250 mg PO Q24H
7. Furosemide 20 mg PO DAILY
8. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth three times per day
Disp #*45 Capsule Refills:*0
2. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Discontinued Oxycodone
RX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours Disp #*12
Tablet Refills:*0
3. ValACYclovir 1000 mg PO Q8H Duration: 16 Doses
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth three times per
day Disp #*16 Tablet Refills:*0
4. Ciprofloxacin HCl 250 mg PO Q24H
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. LevETIRAcetam 500 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Spironolactone 50 mg PO DAILY
10. Thiamine 100 mg PO DAILY
11. Ursodiol 300 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Otalgia - likely secondary to VZV/HSV
Decompensated alcoholic cirrhosis
Secondary:
Macrocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you here at ___!
You were admitted here for ear pain - we had concerns that your
ear pain was caused by Herpes Zoster, so we started you on
antivirals for a total course of 7 days (to end on ___. We did
a CT scan of your head and neck that did not show infection of
your Mastoid bone (behind your ear). While you were here, we
also did a large volume paracentesis to remove fluid from your
abdomen to reduce some of your abdominal pain. We removed 4
liters of fluid, and your abdominal fluid did not show signs of
infection.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
19787679-DS-9
| 19,787,679 | 23,262,426 |
DS
| 9 |
2145-05-14 00:00:00
|
2145-05-14 17:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Rectal Bleeding
Major Surgical or Invasive Procedure:
Sigmoidoscopy ___
History of Present Illness:
___ F with hx of EtOH cirrhosis (with Grade 1 varices EGD
___, ascites, prior alcoholic hepatitis), seizure disorder
reports dizziness w/ no fever, chest pain, shortness of breath,
abdominal pain, who has had 3 days of BRBPR, and bilious
vomiting. She had no blood or coffee grounds. Per report, had
not had alcohol for ___ year and then started drinking alcohol for
1 week, and then stopped 2 days ago. She had increased nausea
and vomiting since then.
In ED initial VS: ___ 18 100% RA
Labs significant for:
OSH HCT 15, INR 2.
Baseline H/H typically ___.
Here- Hgb 4.7, Plt 85< INR 2.6, Lactate 2.5
At OSH given: 5 mg vitamin K, protonix 80mg IVP bolus, 80 mg/hr,
50mcg octeotride bolus and 25mcg/hr, 1L NS bolus, levaquin 500mg
At ___ Patient was given: 2U PRBC, Potassium, IV CTX 2g, IV
25% 25g albumin,
Consults: Hepatology
VS prior to transfer: 98.2 89 96/47 15 100% RA
On arrival to the MICU, she reports above history. She has had
maroon blood from rectum for about a week, no clear trigger but
does endorse also drinking about 3 glasses of vodka/day for 5
days in setting of multiple stressors. She also reports a left
leg bruise from
She confirms her medication list, has been off encephalopathy
and diuretic medications. She reports about 3 days of right
sided abdominal pain, but in setting of a "ex-girlfriend fooling
around", when she jumped on her abdomen, otherwise her abdomen
seems less distended, no fevers, chills, reports +mild nausea,
no hematemesis. Denies melena.
Past Medical History:
-Cirrhosis
-ETOH use disorder
-Seizure Disorder
-Lung Nodule
Social History:
___
Family History:
No family history of liver diseases, otherwise non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: Reviewed in metavision
afebrile, HR ___, SBP 100s-120s, 100% RA
GENERAL: Alert, oriented 3, no acute distress,+ jaundiced
HEENT: Sclera icteric, dry mucous membranes, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: Trace crackles bilaterally at bases, otherwise clear
bilaterally
CV: Regular rate and rhythm, normal S1 S2, no murmurs
ABD: soft, non-tender, distended, bowel sounds present, no
guarding,
EXT: Warm, well perfused, large area of ecchymosis in L. lower
shin, scattered spider angiomas, small areas of ecchymosis, no
active bleeding
RECTAL: no active bleeding currently
DISCHARGE PHYSICAL:
98.2 100/61 98 18 99 Ra
General: NAD, laying back in bed
HEENT: AT/NC, EOMI, no JVD, neck supple
Lung: CTAB
Card: RRR, s1+s2 normal, systolic ejection murmur III/VI best
appreciated at ___
Abd: +BS, mildly distended, non-tender, mild hepatomegaly
appreciated
Ext: +pulses, no edema in ___
Neuro: AAOx3, no motor/sensory deficits elicited
Pertinent Results:
ADMISSION LABS:
=================
___ 02:40AM BLOOD WBC-4.7 RBC-1.45* Hgb-4.7* Hct-14.2*
MCV-98 MCH-32.4* MCHC-33.1 RDW-18.6* RDWSD-61.1* Plt Ct-85*
___ 03:15AM BLOOD ___ PTT-36.0 ___
___ 02:40AM BLOOD Glucose-94 UreaN-8 Creat-0.8 Na-137
K-3.0* Cl-106 HCO3-17* AnGap-14
___ 02:40AM BLOOD ALT-18 AST-102* LD(___)-286* AlkPhos-141*
TotBili-6.7* DirBili-4.4* IndBili-2.3
___ 02:40AM BLOOD Albumin-2.2* Calcium-6.8* Phos-3.1
Mg-1.2*
___ 02:40AM BLOOD Hapto-23*
___ 02:45AM BLOOD Lactate-1.5
DISCHARGE LABS:
___ 04:56AM BLOOD WBC-4.7 RBC-2.74* Hgb-8.6* Hct-25.3*
MCV-92 MCH-31.4 MCHC-34.0 RDW-19.8* RDWSD-62.5* Plt Ct-88*
___ 04:56AM BLOOD Neuts-59.6 Lymphs-18.8* Monos-17.3*
Eos-2.3 Baso-1.1* Im ___ AbsNeut-2.80 AbsLymp-0.88*
AbsMono-0.81* AbsEos-0.11 AbsBaso-0.05
___ 04:56AM BLOOD Plt Ct-88*
___ 04:56AM BLOOD Glucose-90 UreaN-8 Creat-0.8 Na-137 K-3.8
Cl-105 HCO3-19* AnGap-13
___ 04:56AM BLOOD ALT-15 AST-72* LD(___)-286* AlkPhos-145*
TotBili-8.5*
___ 04:56AM BLOOD Albumin-2.3* Calcium-6.8* Phos-2.4*
Mg-1.5*
___ 04:56AM BLOOD ___-21
___ 04:56AM BLOOD 25VitD-20*
IMAGING:
==========
___ Sigmoidoscopy
Brown stool in the colon ruling out a proximal source of
bleeding.Internal hemorrhoids.
___ Liver and Gallbladder US
1. Patent portal veins, however the main and anterior and
posterior right
portal veins now demonstrate reversed hepatofugal flow.
2. Increased splenomegaly at 16.6 cm, previously 13.6 cm.
3. Cirrhotic liver without ascites.
4. Previously noted right hepatic hemangioma is not seen on the
current study.
MICRO:
___: Blood Cx 6x: NGTD
___ 1:32 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 11:46 am 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 (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 11:46 am FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Preliminary): NO GROWTH.
___ 2:16 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 2:16 am URINE CX: NGTD
Brief Hospital Course:
___ y/o woman w/ EtOH cirrhosis w/ known portal HTN, who
presented with dizziness and BRBPR, found to have a Hb of 4.7
from 8.8 in ___. She was stabilized in ICU following 5u
pRBC transfusions and sigmoidoscopy ruling out UGIB with
evidence of internal hemorrhoids likely causing bleed.
Although her TBili remained elevated at the time of discharge,
it did demonstrate a potential peak. She was strongly
recommended by her medical team to remain in-house for further
stabilization of labs, however was adamant about needing to
return home for personal matters. She understood the risks,
including liver failure, bleeding, serious infections among
other sequela. She agreed to short-term f/u in clinic with Dr.
___.
ACUTE ISSUES:
#Anemia
#GI Bleed
#Hemorrhoids
Presented with dizziness and BRBPR, found to have a Hb of 4.7
from 8.8 in ___ and admitted to ICU. Received total 5u pRBC
transfusions in ICU to which she stabilized counts. Flex sig
with evidence of hemorrhoids and no proximal bleeding. Stopped
IV PPI BID, octreotide 50 mcg gtt, ceftriaxone 2g/daily, low
suspicion for variceal bleed. D/ced PPI. CR surgery consulted on
floor, who determined no need for acute intervention and may
look into hemorrhoid management outpatient. Would recommend
outpatient colonoscopy to fully investigate source of lower GI
bleeding (only had sigmoidoscopy inpatient).
#Elevated LFTs:
#Decompensated EtOH cirrhosis:
MELD-na on admission 25. Child's Class C. LFT derangements
likely with acute alcohol use and component of acute hepatitis.
In past, decompensated by large ascites, currently without
significant volume overload or HE. MDF increased during stay due
to INR/Tbili bump on ___. Dx para on ___ negative for SBP.
Infectious workup otherwise remained negative so far. Received
Vit K 10mg IV daily x2 days (___) which assisted with INR.
Avoided steroids initially given bleeding, however, continue to
hold currently (even w/o further bleeding) given concern for
long term placement on prednisone without follow up. She was
restarted on diuretics, escalated to 40mg Lasix and 100mg
spironolactone, in addition to having remained on ursodiol.
Although her TBili remained elevated at the time of discharge,
it did demonstrate a potential peak. She was strongly
recommended by her medical team to remain in-house for further
stabilization of labs, however was adamant about needing to
return home for personal matters. She understood the risks,
including liver failure, bleeding, serious infections among
other sequela. She agreed to short-term f/u in clinic with Dr.
___.
#Coagulopathy: INR elevated in setting of cirrhosis, likely poor
nutrition as well. s/p vitamin K 5x1 in ICU and IV Vit K 10mg on
floor on ___ to which her INR improved. Received nutritional
supplements in house.
#EtOH Use:
Likely exacerbated relapse in setting of relationship and work
stressors, emphasis on the latter per pt. She is likely
suffering from underlying mood and anxiety disturbances given
endorsed insomnia and prior benzo prescriptions. Received
thiamine, folate, MV, SW recs, and consider transitional issue
of psychiatric pharmacotherapy for specific stressors given
presentation.
CHRONIC ISSUES:
#Hx of seizure disorder: Continued keppra 500 mg BID
#Electrolyte derangements: Hypokalemia, hypomagnesemia and
hypophosphatemia
Likely ___ nutritional deficiency with a degree of re-feeding.
Received Neutra-phos PRN, and lytes repletion PRN.
#Thrombocytopenia: Both splenomegaly and chronic ETOH use,
overall stable.
TRANSITIONAL ISSUES:
- discharge Hgb: 8.6
[ ] Please follow up Tbili, LFTs and CBC at next clinic visit in
the immediate week following d/c to ensure appropriate
downtrending.
[ ] Please consider initiation of pharmacotherapy to assist with
crhonic anxiety and stressors such as buspirone or short-term
benzodiazepines PRN.
#Contact: Pt states that she would like to make her daughters
father the HCP. ___: ___ or ___.
#Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LevETIRAcetam 500 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Ursodiol 300 mg PO BID
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
3. LevETIRAcetam 500 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. Ursodiol 300 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Hematochezia
Hemorrhoidal bleeding
Alcoholic hepatitis
Acute anemia
SECONDARY:
Cirrhosis
Alcohol 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 to ___ because you had bleeding from the
rectum.
WHILE YOU WERE HERE:
- You had a flexible sigmoidoscopy (video to look at the rectum
and sigmoid colon). This showed hemorrhoids.
- You received 5 blood tranfusions to replete the amount that
you lost during your active bleed.
- Your blood cell counts remained stable following these
transfuions and monitoring.
- You were seen by the colorectal surgery team who did not
recommend any intervention while you were inpatient.
- Your bilirubin levels, a marker of your liver's decreased
ability to clear natural breakdown products in your body, kept
increasing with a slight decrease on the day of discharge. This
may be concerning for cotnineud liver damage and increased risk
of infection.
WHEN YOU GO HOME:
- Make sure if come back to the hospital if you develop any
fevers (temperature >100.4 F) or are having chills or worsening
symptoms.
- Please make sure you go to your appointment with Dr. ___ to
be scheduled this coming week of ___.
- Make sure you keep your stools soft by using stool softeners.
- You can use the hemorrhoid suppository to help.
- Your medications and appointments are below.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19788100-DS-7
| 19,788,100 | 29,654,295 |
DS
| 7 |
2185-01-09 00:00:00
|
2185-01-09 20:52:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o F w/ PMHx ___, not no
immunosuppression for the past 2 months, who presents with lower
abdominal pain.
Patient states that abdominal pain started around a week ago. It
is located in the lower parts of her stomach, and described as
cramping. It was progressively worsening. The day prior to
admission she also developed nausea and had an episode of
vomiting. She otherwise reports no fevers or chills, no diarrhea
or bloody bowel movements.
On review of records, patient was last seen in GI clinic on
___. At that time she was taking Humira with seemingly good
affect. However, patient reports that since that visit she
developed a worsening rash around her left ear, and around 2
months ago her Humira was stopped. She had a colonoscopy in ___
with significant ulceration and friability in the distal 5cm of
the terminal ileum.
In the ED:
Initial vital signs were notable for: T 97.5, HR 100, BP 102/69,
RR 18, 100% RA
Exam notable for:
Abd: There is tenderness over the suprapubic and RLQ with some
mild guarding. There is no rebound tenderness. Negative
Rovsing's. Negative ___.
Labs were notable for:
- CBC: WBC 9.8 (65%n), hgb 12.3, plt 392
- Lytes:
141 / 101 / 7 AGap=15
-------------- 96
4.4 \ 25 \ 0.5
- LFTs: AST: 8 ALT: <5 AP: 73 Tbili: <0.2 Alb: 3.6
- lipase 12
- CRP 90
- lactate 0.9
Studies performed include:
- CT a/p with approximately 25 cm long continuous diseased
segment of distal and terminal ileum demonstrating acute on
chronic inflammation compatible with Crohn disease, in a similar
distribution to that seen on the prior MR enterography. There is
upstream bowel dilatation without frank obstruction. No fluid
collections or fistulas.
Consults: GI was consulted, recommending patient be NPO,
cipro/flagyl, send cdiff, avoid nsaids/opioids. They will staff
in AM.
Patient was given: none
Vitals on transfer: T 98.8, HR 88, BP 105/74, RR 16, 97% RA
Upon arrival to the floor, patient recounts history as above.
She
states that she is hungry, but does not have much pain or
nausea.
She is hoping to go home in the morning.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- crohns, diagnosed ___
- anxiety
- depression
- B12 deficiency
- iron deficiency
- anemia
- ?psoriasis
- s/p c section
Social History:
___
Family History:
Brother has ___ disease. No FH of colon
cancer.
Physical Exam:
ADMISSION EXAM:
VITALS: T 98.1, HR 82, BP 93/61, RR 16, 96 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, non-distended, moderately tender to palpation
in lower quadrants, L>R, without rebound or guarding. 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:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs
CV: RRR no m/r/g
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
MSK: No erythema or swelling of joints
SKIN: No rashes or ulcerations noted
EXTR: wwp no edema
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 05:05PM WBC-9.8 RBC-4.85 HGB-12.3 HCT-39.6 MCV-82
MCH-25.4* MCHC-31.1* RDW-15.9* RDWSD-47.9*
___ 05:05PM NEUTS-65.6 ___ MONOS-7.9 EOS-0.8*
BASOS-0.4 IM ___ AbsNeut-6.44* AbsLymp-2.47 AbsMono-0.78
AbsEos-0.08 AbsBaso-0.04
___ 05:05PM PLT COUNT-392
___ 05:05PM GLUCOSE-96 UREA N-7 CREAT-0.5 SODIUM-141
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
___ 05:05PM ALT(SGPT)-<5 AST(SGOT)-8 ALK PHOS-73 TOT
BILI-<0.2
___ 05:05PM LIPASE-12
___ 05:05PM ALBUMIN-3.6
___ 05:05PM CRP-90.0*
INTERVAL DATA:
___ 10:30AM STOOL CDIFPCR-POS* CDIFTOX-POS*
___ 05:05PM BLOOD CRP-90.0*
___ 05:57AM BLOOD CRP-66.6*
___ 06:41AM BLOOD CRP-43.0*
___ 06:32AM BLOOD CRP-13.8*
- ___ CT a/p w/ contrast:
1. Approximately 25 cmlong continuous diseased segment of distal
and terminal ileum demonstrating acute on chronic inflammation
compatible with Crohn disease, in a similar distribution to that
seen on the prior MR enterography. There is upstream bowel
dilatation without frank obstruction. No fluid collections or
fistulas.
2. Reactive mesenteric lymphadenopathy in the right lower
quadrant.
3. Normal appendix.
- ___ Colonoscopy:
- Mild erythema and few erosions in the whole colon.
- Polyp (2 mm) in the rectum
- Narrowing at the IC valve. Significant ulceration and
friability in the distal 5cm of the terminal ileum. There
appeared to be sparing from 5cm-10cm until another narrowing
that
could not be traversed due to a combination of looping and
narrowing.
Brief Hospital Course:
SUMMARY:
___ y/o F w/ PMHx ___, not on immunosuppression for the past
2 months, who presented with lower abdominal pain and was found
to have a c diff infection and a Crohns flare. She was started
on PO vancomycin for C diff infection and steroids for Crohns
flare.
PROBLEM BASED HOSPITAL COURSE:
# Crohns flare
# C diff infection
Patient presenting with increased abdominal pain in the setting
of being off of immunosuppression for 2 months for her Crohns
disease. CT scan concerning for acute on chronic inflammation
and CRP elevated at 90 consistent with Crohns flare. C diff
testing came back positive. GI was consulted. She was started
on IV steroids for Crohns flare and PO vancomycin for C diff
(total 14 days). She improved. She is transitioned to PO
prednisone 40 mg daily at discharge. She was also started on
ranitidine for some dyspepsia with initiation of prednisone.
Follow-up will be scheduled with Dr. ___ will determine
further treatment course and whether there is need for PCP ppx,
more aggressive GI ppx, or bone ppx.
# Tobacco use
Counseled on smoking cessation. Declined nicotine patch.
# Vitamin D deficiency
Continued home vit D
# Vitamin B12 deficiency
Continued home vit B12 supplements
==============
==============
TRANSITIONAL ISSUES:
[] close follow-up with Dr. ___ to determine further treatment
course, including decision of whether will need PCP ___
==============
==============
>30 minutes in patient care and coordination of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin ___ mcg PO DAILY
2. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. PredniSONE 40 mg PO DAILY
40 mg daily for now. Dr. ___ to determine final plan
RX *prednisone [Deltasone] 20 mg 2 tablet(s) by mouth once a day
Disp #*42 Tablet Refills:*0
2. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
3. Vancomycin Oral Liquid ___ mg PO QID
for 12 more days
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*48 Capsule Refills:*0
4. Cyanocobalamin ___ mcg PO DAILY
5. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
C diff infection
Crohns flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with abdominal pain and were diagnosed
with a c diff bacterial infection in the bowel, as well as a
Crohns flare. You are prescribed an antibiotic called
vancomycin to treat the c diff infection. You are prescribed a
steroid medication called prednisone to treat the Crohns flare.
You should hear from Dr. ___ office in the next few days to
schedule an appointment, at which time she will discuss with you
the ongoing treatment plan.
Followup Instructions:
___
|
19788141-DS-8
| 19,788,141 | 27,733,659 |
DS
| 8 |
2179-07-28 00:00:00
|
2179-07-30 21:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
neck pain
Major Surgical or Invasive Procedure:
anterior cervical dissection and fusion of C5-7 (___)
History of Present Illness:
___ year old woman with neck pain, LUE radiculopathy, MRI showing
cord narrowing/compression who is admitted for pain control and
consideration of surgical management.
Ms. ___ has had neck pain with radiation down left arm
for ___ months since helping her daughter move in ___ (she
was carrying a refrigerator out of dorm), however this acutely
worsened over last ___ weeks. Pain is sharp, worse with
standing, worse with movement, and the neck and upper back,
radiating down the left arm, described as burning. She has no
weakness. She was seen in the ED at ___ on
___, and was told to follow-up with her outpatient sports
medicine physician who has been concerned she may be developing
frozen shoulder. She also had an MRI done, ordered by her
chiropractor, showing multilevel disc protrusion from C3-C5 with
spinal cord impingement and impingement of the left neural
foramina. Her pain has severally limited her ability to sleep,
she has noticed rare gait unsteadiness but no falls.
No trauma, no other inciting event beyond move mentioned above,
no fevers/chills, no history of IVDU, no personal nor family
history of malignancy. No bowel or bladder incontinence.
Past Medical History:
- remote history of ? ulcer (never had EGD, no h/o GI bleed)
- colonic polyp
Social History:
___
Family History:
mother has had cancer no other diseases run in
family
Physical Exam:
ADMISSION EXAM:
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck full range of motion, +spurling on left
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally both patellar
and Achilles, right brachioradilais 3+ vs 2+ on left. Babinski
is downgoing.
Pertinent Results:
ADMISSION LABS:
___ 01:33PM BLOOD WBC-6.9 RBC-4.28 Hgb-13.9 Hct-40.2 MCV-94
MCH-32.5* MCHC-34.6 RDW-11.9 RDWSD-41.1 Plt ___
___ 01:33PM BLOOD ___ PTT-22.2* ___
___ 01:33PM BLOOD Glucose-137* UreaN-11 Creat-0.7 Na-139
K-3.8 Cl-105 HCO3-23 AnGap-11
___ 01:33PM BLOOD Calcium-9.3 Phos-3.4 Mg-1.8
MRI C-spine in lifeimage with C5-6 posterior disc protrusion and
C6-7 posterior disc protrusion, with compression noted on the C7
nerve root.
Brief Hospital Course:
SUMMARY:
___ year old woman with neck pain, LUE radiculopathy, and MRI
showing cord narrowing/compression who was admitted for pain
control and elective anterior cervical dissection and fusion.
HOSPITAL ___:
# neck pain:
# C6-C7 disc protrusion with spinal cord narrowing:
Patient appeared neurovascuaraly intact without alarm symptoms,
no reason to suspect infections or malignant etiologies. CRP was
normal. Pain did not improve after first two nights with
conservative pain management (naproxen, Tylenol, tizanidine,
gabapentin), and patient continued to have significant pain
especially with standing or sitting up. Elected to undergo ACDF
of C5-7 on ___. After the operation, the patient had
___ soreness, but pain in the neck and arm had
improved significantly. She was able to tolerate liquids and
pain was well managed at time of discharge.
TRANSITIONAL ISSUES:
- Will follow up with Dr. ___ as outpatient in ___ days.
Patient will call office to schedule.
Medications on Admission:
1. Lidocaine 5% Patch 1 PTCH TD QPM
2. PredniSONE 60 mg PO DAILY
3. Tizanidine 4 mg PO TID:PRN spasms
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QPM
Discharge Disposition:
Home
Discharge Diagnosis:
cervical spondylosis
Discharge Condition:
Awake and alert / vss/ ambulating independently
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted for your neck pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You had an operation called an anterior cervical discectomy &
fusion to relieve your neck pain
- Your pain and inflammation were treated with pain medications
and steroids.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Wear your collar when you are walking. You do not need to wear
it when you are at rest.
- You may remove the dressing from the wound in one day. You do
not need to remove the sutures. They are self dissolving.
- Avoid direct water to the wound. Place saran wrap around the
wound when bathing.
- Follow up with Dr. ___ in ___ days. Call his office to set
up an appointment at ___.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19788237-DS-6
| 19,788,237 | 25,989,336 |
DS
| 6 |
2133-07-21 00:00:00
|
2133-07-21 21:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
PCP: ___. ___ Affil Mds
CC: abdominal pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Dr. ___ is a ___ male past medical history of recent
admission for severe biliary pancreatitis, discharged 2 weeks
ago, who presents with abdominal pain.
On review of records, patient was admitted from
___ as a transfer from ___
for gallstone pancreatitis. He was admitted to the surgical
service. He was treated for pain with a morphine PCA and IV
tylenol. However, after a few days he was noted to have an
increase in alk phos, and a CT scan was done showing necrosis.
Despite this hi continued to clinically improve and his diet as
able to be advanced. He was also seen by GI-Pancreas team prior
to discharge with plan in place for clinic follow-up.
Patient reports that at time of discharge he was asymptomatic,
and has been pain-free until the day of admission. Around noon
he developed acute onset severe, sharp epigastric pain, with
radiation to the back. This is similar to the prior episode
leading to his last admission, though he notes that the prior
pain was more gnawing compared to this. He has not had any
fevers, nausea, or vomiting, and no change in bowel movements.
He called ___ clinic and was referred to the ED.
In the ED:
Initial vital signs were notable for: T 97, HR 92, BP 156/102,
RR 18, 99% RA
Exam notable for:
Constitutional: Very uncomfortable, sitting hunched over
Abd: Rigid, with voluntary guarding, focally tender in the
epigastrium, no rebound or guarding.
Extremities: Region over the left flank of what appears to be
livedo reticularis, but states that this is been present for
months.
Labs were notable for:
- CBC: WBC 13.0 (82%n), hgb 12.8, plt 544
- Lytes:
136 / 97 / 10 AGap=15
-------------- 155
4.4 \ 24 \ 1.0
- LFTs: AST: 23 ALT: 29 AP: 87 Tbili: 0.4 Alb: 4.7
- lipase 122
- INR 1.3
- lactate 3.8 -> 1.5
Studies performed include:
- CXR with no acute process
- RUQUS with: The pancreas is not visualized due to overlying
bowel gas. Innumerable echogenic foci within the somewhat
distended gallbladder likely representing cholelithiasis and
gallbladder sludge without other evidence of acute
cholecystitis.
Consults:
- Surgery was consulted, recommending: Fluid resuscitation,
trend lactate. Pain control. If admission necessary, admission
to medical service would be appropriate. ___ surgery will
follow along.
- Case discussed with pancreas fellow who recommended RUQUS and
admission to medicine for fluids and pain control
Patient was given:
___ 15:43 IV Morphine Sulfate 4 mg
___ 15:43 IV Ondansetron 4 mg
___ 16:12 IV Morphine Sulfate 4 mg
___ 17:13 IVF LR 1000 mL
___ 18:36 IVF LR 1000 mL
___ 19:05 IV Morphine Sulfate 4 mg
___ 19:48 IV Morphine Sulfate 4 mg
___ 20:36 IVF LR ( 1000 mL ordered)
___ 20:46 IV Morphine Sulfate 8 mg
___ 22:25 IV Morphine Sulfate 4 mg
Vitals on transfer: T 97.3, HR 89, BP 144/92, RR 18, 100% RA
Upon arrival to the floor, patient recounts history as above. He
notes that pain control in the ED has been an issue. He states
that last admission he was requiring high doses of morphine, up
to 10mg an hour.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- severe gallstone pancreatitis with necrosis ___
- small fiber neuropathy on lyrica
- ACL repair
- s/p tonsillectomy age ___
- inguinal hernia repair ___
Social History:
___
Family History:
No family hx of pancreatitis. Mother with hx of cholecystitis
s/p
cholecystectomy
Physical Exam:
ADMISSION EXAM
VITALS: T 97.8, HR 85, BP 116/71, RR 18, 97% RA
GENERAL: Alert and in no apparent distress, appears in mild
discomfort
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, moderately tender in LUQ,
significant epigastric tenderness, limiting exam. 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
24 HR Data (last updated ___ @ 745)
Temp: 99.0 (Tm 99.0), BP: 125/74 (125-141/74-88), HR: 105
(84-105), RR: 18, O2 sat: 94% (94-99), O2 delivery: Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs
CV: RRR no m/r/g
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.
MSK: No erythema or swelling of joints
SKIN: No rashes or ulcerations noted
EXTR: wwp no edema
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric
PSYCH: pleasant, appropriate affect
Pertinent Results:
LABS
CBC
___ 03:33PM BLOOD WBC-13.0* RBC-5.44 Hgb-12.8* Hct-40.8
MCV-75* MCH-23.5* MCHC-31.4* RDW-14.3 RDWSD-37.9 Plt ___
___ 05:25AM BLOOD WBC-6.2 RBC-4.52* Hgb-10.5* Hct-33.9*
MCV-75* MCH-23.2* MCHC-31.0* RDW-14.5 RDWSD-39.4 Plt ___
___ 05:45AM BLOOD WBC-6.8 RBC-4.28* Hgb-10.0* Hct-32.7*
MCV-76* MCH-23.4* MCHC-30.6* RDW-14.6 RDWSD-39.9 Plt ___
COAG
___ 03:33PM BLOOD ___ PTT-33.6 ___
BMP
___ 03:33PM BLOOD Glucose-155* UreaN-10 Creat-1.0 Na-136
K-4.4 Cl-97 HCO3-24 AnGap-15
___ 05:25AM BLOOD Glucose-114* UreaN-8 Creat-1.0 Na-138
K-4.9 Cl-99 HCO3-25 AnGap-14
___ 05:45AM BLOOD Glucose-94 UreaN-6 Creat-0.9 Na-141 K-4.5
Cl-99 HCO3-29 AnGap-13
OTHER CHEM
___ 03:33PM BLOOD ALT-29 AST-23 AlkPhos-87 TotBili-0.4
___ 05:45AM BLOOD ALT-14 AST-12 AlkPhos-62 TotBili-0.5
___ 03:33PM BLOOD Lipase-122*
___ 03:33PM BLOOD Albumin-4.7 Calcium-10.3 Phos-2.0* Mg-1.9
___ 05:25AM BLOOD Calcium-9.1 Phos-5.0* Mg-1.8
___ 05:45AM BLOOD Calcium-9.1 Phos-5.0* Mg-1.8
___ 03:46PM BLOOD Lactate-3.8*
___ 07:57PM BLOOD Lactate-1.5
MICRO: Reviewed in OMR, significant for:
- ___ blood cultures x2 - pending
- ___ urine culture - NG
___ RUQUS
IMPRESSION:
Limited examination due to pain.
1. The pancreas is not visualized due to overlying bowel gas.
2. Innumerable echogenic foci within the somewhat distended
gallbladder likely representing cholelithiasis and gallbladder
sludge without other evidence of acute cholecystitis, similar to
reference ultrasound dated ___.
MRCP ___ (PRELIMINARY)
1. Redemonstration of acute hemorrhagic pancreatic necrosis
with no
significant change in extent of pancreatic necrosis and interval
increased
organization of a 9.7 cm acute peripancreatic fluid collection
surrounding the
area of necrosis in the pancreatic neck and body. A segment of
pancreatic
duct spanning approximately 2.5 cm within this area of necrosis
is not well
seen and may be disrupted.
2. Increased attenuation of the portal vein, splenic vein and
SMV at the
portal confluence, with severe attenuation of the proximal SMV
which likely
Brief Hospital Course:
#Necrotizing gallstone pancreatitis
#Suspected pancreatic duct disruption
#Peripancreatic collection
___ is a ___ year old man who recently developed severe
necrotizing pancreatitis and has been awaiting outpatient
cholecystectomy, who presented within two weeks of discharge due
to worsening epigastric pain. The initial concern was for
recurrent acute pancreatitis. however his LFTs were normal and
after reviewing MRCP images and his clinical course, the
pancreatology team felt that duct disruption and ongoing related
peripancreatic collection might better explain his symptoms.
Neither the surgery nor the pancreatology team recommended any
further inpatient procedures. He was able to tolerate a diet
prior to discharge. He will follow-up closely with both teams
for likely advanced endoscopic intervention and ultimately
cholecystectomy. He was discharged with one week of PRN
oxycodone and low dose ativan for anxiety and sleep. He was
counseled on safe use of these medications.
# Neuropathy
- continue home pregabalin
============================
TRANSITIONAL ISSUES:
- close follow-up with pancreatology and surgery
============================
>30 minutes in patient care and coordination of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pregabalin 200 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. LORazepam 0.5 mg PO QHS:PRN sleep/anxiety
RX *lorazepam [Ativan] 0.5 mg 0.25-0.5 mg by mouth nightly as
needed Disp #*7 Tablet Refills:*0
3. Melatin (melatonin) 3 mg oral QHS
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four hours as
needed Disp #*35 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO BID:PRN Constipation - First
Line
6. Pregabalin 200 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Necrotizing pancreatitis
Peripancreatic collection
Possible pancreatic duct disruption
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 due to abdominal pain. Based
on the imaging, we are concerned about a possible disruption of
the pancreatic duct, resulting in an ongoing peripancreatic
collection. You were seen by the gastroenterology and surgical
teams, who will follow-up with you closely as an outpatient. You
may need an advanced endoscopic procedure to address this issue
and also will likely need your gallbladder removed. We have
prescribed you a brief course of oxycodone for pain and Ativan
for sleep. Please follow the important safety precautions we
discussed while taking these medications, including no driving,
working, or other potentially dangerous activities while taking
them.
Followup Instructions:
___
|
19788295-DS-8
| 19,788,295 | 23,441,175 |
DS
| 8 |
2167-09-15 00:00:00
|
2167-09-15 16:21:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / trimethoprim
Attending: ___.
Chief Complaint:
bilateral SDHs and right temporal intracranial hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ year old man with a past medical history of
PD, afib not on anticoagulation ___ falls, HTN, and COPD who
presents today with confusion. He was initially brought to ___, and was transferred here upon finding of left
hemispheric
SDH and left temporal IPH. History is obtained from his son who
is in the room.
The patient lives in an assisted living facility, and has
regular
home health aides with him about 16 hours a day (they are gone
from about 10pm to 8am). He had reportedly been in his usual
state of health on ___, and his son talked to him on the
phone (although, there is some concern for confusion as he
called
his daughter many times for his son's phone numbers, which he
had
and usually knows this). His other son was at the patient's
house
for dinner last night and did not note anything unusual. Then,
this morning, when his regular home health aide came to see him,
she felt that he was somewhat confused. Not many details are
available, however it seems he was innattentive, and had to be
fed, which is unusual. The aide put him in his recliner, and he
seemed "out of it." She talked to his family, and the plan was
to
check his urine for a UTI. Around 3pm, a new aide came, and she
could not rouse him. Therefore he was brought to ___.
There, he was noted to have a left facial droop and drift. Heart
rate 90-130s, BP unknwon. ___ showed an acute left SDH and
left
temporal IPH. Labs, including BMP, CBC, LFTs, and coags were
wnl.
Troponin was 0.05. He was transferred to ___ ___ where
neurology
was called.
He has had no falls or head injuries that anyone knows of. He
has
a urinal with him in bed, so son does not think that he gets out
of bed to go to the bathroom in the middle of the night. The son
thinks it is unlikely he had an unwitnessed fall because if he
did, he would not be able to get himself up off the floor. When
asked if he hit his head, he says "no."
At baseline, he has hypophonia and trouble getting his words out
(freezing when talking) and has speech therapy. Otherwise he is
described as "very sharp and alert" (would know the date, the
president, etc). He can still prepare meals. (esually
microwaves). He mainly uses a wheelchair to get around. He has
frozen shoulders, torn rotator cuffs, R>L. He has had
___
for about ___ years. He has not missed any medicines.
ROS not obtained due to altered mental status/aphasia. He denies
pain.
Past Medical History:
- ___ Disease
- Afib ___ ___ not anticoagulated due to falls)
- HTN
- COPD
- C1 fracture ___
- chronic venous stasis (___)
- h/o traumatic injury to LLE
- carpal tunnel syndrome
- cellulitis
- high grade neuroendocrine ampullary tumor w/ ? liver mets (s/p
Whipple at ___)
Social History:
___
Family History:
NC
Physical Exam:
Physical Exam on Admission:
Physical Exam:
Vitals: 99.5 90 141/71 16 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Lying in bed with eyes closed, opens to voice.
Limited verbal output, follows commands. Attends to both sides
and looks to both sides but does not fully look to the right
(requires encouragement). Follows midline and appendicular
commands. +grasp reflex b/l.
-Cranial Nerves:
I: Olfaction not tested.
II: Left pupil 2-->1.5, right 1.5 minimally reacts. Blinks to
threat consistently on the left, appears to have right upper
field cut. III, IV, VI: EOMI without nystagmus except some
difficulty with rightward gaze as above, crosses the midline.
Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, increased tone throughout. Right pronator
drift. No adventitious movements, such as tremor, noted. No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
___ Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No tremor or dysmetria noted.
-Gait: Not tested.
Physical Exam on Discharge:
afebrile, normotensive
MS - awake, alert, regards examiner, able to follow midline and
appendicular commands, unable to give name/location/date, able
to repeat one word, motor persistence
CN - blinks to threat in all quadrants, restriction of gaze in
all directions (vertical and horizontal > lateral), face is
grossly symmetric at rest and with activation, hearing intact to
loud voice, voice is severely hypophonic, tongue is midline
MOTOR - +paratonia and cogwheeling (RUE > LUE), no adventitious
movements noted; downward drift with LUE, no pronator drift
appreciated, increased tone in B/L ___ ___nd
LUE; briefly antigravity with B/L IPs, R TA and Gas ___, L TA
5-, L Gas 5
SENSORY - withdraws to nox in B/L ___ - +glabellar, +grasp (L>R)
COORD - no gross evidence of truncal or appendicular ataxia
Pertinent Results:
Relevant Labs:
___ 07:08PM WBC-7.0 RBC-4.46* HGB-11.7* HCT-35.6*
MCV-80*# MCH-26.2* MCHC-32.8 RDW-14.9
___ 07:08PM NEUTS-81.9* LYMPHS-11.5* MONOS-5.5 EOS-0.8
BASOS-0.3
___ 07:08PM ___ PTT-34.3 ___
___ 03:56AM GLUCOSE-117* UREA N-21* CREAT-0.6 SODIUM-138
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-27 ANION GAP-12
___ 03:56AM ALT(SGPT)-3 AST(SGOT)-13 LD(LDH)-155
CK(CPK)-108 ALK PHOS-98 TOT BILI-0.7
___ 03:56AM %HbA1c-5.9 eAG-123
___ 03:56AM TSH-0.56
___ 03:56AM TRIGLYCER-49 HDL CHOL-37 CHOL/HDL-2.7
LDL(CALC)-53
Imaging:
___ ___
Small left-sided temporal lobe conclusion and small subdural
collection again identified. No significant interval change is
seen. A right inferomedial frontal the encephalomalacia is again
identified. There is no acute hemorrhage seen. There is no
midline shift or hydrocephalus. Bilateral cerebellar
calcifications are seen.
MRI/A brain ___. Unchanged left temporal lobe intraparenchymal hematoma as
described in
detail above. Unchanged areas of encephalomalacia on the frontal
lobes and left basal ganglia.
2. Bilateral subdural collections are seen with no significant
mass effect, more evident on the left side causing mild midline
shifting of the normally midline structures towards the right.
Small trace of intraventricular blood is identified in the right
occipital ventricular horn.
3. Unremarkable MRA of the head with no evidence of flow
stenotic lesions or aneurysms. Unremarkable MRV of the head with
no evidence of dural venous sinus thrombosis.
Chest xray
Lung volumes are lower today, but mild cardiomegaly is stable.
Lungs are
grossly clear. There is no pleural abnormality.
Brief Hospital Course:
Mr. ___ is an ___ M w PMHx of PD, AFib not on anticoagulation
___ falls, HTN, and COPD who presents today with complaint of
confusion at home. He was initially brought to ___ and was
transferred to ___ after ___ showed left hemispheric SDH and
left temporal IPH as well as very small R sided SDH. Although
there is no history of any trauma, the location and different
types of bleed are most consistent with a traumatic mechanism.
Also, patient does have frequent falls at home. It is also
possible that he struck his head on something and does not
remember this.
#NEUROLOGY -
L SDH, L temporal IPH, small R SDH.
NCHCT was stable day after admission. MRI/A head showed no
evidence of infarct, mass, vascular malformation, or VST. He
was started on Keppra for a 7 day course of seizure prophylaxis.
That should be discontinued after ___. His aspirin has been
held in the setting of the hemorrhage. Aspirin 81mg can be
re-started on ___.
History of PD: home sinemet and selegine were continued. It is
imperative that the patient takes these medications regularly.
#CV
Patient has known afib. Heart rates were slightly elevated to
the mid teens and home metoprolol was increased from 25mg bid to
37.5mg bid. He is not on anticoagulation as he is at high risk
for fall. Lasix was discontinued as it was not needed.
TRANSITIONS OF CARE:
- Keppra 500mg bid should be discontinued after ___
- Aspirin 81mg can be re-started on ___.
Medications on Admission:
Carbidopa-Levodopa (___) 1 TAB PO QID (8am, noon, 4pm, 8pm)
- Carbidopa-Levodopa CR (50-200) 1 TAB PO HS (11pm)
- Selegiline HCl 5 mg PO BID (8am, 4pm)
- Aspirin 325 mg PO DAILY
- Metoprolol Succinate XL 25 mg PO HS
- Lasix 40mg PO as needed for ___ edema
- Loratidine 10mg daily
- MV daily
- Miconazole Powder 2% 1 Appl TP TID:PRN rash
- OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
- Acetaminophen 650 mg PO Q8H
- Docusate Sodium 100 mg PO BID
- Senna 17.2 mg PO HS
- Ascorbic Acid ___ mg PO BID
- Fluticasone Propionate NASAL 1 SPRY NU BID
Discharge Medications:
1. Carbidopa-Levodopa (___) 1 TAB PO QID
2. Carbidopa-Levodopa CR (50-200) 1 TAB PO QHS
3. Selegiline HCl 5 mg PO BID
4. Senna 8.6 mg PO BID:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC TID
7. LeVETiracetam 500 mg PO BID
LAST DAY OF ADMINISTRATION SHOULD BE ___ DISCONTINUE ON ___. Metoprolol Tartrate 37.5 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left SDH/temporal IPH and small R SDH
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with confusion and were found
to have bleeding in your brain. We think this is most likely
due to trauma to your head. We did an MRI brain which did not
show any other explanations for the bleeding. You can re-start
your aspirin on ___. After discharge, you will follow
up in stroke neurology clinic with Dr. ___. The office will
call you to schedule this. In case you need it, the # is ___.
The following changes were made to your medications:
STOP
Aspirin 325mg
Lasix 40mg
START
Aspirin 81mg on ___
INCREASE
Metoprolol to 37.5mg bid
It was a pleasure taking care of you, we wish you all the best!
Followup Instructions:
___
|
19788382-DS-5
| 19,788,382 | 23,706,687 |
DS
| 5 |
2170-08-07 00:00:00
|
2170-08-08 08:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___
Chief Complaint:
fall, weakness, bradycardia
Major Surgical or Invasive Procedure:
Dual chamber pacemaker placement ___
History of Present Illness:
Mr. ___ is a ___ year old man with a history of hairy cell
leukemia s/p cladribine on ___ who presented to the ER with
generalized weakness and a fall the day prior to admission. He
reports feeling unwell for the past few days with fatigue and
according to his wife has been eating and drinking much less.
He cannot recall if he experienced any lightheaded symptoms
prior to the fall and does not know the circumstances
surrounding the fall. He was recently in a rehab facility after
receiving Cladribine and was treated for PNA with levaquin, now
home and off abx.
In the emergency department, initial vitals: 97.8 71 121/71 18
100%. CXR and head CT were clear. ECG showed a junctional
rhythm with a rate of 69 bpm. No ST/T changes.
.
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. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Atrial fibrillation (not on anticoagulation)
systolic/diastolic heart failure (EF 30%)
hypertension/LVH
hairy cell leukemia
memory loss
Shatzki's ring
hiatal hernia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: BP 98.3 BP 99/66 HR 65 RR18 96%RA
GENERAL: alert and oriented, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: NABS. Soft, mildly distended abdomen without
tenderness.
EXTREMITIES: trace peripheral edema, 2+ dorsalis pedis/
posterior tibial pulses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. ___ reflexes,
equal ___. Gait assessment deferred
DISCHARGE PHYSICAL EXAM:
VS: T: 97.4 BP: 120/79 (90-126/56-93) HR:90 RR:16 O2 sat: 96%RA
GENERAL: WDWN male in NAD. Oriented x3.
NECK: Supple without elevated JVP.
CARDIAC: regular rate, rhythm, normal S1/S2, II/VI systolic
murmur at base.
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, minimal TTP in lower abdomen. No HSM or
tenderness. EXTREMITIES: WWP, 1+ ankle edema.
PULSES: equal and 2+ bilaterally
Pertinent Results:
___ 05:45PM BLOOD WBC-2.4*# RBC-3.43* Hgb-11.3* Hct-35.5*
MCV-104*# MCH-33.1* MCHC-31.9 RDW-18.6* Plt ___
___ 05:45PM BLOOD Neuts-92.5* Lymphs-4.7* Monos-0.8*
Eos-2.0 Baso-0.1
___ 05:45PM BLOOD Glucose-118* UreaN-37* Creat-1.8* Na-138
K-4.7 Cl-101 HCO3-27 AnGap-15
___ 05:45PM BLOOD ALT-21 AST-35 CK(CPK)-52 AlkPhos-183*
TotBili-1.7* DirBili-0.7* IndBili-1.0
___ 05:45PM BLOOD cTropnT-0.18*
___ 05:45PM BLOOD CK-MB-4 ___
___ 05:45PM BLOOD Albumin-3.6 Calcium-9.2 Phos-3.7 Mg-2.1
___ CXR:
Slight interval increase in size of moderate left pleural
effusion. Left basilar opacity likely reflects atelectasis.
Trace right pleural effusion also noted. Mild pulmonary
vascular congestion, similar compared to the prior study.
___ Head CT:
No intracranial hemorrhage or acute territorial infarction.
___ ECG:
junctional rhythm at ___hanges.
2D-ECHOCARDIOGRAM (___): The left atrium is moderately
dilated. The right atrium is moderately dilated. The estimated
right atrial pressure is ___ mmHg. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is
moderately depressed (LVEF= ___ %) secondary to severe
hypokinesis of the inferior and infero-lateral walls and mild
hypokinesis of the remaining segments. The LV apex contracts
best. Right ventricular chamber size is normal. with moderate
global free wall hypokinesis. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
left ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. [In the setting of at least moderate to
severe tricuspid regurgitation, the estimated pulmonary artery
systolic pressure may be underestimated due to a very high right
atrial pressure.] There is a trivial/physiologic pericardial
effusion.
DISCHARGE LABS:
___ 08:51AM BLOOD WBC-1.6* RBC-2.93* Hgb-9.8* Hct-30.2*
MCV-103* MCH-33.5* MCHC-32.4 RDW-18.3* Plt ___
___ 08:51AM BLOOD Glucose-128* UreaN-33* Creat-1.4* Na-137
K-4.4 Cl-102 HCO3-28 AnGap-11
Brief Hospital Course:
Mr. ___ is a ___ y/o M with PMH significant for atrial
fibrillation, systolic & diastolic heart failure (EF 30%),
hypertension, and hairy cell leukemia who was admitted to the
oncology service with weakness and lethargy and was noted to
have bradycardia was transferred to ___ for management of
symptomatic bradycardia.
# Symptomatic Bradycardia: Pt was noted to have HRs in the ___
on the onc service, which while not associated with syncope, may
be leading to symptoms of weakness and lethargy. His recent
decline in functional status may be due to bradyarrhythmia. He
was on a beta-blocker at low dose which was stopped. Despite
this, he continued to be bradycardic in the ___ and ___. Since
patients weakness and lethargy could be from the bradycardia it
was discussed with patient and family and decided that a
pacemaker would be implanted to treat the bradycardia with the
hope that this would improve his current symptoms. Pt had a dual
chamber PPM permanent pacemaker placed on ___. He also had
episodes of AVNRT so metoprolol succinate 25 mg PO daily was
restarted. He was discharged on Cephalexin 250 mg PO Q8H
Duration for 2 days for prophylaxis for pacemaker placement.
# Atrial Fibrillation: CHADS2 score of ___ so should be on
anticoagulation but is not currently. We held anticoagulation
given that he needed a pacemaker insertion. Spoke with
outpatient cardiologist who wants to hold off on anticoagulation
given patients history of multiple prior falls at this time. Pt
will consider starting coumadin when he follows up with his
outpatient cardiologist.
# chronic systolic & diastolic heart failure (EF 30%): We
stopped his beta-blocker given his symptomatic bradycardia. We
continued aspirin 325 mg PO DAILY. Would consider starting
lisinopril 2.5 mg daily as outpatient if renal function and BP
remains stable.
# Dementia: Pt with normal TSH of 1.1 and Vitamin B12 level of
840. We stopped Aricept due to anticholinergic effect and
continued Memantine 5 mg PO DAILY.
# Hairy Cell Leukemia: Pt is s/p 1 cycle of Cladribine. Pt was
going to get Rituxan on ___ but this is currently on hold. Pt
will follow up with outpatient oncologist Dr. ___.
Transitional Issues:
1. Pt to discuss starting anticoagulation and ACE-inhibitor with
outpatient cardiologist
2. Pt will follow up with Dr. ___ Hairy cell
Leukemia
3. Pt will follow up in device clinic in 1 week on ___ and
then with Dr. ___ in EP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Furosemide 20 mg PO 3X/WEEK (___)
3. Aspirin 325 mg PO DAILY
4. Donepezil 10 mg PO HS
5. Memantine 5 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO BID
8. Calcium Carbonate 500 mg PO Frequency is Unknown
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Memantine 5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
5. Vitamin D 400 UNIT PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Calcium Carbonate 500 mg PO DAILY
8. Furosemide 20 mg PO 3X/WEEK (___)
9. Cephalexin 250 mg PO Q8H Duration: 2 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Symptomatic Bradycardia
Secondary:
Hairy Cell Leukemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You came to the
hospital because you were feeling very weak. We found that your
heart was beating very slow and you were having symptoms from
it. We stopped your metoprolol but your heart rate was still
slow. You then had a pacemaker implanted in order to increase
your heart rate and prevent the slow rate. Please follow up with
the appointments scheduled below.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19788382-DS-6
| 19,788,382 | 24,958,657 |
DS
| 6 |
2170-08-08 00:00:00
|
2170-08-08 18:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with hx afib not on warfarin, systolic/diastolic
heart failure (EF 30%), hypertension/LVH, and hairy cell
leukemia, with recent admission for bradycardia now s/p
pacemaker placment.
For his last admission, he presented with symptomatic
bradycardia with symptoms of weakness and lethargy. His recent
decline in functional status was thought to be due to
bradyarrhythmia. He was on a beta-blocker at low dose which was
stopped. A dual chamber permanent pacemaker was placed on
___ to improve his symptoms. He had episodes of AVNRT so
metoprolol succinate 25 mg PO daily was restarted thereafter.
He was discharged to rehab yesterday at ___, where he
had fall at 9:15pm while trying to get up and use the urinal. He
reports that he tripped on a nearby commode. He denies CP, SOB,
dizzines or LH. He sustained a small hematoma on the occipital
area with a small open area at the site. Neuro signs at that
time were reported as normal. VS at that time were noted to be
98 117/63 91 18 99% on RA.
He was sent to ___ where he had a negative
CT head and neck and was found to have a trop 0.14.
In the ED, initial VS were: 97.6 96 115/73 20 98% RA. Exam
notable for volume overload, bruising to the arms, abdomen, and
legs, with a stage 1 decub on the buttocks and a posterior head
hematoma. Bedside echo reports no pericardial effusion. Labs
were notable for pancytopenia and a small troponin leak. UA was
negative but urine culture was sent. Blood cultures were sent.
VS on transfer: 91 112/64 16 100% on RA.
Upon arrival to the floor, he reports pain in the back of his
head and mild pain at the site of the pacer.
REVIEW OF SYSTEMS:
(+) Per HPI, occaisional dysuria
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies frequency, or urgency. Denies arthralgias
or myalgias. Denies rashes or skin changes.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD: dual chamber permanent pacemaker was placed on
___ for symptomatic bradycardia
3. OTHER PAST MEDICAL HISTORY:
Atrial fibrillation (not on anticoagulation)
systolic/diastolic heart failure (EF 30%)
hypertension/LVH
hairy cell leukemia
memory loss
Shatzki's ring
hiatal hernia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.7 101/55 90 18 96% RA
GENERAL: well appearing elderly male in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD at 10mmHg
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, normal S1/S2, no m/r/g, pacer pocket is c/d/i and
mildly tender
ABDOMEN: normal bowel sounds, soft, mild suprapubic tenderness,
non-distended, no rebound or guarding, no masses
EXTREMITIES: 1+ bilateral ___ edema, 2+ pulses radial and dp
NEURO: awake, A&Ox2 to name and month, CNs II-XII grossly
intact, muscle strength ___ throughout, sensation grossly intact
throughout, able to do days of the week backwards
DISCHARGE PHYSICAL EXAM:
unchanged
wt. 71kg
Pertinent Results:
ADMISSION LABS:
___ 03:30AM URINE HOURS-RANDOM
___ 03:30AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.5
LEUK-NEG
___ 03:19AM ___ PTT-35.6 ___
___ 02:35AM GLUCOSE-134* UREA N-30* CREAT-1.3* SODIUM-136
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-30 ANION GAP-7*
___ 02:35AM cTropnT-0.11*
___ 02:35AM WBC-1.7* RBC-2.81* HGB-9.4* HCT-29.1*
MCV-103* MCH-33.3* MCHC-32.2 RDW-17.5*
___ 02:35AM NEUTS-70.1* ___ MONOS-2.8 EOS-5.1*
BASOS-1.4
___ 02:35AM PLT COUNT-122*
___ 08:51AM GLUCOSE-128* UREA N-33* CREAT-1.4* SODIUM-137
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-28 ANION GAP-11
___ 08:51AM MAGNESIUM-2.0
___ 08:51AM WBC-1.6* RBC-2.93* HGB-9.8* HCT-30.2*
MCV-103* MCH-33.5* MCHC-32.4 RDW-18.3*
___ 08:51AM PLT COUNT-130*
STUDIES:
___ CXR: The pacemaker leads are in the appropriate
position. The heart is enlarged. A left effusion is present. No
other evidence of failure is seen. IMPRESSION: Pacemaker leads
in good position, no pneumothorax.
___ EKG: AV paced at 90
OSH STUDIES:
___ CT head and neck (prelim report): possible low
attenuating focus seen within the bilateral internal capsules in
the posterior limbs which could represent lacunar infarcts, mild
periventricular white matter microangiopathy ischemic disease,
no evidence for hemorrhage or mass, mild diffuse volume loss,
intracranial vascular calcifications, no evidence of acute
cervical spine fracture or subluxation, severe multilevel
degenerative changes of cervical spine, reversal of normal
cervical lordotic cruvature at C3-C4, partial fusion of C3-C4,
disc space narrowing at C4-5, C5-6, C6-7 with endplate sclerosis
and posterior marginal osteophytes
Brief Hospital Course:
Mr. ___ is a ___ yo male with history of afib not on warfarin,
systolic & diastolic heart failure (EF 30%), hypertension/LVH,
and hairy cell leukemia who was recently admitted with weakness
and lethargy found to have bradycardia s/p pacemaker placement
currently being readmitted after fall at rehab.
# Fall: Patient reports mechanical fall, however, since pt is a
poor historian he was kept overnight to monitor on tele due to
recent h/o bradycardia. Only infectious symptom was occaisional
dysuria but UA was normal. CXR was clear. Pacer pocket site
looks good. No fevers to suspect other infections. No problems
on tele overnight. In AM OSH called and there was concern that
there was a C1 on C2 subluxation that was missed on prelim read.
Pt denied neck pain. CT c-spine was repeated and was negative.
# Bradycardia s/p pacer placement: His HR is now improved to
with rate at 90. The pacer pocket appears clean, dry, intact and
without evidence of infection. We continued cephalexin for two
more days. No issues on tele overnight.
# Atrial Fibrillation: CHADS2 score of ___ but not currently on
anticoagulation. Pt with multiple falls in the past and a
current one less than 24 hours s/p prior discharge. Also h/o
thrombocytopenia on occasion due to chemo. Pt to discuss
anticoagulation with outpatient cardiologist. We continued rate
control with metoprolol succinate XL 25 mg PO daily and pacer.
# Acute on chronic systolic & diastolic heart failure (EF 30%):
appears mildly overloaded on exam with elevated JVD and ___
edema. He was given an additinal doese of furosemide 40mg on
admission. We continued furosemide 20 mg PO 3X/WEEK (MO, WED,
FRI). We continued asa 325, metoprolol, and lisinopril
# Pancytopenia: stable, at baseline.
# Dementia: No signs of delirium but at high risk while
hospitalized.
-continued memantidine
# Hairy Cell Leukemia: s/p 1 cycle of Cladribine. Pt was going
to get Rituxan on ___ but this is currently on hold. Pt will
follow up with Dr. ___ as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Memantine 5 mg PO DAILY
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Vitamin D 400 UNIT PO DAILY
6. Fish Oil (Omega 3) 1000 mg PO BID
7. Calcium Carbonate 500 mg PO DAILY
8. Furosemide 20 mg PO 3X/WEEK (___)
9. Cephalexin 250 mg PO Q8H
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Cephalexin 250 mg PO Q8H Duration: 1 Days
6. Furosemide 20 mg PO 3X/WEEK (___)
7. Memantine 5 mg PO DAILY
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10. Acetaminophen 1000 mg PO Q8H:PRN pain
11. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
Mechanical Fall
Secondary:
Atrial Fibrillation
chronic systolic & diastolic heart failure
Dementia
Hairy Cell Leukemia
Discharge Condition:
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___. You came to the
hospital because you fell at the rehab facility. It was
determined that your fall was due to tripping over a commode.
There was no evidence of cervical spine fracture or dislocation.
You were monitored on telemetry overnight and there were no
concerning events to suggest that your fall was cardiac.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Followup Instructions:
___
|
19788459-DS-17
| 19,788,459 | 20,435,901 |
DS
| 17 |
2183-02-13 00:00:00
|
2183-02-14 17:48:00
|
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:
ERCP
History of Present Illness:
___ y/o F with PMhx of HCV s/p treatment, Bipolar Disorder,
Tobacco dependence and was seen on ___ at the ___ for
abd pain, N/V and presents to ___ with persistent abd pain,
N/V. Pt was evaluated in ___ and was noted to have a
mildly elevated lipase, normal CT abd without any note of
biliary
dilation or CBD stone. However, the ___ physician was concern
for
possible gallstone pancreatitis as the recent hepatology notes
refer to MRCP from ___ that raised question of a 2mm filling
defect in the CBD. Pt was encouraged to consider transfer to
___ for MRCP/ERCP but she decided to leave AMA to care for her
dogs with plan to return to ___ in the morning. Pt received
some IV pain meds and had some relief in symptoms. She
returned
home in the evening but woke up with recurrent abd pain, nausea
and diarrhea which prompted her presentation at ___ today.
On arrival to the ___ ___, VS 98.2 HR 69 RR 20 BP 145/89 and
SAts 100% on RA. Pt was reporting ___ abd pain. Labs were
notable for normal CBC, normal LFTs and UA with ketones. RUQ
u/s
showed stable mild intra and extrahepatic biliary dilation (as
compared to MRCP in ___. CXR showed a 1cm LUL nodule for
which
follow up was recommended. Pt was given IVF, Morphine and
Dilaudid prior to admission.
On arrival to the floor, pt was reporting ongoing ___ abd pain
that is located over RUQ and RLQ. She has some associated
nausea, poor appetite and general malaise. She did have some
pain relief after dilaudid but otherwise, nothing has been
helpful at relieving the pain. She reports that the abd pain
woke her up on ___ morning and has been fairly constant
since that time. She has had associated N/V and loose stools.
Denies any hematemesis, BRBPR or black stools. She did note a
temp of 100.2 with sweats/chills at home. She has had
associated
joint pains, back ache and feeling washed out due to very
limited
po intake over the last few days. She also notes 15lb weight
loss over the last ___. Reports dark urine without any
dysuria or hematuria. Denies any sick contacts, no ETOH or
illicits.
Past Medical History:
Remote hx of ETOH Abuse (none in ___
Bipolar Disorder
Hx of gastritis
COPD, tobacco dependence
HCV s/p Harvoni with SVR
S/p lap cholecystectomy in ___
Social History:
___
Family History:
sister with breast cancer recently died and father died at ___ in
the hospital
Physical Exam:
Admission exam
97.5 133/78 49 18 98 RA
GEN: young, thin female in NAD, appears tired
HEENT: white exudate on tongue
CV: RR, bradycardic
RESP: CTAB no w/r appreciated
ABD: soft, BS present, no rebound/guarding, mild TTP over RUQ
GU: no foley
EXTR: warm, no edema
NEURO: alert, appropriate, oriented
PSYCH: anxious, no psychomotor agitation, normal eye contact
Discharge exam
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert, resting in bed, NAD
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: appropriate affect
Pertinent Results:
Admission labs
___ 04:00PM BLOOD WBC-7.9 RBC-4.44 Hgb-14.3 Hct-43.4 MCV-98
MCH-32.2* MCHC-32.9 RDW-12.7 RDWSD-45.7 Plt ___
___ 04:00PM BLOOD Glucose-99 UreaN-9 Creat-0.6 Na-140 K-4.2
Cl-100 HCO3-27 AnGap-13
___ 04:00PM BLOOD ALT-7 AST-12 AlkPhos-68 TotBili-0.8
___ 04:00PM BLOOD Lipase-26
___ 04:00PM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.2 Mg-1.7
Discharge labs
___ 06:55AM BLOOD WBC-4.1 RBC-3.95 Hgb-12.7 Hct-38.4 MCV-97
MCH-32.2* MCHC-33.1 RDW-12.6 RDWSD-44.8 Plt ___
___ 06:55AM BLOOD Glucose-84 UreaN-4* Creat-0.6 Na-144
K-3.2* Cl-103 HCO3-30 AnGap-11
___ 06:55AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2
Imaging
==================================
CXR ___
IMPRESSION:
-No focal consolidation
-1 cm nodule in the left upper lobe. Please refer to ___
___ follow-up recommendations below.
RECOMMENDATION(S): For incidentally detected single solid
pulmonary nodule bigger than 8mm, a follow-up CT in 3 months, a
PET-CT, or tissue sampling is recommended.
RUQ US ___
IMPRESSION:
1. Mild central intrahepatic and extrahepatic biliary ductal
dilatation,
which is not significantly changed compared to prior MRI. No
intraductal
stone is identified.
2. Cholecystectomy.
Transvaginal US ___
FINDINGS:
The uterus is anteverted and measures 5.7 cm x 3.2 cm x 4.3 cm.
The
endometrium is heterogenous and measures 8 mm. I get the
impression of an
endometrial polyp measuring 15 x 4 x 15 mm, but no internal
vascularity
identified. Minimal surrounding hypoechoic endometrial fluid.
The right ovary is normal. The left ovary was not visualized.
There is no free fluid.
IMPRESSION:
Suspected endometrial polyp measuring 15 x 4 x 15 mm.
CT chest ___
IMPRESSION:
9 mm nodule in the left upper lobe with central calcification
could represent a granuloma.
Noncalcified right middle lobe pulmonary nodule measuring 4 mm
is
indeterminate. Three-month follow-up is recommended.
Small diffuse moderate to severe centrilobular emphysema.
Small bilateral axillary lymph nodes are most likely reactive.
ERCP - see OMR report
Micro
===========================
___ UCx - negative
___ BCx - NGTD
Brief Hospital Course:
___ y/o F with PMhx of HCV s/p treatment, bipolar disorder, s/p
CCY who p/w 4 days of abd pain, N/V and mildly elevated lipase
on ___. Given a previous MRCP ___ with
possible 2mm filling defect in the CBD, there was concern for
possible gallstone pancreatitis and pt was referred to ___ for
further evaluation.
#Abdominal pain
#Mild Pancreatitis: Pt has ongoing epigastric abd pain,
inability to tolerate po with N/V but normal LFTs. Pt did not
have any e/o of CBD obstruction on CT from ___ on ___ or
RUQ u/s on ___. She did have a possible 2mm filling defect on
MRCP dated ___. She had mildly elevated lipase on OSH
that was normal on admission to ___ although patient with
ongoing sypmtoms. ERCP/EUS was performed and revealed small 2mm
area of hyperplasia in the CBD but no pathologic findings
otherwise. She also had transvaginal US notable for endometrial
polyp but no clear source of pain. She was given oxycodone and
bowel regimen with good effect. Her pain resolved.
#Bipolar with Anxiety: resumed home med regimen
#ADHD: held home Adderall while inpt
#LUL Lung nodule seen on CXR, approx. 1cm: given pt report of
weight loss and tobacco dependence, CT chest ordered which
revealed 9 mm granuloma in LUL and another 4 mm nodule in RML.
Patient was set up in lung ___ clinic for further monitoring
and management.
#Hx of HCV s/p treatment in SVR: outpt f/u with Dr. ___
___ issues
[ ] f/u with outpatient gynecology for management of endometrial
polyp
[ ] f/u in lung ___ clinic for continued monitoring of lung
nodules
[ ] patient will need repeat MRCP in 6 months for surveillance
of CBD 2mm soft tissue mass
Greater 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. ClonazePAM 2 mg PO QID:PRN anxiety
2. Amphetamine-Dextroamphetamine XR 60 mg PO DAILY
3. DULoxetine ___ 60 mg PO DAILY
4. Gabapentin 1200 mg PO BID
5. Latuda (lurasidone) 120 mg oral DAILY
6. Evista (raloxifene) 60 mg oral DAILY
7. TraZODone 200 mg PO QHS
8. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
9. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*18 Tablet Refills:*0
3. Amphetamine-Dextroamphetamine XR 60 mg PO DAILY
4. ClonazePAM 2 mg PO QID:PRN anxiety
5. DULoxetine ___ 60 mg PO DAILY
6. Evista (raloxifene) 60 mg oral DAILY
7. Gabapentin 1200 mg PO BID
8. Latuda (lurasidone) 120 mg oral DAILY
9. TraZODone 200 mg PO QHS
10. Vitamin D 1000 UNIT PO DAILY
11. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
lung nodule
endometrial polyp
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for abdominal pain. You had an ERCP which
re-demonstrated a very small mass in your common bile duct which
did not appear cancerous. This should be followed by repeat MRCP
every 6 months. You also had an ultrasound of your uterus and
ovaries which showed a polyp however no clear explanation of
your pain. Your pain improved with pain meds. Please schedule an
appointment with your gynecologist after discharge.
You also had a CT scan which showed two small nodules that will
need to be followed with additional CT scans every ___ months to
ensure they are not growing larger. You were also set up with an
appointment to see the lung specialists to monitor these
nodules.
Thank you for allowing us to participate in your care,
Your ___ team
Followup Instructions:
___
|
19788566-DS-9
| 19,788,566 | 20,912,313 |
DS
| 9 |
2156-10-18 00:00:00
|
2156-10-19 17:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / hydromorphone
Attending: ___.
Chief Complaint:
Ankle pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female, with history of Down's
Syndrome, Alzhemier's Dementia, seizure disorder currently on
AED, hypothyroidism, who presents today for dysuria and ankle
pain.
History obtained by collateral information. Patient reportedly
has been grabbing her ankle and her foot for almost two weeks.
By report it seemed as though she had sprained her ankle/foot,
and sometimes holding her ankle in the daytime. She was also
having some dysuria with urination, and increased confusion over
the past 2 weeks as noted by her group. Contact information for
her group home leader is ___ ___ group home
___) - informed team at ___ that for the past 2 weeks she
has been having this intermittent left leg shaking with ankle
deviation, sometimes it goes straight and she is able to walk on
it. Also she is attention seeking and sometimes tremulous.
Patient was originally seen at ___, at which point was
found to have clonic activity of her left arm and left ankle
with medial deviation. She was alert and answering questions
appropriately. Given concerns of this clonic activity of her
left arm, ___ discussed with Dr. ___ outpatient
neurologist recommended transfer to ___ for further neurologic
evaluation and for EEG monitoring. Patient was given 1 mg of
Ativan IV, and then still continued to have left ankle clonus.
At ___, patient was also given imipenem (prior ESBL+ urine
culture), and underwent chest x-ray which was clear and ankle
x-rays which were negative for acute fracture or dislocation.
Of note, the patient was recently admitted to ___
___ with acute urinary retention and bronchitis. A
foley catheter was placed and she was discharged home. Per
sisters, followed up with urology and failed voiding trial so
___ replaced. They report that she has an appointment with
urology coming up for repeat voiding trial.
On eval at ___ the patient is alert, following commands. L
foot medially deviated, clonus of LLE. Had a normal formed BM in
the ED.
In the ED, initial vital signs were: 97.6 55 93/53 18 94% RA
- Labs were notable for: Creatinine 0.7,
- Imaging: nml CBC, Chem-7, lactate 2.6, UA w/ > 182 WBCs, 0
Epis, few bacteria, positive nitrites
Consults: Neurology was consulted in the ED for concerns of a
focal seizure, and was thought that likely a dystonic reaction
thought to be ___ to medications, and not a focal seizure.
Recommended full EEG.
The patient was given:
___ 01:56 IV CeftriaXONE 1 gm
Vitals prior to transfer were: 57 119/58 20 94% RA
Upon arrival to the floor, she complains of "pain in my veins,"
which her sisters at bedside say is how she communicates her
ankle pain.
Past Medical History:
1. Down Syndrome
2. Dementia
3. Hypothyroidism
4. Allergic Rhinitis
5. Sleep Apnea
6. Seizure Disorder, Dr. ___ - ___ report only one time in
___, sounds like GTC
7. Hyperlipidemia
8. Chronic Constipation
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL
==================
VITALS - 97.6 124/51 59 16 95% RA
GENERAL - AAOx1, thought "___" and ___
sisters report this is baseline mental status, pleasant,
well-appearing, in no apparent distress
___ - Down syndrome facies, no conjunctival pallor or scleral
icterus, PERRLA, EOMI, OP clear
NECK - supple
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
BACK - no CVA tenderness
ABDOMEN - normal bowel sounds, soft, non-tender, distended
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema. L foot inverted and twitching at around ___ Hz, both
hands and R foot are also twitching at the same frequency. Pt
endorses pain when I try to extend the L ankle
SKIN - without rash
NEUROLOGIC - A&Ox1, CN II-XII normal, normal sensation, with
strength ___ throughout. Gait assessment deferred. Normal tone
in RLE and bilateral upper extremities
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
DISCHARGE PHYSICAL
==================
T T 97.8 BP 110/54 HR 60 RR 18 94 % RA
General: A&Ox1, in severe pain screaming continuously at times,
sometimes quiet and affectionate with ___ bear, will sotp
screaming when provider is in room
___: Down syndrome facies, sclera anicteric
Lungs: Clear to auscultation bilaterally
CV: regular rhythm, normal S1 + S2, ___ systolic murmur auculted
over precordium
Abdomen: soft, tender diffusely, non-distended
Ext: Warm, well perfused, L foot inversion appears to be more
severe than day prior ; mild R foot inversion. significant
spasms noted in calf and thigh. screams in pain when left foot
is slightly everted.
Neuro: occasional tremor.
Extremities. Moving toes bilaterally. No clonus.
Pertinent Results:
ADMISSION LABS
==============
___ 10:00PM BLOOD WBC-8.0 RBC-4.06 Hgb-12.6 Hct-39.2 MCV-97
MCH-31.0 MCHC-32.1 RDW-17.5* RDWSD-55.4* Plt ___
___ 10:00PM BLOOD Neuts-69.7 Lymphs-17.9* Monos-8.8 Eos-2.3
Baso-0.9 NRBC-0.0 Im ___ AbsNeut-5.57 AbsLymp-1.43
AbsMono-0.70 AbsEos-0.18 AbsBaso-0.07
___ 10:00PM BLOOD Glucose-103* UreaN-14 Creat-0.7 Na-141
K-5.1 Cl-104 HCO3-22 AnGap-20
___ 10:45PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 10:45PM URINE RBC-10* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
IMAGING
=======
CT head ___
IMPRESSION:
1. No acute intracranial pathology. Stable ventriculomegaly.
Possible communicating hydrocephalus
2. No pathologic postcontrast enhancement.
3. Upper left maxillary sinus opacification.
X-ray L ankle, tib/fib
FINDINGS:
Fine bony detail is obscured by an overlying cast. Alignment of
the ankle mortise is significantly improved when compared to the
prior study. No asymmetry of the ankle mortise now seen. A
well corticated bony fragment is again seen medial to the medial
malleolus. No definite fracture seen. Bony spurring along the
lateral aspect of the lateral tibial plateau.
IMPRESSION:
Improved alignment following closed reduction. The ankle
mortise is now congruent.
MICROBIOLOGY
============
NEURO
=====
EEG ___
IMPRESSION: This is an abnormal EEG due to the presence of a
slow and disorganized background. No focal or epileptiform
features were seen. These findings are indicative of a mild to
moderate encephalopathy, or may indicate dysfunction of deep
and/or midline structures. Stage 2 sleep is not recorded.
OTHER RELEVANT LABS
===================
___ 10:15PM BLOOD Lactate-2.6*
___ 07:22AM BLOOD Lactate-3.5*
___ 01:35PM BLOOD Lactate-1.7
DISCHARGE LABS
==============
Brief Hospital Course:
___ with history of Down Syndrome, Alzhemier's Dementia (severe
cognitive difficulties, not independent), EEG-proven seizure
disorder on Keppra, hypothyroidism, who presents for
ESBL-producing E coli UTI, ankle pain, and tremulous/clonic
activity at ___. She was transferred to ___ for further
management.
ACTIVE ISSUES
=========
# Complicated UTI: Patient had been discharged from ___
with indwelling Foley for urinary retention in ___. Presented
to ___ on ___ with dysuria. UA was ___, nitrate+.
Received imipenem at ___ on ___ and then was started on
meropenem once transferred to ___. She had had ESBL-producing
E coli (sensitive to carbapenems, nitrofurantoin) on outpatient
___ at ___ in early ___ no evidence that patient had
received treatment based on this culture. E coli with same
sensitivity spectrum grew from ___ ___. While at
___, Foley was discontinued but then had to be replaced given
bladder scan showing urinary retention of 484cc. She received
antibiotics for 10 days which she completed prior to discharge,
and was in stable condition.
# Fever: Patient was afebrile at admission but had fever to
100.7 on ___ with other vital signs stable. Differential
included infection (either from known UTI or other source) vs.
drug effect from meropenem. Fever resolved with other infectious
work up negative.
# Dystonia/clonus: Patient was noted to have tremors/clonus in
her upper and lower extremities prior to her transfer to ___
but few episodes were noted on the floor. Differential included
seizure vs. dystonia vs. agitation. Neuro consult was less
concerned for seizure given no response to Ativan and no clear
post-ictal state. Routine EEG showed slow background but no
focal or epileptiform features. Given concern for dystonia,
patient's donepezil and olanzapine were held, and CT head was
performed, showing no acute intracranial process. This was
thought to be dystonic reaction secondary to her medications and
progression of her dementia. She was treated with baclofen and
ativan. Medications were limited given her dementia and
delirium, there was concern as anticholinergics may worsen her
confusion. She was ultimately managed with a regimen of of 5 mg
tid baclofen, with breakthrough doses of .125 iv Ativan for
severe agitation and 2.5 mg baclofen. She did well with QHS
lorazepam for discomfort and sleep. She had a ___ injection
for her dystonia/left foot inversion on ___ by Dr. ___ and
___ have follow up with him.
# Left Foot Inversion: Patient had complaints about discomfort
in the L foot. At admission, L foot was noted to be fixed in
severely inverted position and R foot was mildly inverted. No
tremors or clonus were noted. ___ X-ray expressed concern
for L ankle ligament injury, but Ortho consult felt inversion
likely represented a chronic deformity potentially ___ dystonia.
She underwent L ankle closed reduction at bedside with splint,
and repeat X-ray of L ankle and tib/fib showed improved
alignment of mortise. Patient continued to have pain and spasms
and lower extremity ultrasounds were negative for DVT. She
continued to have spasms so for comfort the splint was removed
after 1 week. She was started on baclofen as above and had ___
injection ___ as above. Decision was made to hold antipsychotics
as this may worsen dystonia above.
# Delirium: presumed due to on-going discomfort from left foot
dystonia, her previously prescribed olanzapine per Neurology
given potential contribution to dystonia. Her discomfort was
treated with Tylenol and PRN oxycodone (oxycodone seemed to
worsen her delirium and was thus discontinued), she seemed to
gain some benefit from PRN lorazepam
# Epilepsy: Patient at risk for seizure I/s/o UTI. Regarding her
seizure history, she is followed by Dr. ___ had two
events concerning for GTC in the past. She is maintained on
Keppra 500mg BID.EEG non specific in house (___). She will
follow up with Dr. ___ on d/c.
#Tinea cruris- patient treated with fluconazole for three days
and started on topical miconazole.
CHRONIC ISSUES
==========
# Epilepsy: The patient was continued on home keppra and put on
seizure precautions.
# Hypothyroidism: Continued levothyroxine.
# Alzheimer: Held donepezil per Neurology given potential
contribution to dystonia.
# Sick sinus syndrome: HR ___ in house, stable. Her
arrhythmia was discussed with the patients HCP and family and
decision to forego any aggressive intervention was arrived at by
family. They state that the patient would not wish to have a
pacemaker implanted even if it were deemed necessary to save her
life.
Goals of Care: Given ___ progressive decline in cognition
and newly diagnosed dystonia, it was requested that no attempts
at resuscitation or intubation be made should she develop
cardiorespiratory failure. Her code status was transitioned to
DNR/DNI this admission, a MOLST form was completed prior to
discharge
TRANSITIONAL ISSUES
===============
-patient to F/U with orthopedics regarding left foot invesion
and splint above
-patient has significant difficulties with loneliness and pain;
will often scream when left alone in room. Please try to
reassure before giving breakthrough medications for spasm
-Patient d/ced with hemorrodi suppository, bowel regimen and
miconazole cream for rash
-Patient being discharged on regimen of baclofen for foot spasm
___ dystonia, with prn IV low dose Ativan for severe agiation in
relation. She did well with QHS 0.125mg lorazepam, would
recommend that this be continued. Please hold for sedation. Home
antipsychotics held given concern for worsening dystonia
-Patient kept on home dose keppra; however antipsychotics d/ced
given concern for dystonia above; patient to F/U with Dr. ___ with Dr. ___ repeat ___ injection as above
-Patient discharged to rehab given left foot inversion above,
expected length of stay < 30 days.
-While immobile patient will need DVT prophylaxis; dced on bid
heparin. ___ switch to ppx lovenox if easier to deliver at rehab
as well
-Following PCP appointment patient may need outpatient
appointment with outpatient urologist Dr. ___ UTI
above
-CODE STATUS CHANGED TO DNR/DNI ON D/C AFTER DISCUSSION WITH
FAMILY as above
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Donepezil 10 mg PO QHS
2. Lorazepam 0.5 mg PO QHS
3. Levothyroxine Sodium 200 mcg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Loratadine 10 mg PO DAILY:PRN allergies
8. Fluoxetine 20 mg PO DAILY
9. OLANZapine 5 mg PO DAILY
10. Acetaminophen 500 mg PO Q8H:PRN pain
11. Senna 8.6 mg PO BID:PRN constipation
12. LeVETiracetam 500 mg PO BID
13. Albuterol Inhaler 1 PUFF IH Frequency is Unknown shortness
of breath
Discharge Medications:
1. Acetaminophen (Liquid) 1000 mg PO Q8H
2. Fluoxetine 20 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. LeVETiracetam 500 mg PO BID
5. Levothyroxine Sodium 200 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Senna 8.6 mg PO BID:PRN constipation
9. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
10. Simethicone 40-80 mg PO QID:PRN gas pain
11. Miconazole 2% Cream 1 Appl TP BID
12. LORazepam .125 mg IV BID:PRN pain/anxiety
13. Heparin 5000 UNIT SC BID
14. Baclofen 5 mg PO TID
15. Baclofen 2.5 mg PO BID:PRN pain foot
16. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
17. Docusate Sodium 100 mg PO BID
18. Guaifenesin ___ mL PO Q6H:PRN cough
19. Hemorrhoidal Suppository ___AILY PRN pain
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY: URINARY TRACT INFECTION, DYSTONIA
SECONDARY: ALZHEIMER'S DEMENTIA, HYPOTHYROIDISM, SEIZURES
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___. You were hospitalized for urinary
tract infection and muscle spasms. Your UTI was treated with 10
days of antibiotics in the hospital. Your muscle spasms were
difficult to treat. They were thought to be secondary to your
medications and dementia. You were started on baclofen to treat
your spasms, and had a ___ injection. You will be discharged
to rehab.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19788583-DS-5
| 19,788,583 | 22,864,312 |
DS
| 5 |
2133-01-11 00:00:00
|
2133-01-13 19:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fatigue, easy bruising, chest pain
Major Surgical or Invasive Procedure:
Bone marrow biopsy
History of Present Illness:
Ms. ___ is a ___ year old previously healthy lady who
presented
to ED today with 2 months history of easy bruising and 3 weeks
history of severe fatigue.
She was in her usual state of health until about 2 months ago
when she started developing spontaneous bruising (with no
history
of trauma). Over the last ___ weeks, she developed severe
fatigue, body aches, back pain along with difficulty breathing,
palpitations and chest tightness on moderate exertion. She also
noticed she was bleeding more easily from her gums and that her
menstrual periods were heavier than usual. She also developed
headaches on both sides of her skull along with a throbbing
sensation in her left ear.
Review of symptoms positive for chronic intermittent low back
pain associated with intermittent numbness in right leg.
She denied any fever/ chills, night sweats, weight loss, vision
changes, constipation/diarrhea, abdominal pain, nausea/vomiting,
bleeding per rectum, dark stools, bleeding from any other site,
leg swelling, or focal weakness or numbness.
ED course: She was afebrile, tachycardic with normal blood
pressure and normal SPO2. She was noted to have leukocytosis,
severe anemia and thrombocytopenia. Hematology team was
consulted due to suspicion for acute leukemia. She received 2U
PRBC in ED.
Past Medical History:
- Migraine (associated with OCP use) in ___, associated with
transient loss of vision on left side [___]
- ___ for palpitations at ___ in ___,
workup per patient revealed no abnormalities
Social History:
___
Family History:
-___ grand mom-thyroid cancer at age of ___ status post
resection, doing well
-Maternal uncle-congenital enlarged heart requiring pacemaker
-Paternal grand mom-diabetes
Physical ___:
ADMISSION PHYSICAL EXAM:
Vitals: Afebrile, Tachycardic to 120-130s, Normotensive, SpO2
wnl
General: NAD
HEENT: PERRL, EOMI, MMM
CV: S1, S2, Regular,Tachycardic, no m/r/g
Respiratory: CTAB, normal WOB
Abdomen: S, NT, ND, BS+, no HSM
Extremities: WWP, no c/c/e
Lymph: No cervical, axillary, or inguinal LAD
Skin: No rash or petechiae
DISCHARGE PHYSICAL EXAM:
VS: 97.6 PO 130 / 60 118 18 100 RA
Gen: ___ woman, sitting up in bed, appears fatigued, but
comfortable. In no acute distress.
HEENT: Mild-moderate conjunctival pallor, no scleral icterus.
Non-tender mastoid region. MMM. Oropharynx clear with no
erythema or exudates.
CV: tachycardic, regular rhythm, +s1/s2, no murmurs, rubs,
gallops, or thrills
Pulm: CTAB, no wheezes, rales, or rhonchi. Good inspiratory
effort.
Abd: +bowel sounds. Soft, non-tender, non-distended. No
hepatosplenomegaly. No rebound or guarding.
Ext: WWP, no clubbing, cyanosis, or lower extremity edemae
Neuro: A&Ox3. Moving all 4 extremities with purpose.
Skin: Numerous echymosses on the arms and legs bilaterally. No
rashes or petechiae noted.
Pertinent Results:
ADMISSION LABS:
___ 03:30PM BLOOD WBC-45.7* RBC-1.48* Hgb-5.4* Hct-16.6*
MCV-112* MCH-36.5* MCHC-32.5 RDW-16.3* RDWSD-63.4* Plt Ct-20*
___ 03:30PM BLOOD Neuts-3* Bands-1 Lymphs-9* Monos-0 Eos-0
Baso-2* ___ Myelos-1* Promyel-2* Other-82*
AbsNeut-1.83 AbsLymp-4.11* AbsMono-0.00* AbsEos-0.00*
AbsBaso-0.91*
___ 03:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-3+* Microcy-NORMAL Polychr-NORMAL
___ 03:30PM BLOOD ___ PTT-28.7 ___
___ 03:30PM BLOOD ___
___ 03:30PM BLOOD Glucose-123* UreaN-13 Creat-0.6 Na-146*
K-3.6 Cl-106 HCO3-25 AnGap-15
___ 03:30PM BLOOD ALT-39 AST-47* LD(LDH)-774* CK(CPK)-52
AlkPhos-53 Amylase-37 TotBili-0.3 DirBili-<0.2 IndBili-0.3
___ 03:30PM BLOOD Lipase-45
___ 09:10PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 03:30PM BLOOD Albumin-4.5 Calcium-9.5 Phos-3.6 Mg-2.1
UricAcd-5.1 Iron-186*
___ 03:30PM BLOOD calTIBC-304 ___ Ferritn-560*
TRF-234
___ 03:30PM BLOOD TSH-1.9
___ 03:46PM BLOOD Lactate-1.6
PERTINENT LABS:
___ 01:28AM BLOOD WBC-24.4* RBC-1.82* Hgb-6.3* Hct-18.1*
MCV-100* MCH-34.6* MCHC-34.8 RDW-21.2* RDWSD-72.9* Plt Ct-12*
___ 09:20AM BLOOD WBC-18.4* RBC-2.27* Hgb-7.8* Hct-22.0*
MCV-97 MCH-34.4* MCHC-35.5 RDW-20.4* RDWSD-66.8* Plt Ct-14*
___ 01:28AM BLOOD ___
___ 01:28AM BLOOD Glucose-117* UreaN-13 Creat-0.5 Na-141
K-3.8 Cl-104 HCO3-24 AnGap-13
___ 01:28AM BLOOD ALT-32 AST-39 LD(LDH)-729* AlkPhos-43
TotBili-0.7
___ 01:28AM BLOOD Albumin-4.2 Calcium-8.9 Phos-4.1 Mg-1.9
UricAcd-4.0
___ 01:28AM BLOOD D-Dimer-1012*
___ 01:28AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 01:28AM BLOOD HIV Ab-NEG
___ 01:28AM BLOOD HCV Ab-NEG
PENDING LABS:
___ 03:30PM BLOOD G6PD-PND
DISCHARGE LABS:
___ 01:15PM BLOOD WBC-21.6* RBC-2.27* Hgb-7.5* Hct-22.0*
MCV-97 MCH-33.0* MCHC-34.1 RDW-20.8* RDWSD-68.6* Plt Ct-40*#
___ 01:15PM BLOOD ___ PTT-28.1 ___
___ 01:15PM BLOOD ___
___ 01:15PM BLOOD Glucose-196* UreaN-11 Creat-0.7 Na-143
K-4.1 Cl-105 HCO3-23 AnGap-15
___ 01:15PM BLOOD ALT-35 AST-43* LD(LDH)-794* AlkPhos-49
TotBili-1.4
___ 01:15PM BLOOD Calcium-9.4 Phos-3.0 Mg-2.0 UricAcd-3.7
IMAGING/STUDIES:
CXR (PA/Lateral, ___: No acute cardiopulmonary process.
CT Head (___): No acute intracranial process.
CT PE Study (___): No evidence of pulmonary embolism or
aortic abnormality.
TTE (___): No pericardial effusion. Normal biventricular
cavity sizes with preserved regional and global biventricular
systolic function. Mild pulmonary artery systolic hypertension.
Brief Hospital Course:
Patient is a ___ F with no significant past medical history who
presented with increased fatigue, easy bruising, and chest pain.
Outpatient labs concerning for a leukemic process and patient
was ultimately shown to have acute myeloid leukemia.
ACUTE ISSUES:
#AML: The patient had a peripheral smear and bone marrow biopsy
in the ED that showed likely acute myeloid leukemia. She was
given fluids, blood products, Hydrea, allopurinol, and ATRA
before being transferred to the floor. On the floor, the patient
remained stable and was given blood, platelets, and second doses
of ATRA and Hydrea. Of note, patient was determined to be
t(15;17) negative. The patient remained stable and was deemed
safe for transfer to ___. She was given 1g of Hydrea just prior
to transfer.
#Chest pain: Patient noted sharp L anterior chest pain that
traveled to her L shoulder. CTA showed no pulmonary emboli, but
possible incidental pericardial effusion. EKG showed diffuse ST
segment changes. Patient underwent TTE with no pericardial
effusion. Regardless, this picture is ultimately concerning for
pericarditis, though this still needs to be further evaluated at
the time of discharge. Patient was given dexamethasone 10mg in
the ED with resolution of pain and prednisone 60 mg X 1 the
following day.
#Decreased hearing in L ear: Patient also noted 1.5 weeks of
decreased hearing in her L ear. Recommendation was made for ENT
consult or dedicated CT temporal bone study at the time of
discharge.
#RLE numbness: Patient also described intermittent RLE numbness
and tingling of unclear etiology. This may need to be further
evaluated pending patient symptoms.
CHRONIC ISSUES:
None
TRANSITIONAL ISSUES:
[]___ ACCEPTING PHYSICIAN: ___, MD
[]Currently getting q8h labs for DIC and TLS
[]Primary oncologist at ___ will need to fax slide request and
appropriate documentation to ___ Heme Path for peripheral
smear and bone marrow biopsy slides; fax number ___ if
any questions please call ___
[]Patient does not have t(15;17) PML-RARA translocation
[]G6PD level pending, though less likely to need rasburicase for
now given unconcerning TLS labs at this time
[]Will need HLA typing
[]Consider cardiology consult for possible pericarditis
regarding duration of steroid treatment and other diagnostic
testing needed; received one time dose of prednisone 60mg on
floor and dexamethasone 10mg in the ED x1
[]Consider ENT consult vs. dedicated temporal bone CT to
evaluate L sided decreased hearing
[]Currently only has peripheral access; central access deferred
to prevent delay of transfer, will need temporary central line
vs. ___ vs. ___'s
[]Sent over with discharge worksheet, discharge summary, H&P,
lab records, radiology reports
[]For further questions can contact ___, MD, intern
at ___ at ___
FULL CODE (presumed)
Contact: ___ (MOTHER) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
None. Patient's care being transferred to ___
___.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
acute myeloid leukemia
pericarditis
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 in the hospital?
- You were feeling tired, had chest pain, and noticed that you
bruised more easily
- Blood tests and a biopsy showed that you had acute leukemia,
anemia, and low platelets
What was done while I was in the hospital?
- You had a bone marrow biopsy that showed you had a blood
cancer called acute myeloid leukemia
- You were given medications and fluids to decrease the number
of white blood cells you had in your blood
- You were given blood and platelets to raise your blood counts
What should I do when I go home?
- You are being transferred to the ___ Cancer Institute.
Please follow up with the doctors there for ___ for
what to do when you are able to go home
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
19789057-DS-19
| 19,789,057 | 20,640,017 |
DS
| 19 |
2157-03-25 00:00:00
|
2157-03-27 17:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Leg pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo F with PMH atrial fibrillation, basal cell carcinoma,
melanoma, osteoarthritis, peripheral neuropathy, sleep
apnea,osteoporosis c/b compression fractures, hyperglycemia,
back pain coming in for eval of L anterior leg wound. She fell
___ at home and hit her leg on a chair. Was seen in ___ ED at
that time where CT head /spine were negative. Had steri strips
placed to L ant leg lac. Had worsening swelling/redness around
wound over next 4 days so she went to ___ urgent care
___. There, x ray neg, u/s for dvt given swelling was neg.
Started Bactrim/Keflex. Has been taking the abx. No drainage,
small spot of blood on gauze this AM. Since that time her
redness has improved slightly each day but still w/significant
paint to light touch, redness, edema prompting her to come to ED
today. No f/c/lightheadedness, eating/drinking normally. No
numbness/tingling in foot.
In the ED, initial vitals were: 98 51 134/60 18 100% RA
- Exam notable for:
LLE edematous from upper calf down to toes
brick red erythema surrounding a 2 cm wound covered by steri
strips. No drainage. No fluctuance.
very tender and warm to touch over anterior shin wrapping
around to the medial/lateral calf. erythema extends down almost
to ankle, up ___ to knee.
petichiae over both calves
- Labs notable for: INR 2.9
- Patient was given: Vancomycin x2
She was observed in the ED however did not show improvement.
She was admitted for continuation of IV abx.
Upon arrival to the floor, patient reports significant pain and
swelling in the extremity, no fevers, chills, lightheadedness or
chest pain.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
Atrial fibrillation, basal cell carcinoma,
melanoma, osteoarthritis, peripheral neuropathy, sleep apnea,
osteoporosis, compression fractures, hyperglycemia, back pain.
Social History:
___
Family History:
Positive for mother with hearing loss and heart
disease, father with diabetes. The patient also reports history
of DM, father: stomach CA.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 98.0 87 132/70 14 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: asymmetric swelling Lt>Rt. there is a 2cm wound healing
edges with eschar at the base. surrounding the wound is a large
area of erythema which is tender to slight touch. pocking with
the methylin blue pen was painful. The edge of the redness was
traced. Otherwise the lower limbs are well perfused, 2+ pulses,
no clubbing, cyanosis
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM
=======================
VS: Temp 96.8 BP 136/82 HR 46 RR 20 SaO2 98%
I/O: ___ unrecorded void
General: Alert, oriented, no acute distress.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: regular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Still with improvement in exam overall. Border of
cellulitis has receded from drawn line ~ 2 cm proximally, less
erythema overall, less swelling but more warmth compared to
yesterday. 1+ pitting over ankle. Central 1.5 cm black eschar,
dry and well-healing.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
LABS ON ADMISSION
=================
___ 12:19PM BLOOD WBC-7.2 RBC-3.85* Hgb-12.3 Hct-37.7
MCV-98 MCH-31.9 MCHC-32.6 RDW-13.0 RDWSD-46.6* Plt ___
___ 12:19PM BLOOD Neuts-59.9 ___ Monos-9.2 Eos-2.5
Baso-0.4 Im ___ AbsNeut-4.29 AbsLymp-1.95 AbsMono-0.66
AbsEos-0.18 AbsBaso-0.03
___ 12:19PM BLOOD ___ PTT-37.2* ___
___ 12:19PM BLOOD Glucose-92 UreaN-26* Creat-1.2* Na-132*
K-4.5 Cl-99 HCO3-21* AnGap-17
___ 12:28PM BLOOD Lactate-1.1
NOTABLE LABS
============
___ 12:19PM BLOOD Glucose-92 UreaN-26* Creat-1.2* Na-132*
K-4.5 Cl-99 HCO3-21* AnGap-17
___ 06:00AM BLOOD Glucose-97 UreaN-18 Creat-1.0 Na-139
K-4.2 Cl-105 HCO3-22 AnGap-16
___ 06:00AM BLOOD CRP-6.1*
___ 10:10AM BLOOD Vanco-11.3
___ 08:27AM BLOOD SED RATE-Test
LABS ON DISCHARGE
=================
___ 06:40AM BLOOD WBC-6.4 RBC-3.91 Hgb-12.6 Hct-39.2
MCV-100* MCH-32.2* MCHC-32.1 RDW-13.2 RDWSD-48.4* Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-106* UreaN-25* Creat-1.0 Na-138
K-4.6 Cl-104 HCO3-22 AnGap-17
___ 06:40AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.1
MICROBIOLOGY
============
__________________________________________________________
___ 10:10 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:25 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:30 am SWAB Source: groin.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 6:30 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 1:40 pm BLOOD CULTURE SET#2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:19 pm BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
IMAGING
========
XR Left Tib/fib ___
There is no evidence for a fracture, periosteal reaction, or
focal bone
lesion. Degenerative changes are again noted in the partially
visualized left
knee, not optimally assessed. The tibiotalar joint is not
assessed in detail,
but appears grossly aligned. A small plantar calcaneal spur is
noted.
IMPRESSION:
No evidence for a fracture.
___ ___. No evidence of deep venous thrombosis in the left lower
extremity veins.
2. Edema and fluid in the subcutaneous tissues anterior to the
tibia. Of
note, there was an open skin wound near this area.
Brief Hospital Course:
Ms. ___ is a very pleasant ___ yo female with history of AF
on warfarin, depression and OSA who is admitted due to
unresolving cellulitis. Over the course of her hospital stay,
the following issues were addressed:
# Cellulitis: Patient sustained a fall and injured left shin
injury on metal chair on ___ with resultant erythema and
swelling that started ~48 hours after her initial injury. She
noted some improvement in erythema and swelling since starting
Bactrim and Keflex on ___ but noted significant increase
overall in pain and swelling. On exam, found to have asymmetric
swelling Lt>Rt, ___ pitting over ankle with central 1.5 cm
black eschar with granulation tissue at edges and 5x7 cm area of
beefy red cellulitis. Patient was admitted for administration of
IV antibiotics given recent failure of significant improvement
after 48 hours of oral therapy. She received vancomycin 1500 mg
Q24 from ___. XR of LLE showed no gas concerning for
developing necrotizing fasciitis (and no crepitus on exam) and
ultrasound without evidence of DVT or underlying abscess (though
this study was a venous exam). Patient remained neurovascularly
intact save for some stable parasthesia felt over the last 7
days, which resolved by hospital day 3. She was discharged on
___ with plan for 10 days of antibiotics from start of
vancomcyin administration, doxycycline and cephalexin (start
date of IV antibiotics ___ | projected end date ___
# Symptomatic bradycardia and hypotension. Patient had episode
of lightheadedness morning of ___ and was noted to have BP
103/59 and HR 46, thought likely due to atenolol. On review of
record patient had bradycardia on outpatient heart monitor and
there was some consideration of changing atenolol 50 mg BID to
atenolol 50 mg daily. Blood pressure same in both arms, less
concern for aortic dissection. Well's score of 0, low
probability for PE. Held home atenolol for the day and restarted
at reduced dose of 25 mg daily on ___.
# Paroxysmal atrial fibrillation initially diagnosed in ___,
managed with amiodarone as well as warfarin for thromboembolic
prophylaxis. Has had tachy-brady event in the past and is going
to f/u with Dr. ___ a pacemaker. Continued amiodrone,
atenolol and warfarin.
# Coagulopathy: Patient presented with INR of 3.2. Her warfarin
was held on 315 in ED and she was restarted on her home dose
once back on the medicine floor. INR on discharge was 1.9 (see
INR management flowsheet for further details.
# Chronic bilateral lower limb edema: Thought to be related to
CCB usage. Continued home lasix.
Transitional Issues
============
- Patient on flaxseed and warfarin. She should discontinue flax
seed due to interaction with warfarin.
- Antibiotics on discharge: Patient showed clinical improvement
on vancomycin and was transitioned to doxycycline and cephalexin
to be for a total of 10 days since starting IV vancomycin (start
date of IV antibiotics ___ | projected end date ___
- Continued home coumadin regimen (though was held in ED for 2
days). INR on discharge was 1.9
New Meds:
o TraZODone 25 mg PO/NG QHS:PRN insomnia
o Doxycycline Hyclate 100 mg PO Q12H.
o Cephalexin 500 mg PO/NG Q8H.
Stopped/Held Meds: None
Changed Meds: Atenolol 25 mg PO/NG DAILY instead of Atenolol 50
mg PO BID
Post-Discharge Follow-up Labs Needed: INR per routine
Discharge weight: 94.7 kg
# CODE: Full
# CONTACT: daughter ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO BID
2. Denosumab (Prolia) 60 mg SC 1X / 6MONTHS
3. Amiodarone 200 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Warfarin 2.5 mg PO 6X/WEEK (___)
6. Warfarin 5 mg PO 1X/WEEK (WE)
7. Estrogens Conjugated 0.5 gm VG DAILY
8. Atorvastatin 20 mg PO QPM
9. urea 40 % topical QHS
10. Furosemide 20 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
13. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
14. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral TID
15. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO Q8H
2. Doxycycline Hyclate 100 mg PO Q12H Duration: 5 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*10 Tablet Refills:*0
3. TraZODone 25 mg PO QHS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*15 Tablet Refills:*0
4. Atenolol 25 mg PO DAILY
RX *atenolol 25 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
5. Amiodarone 200 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral TID
8. Denosumab (Prolia) 60 mg SC 1X / 6MONTHS
9. Estrogens Conjugated 0.5 gm VG DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU BID
11. Furosemide 20 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. urea 40 % topical QHS
15. Vitamin D 400 UNIT PO DAILY
16. Warfarin 2.5 mg PO 6X/WEEK (___)
17. Warfarin 5 mg PO 1X/WEEK (WE)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
=====
Left lower extremity non-purulent cellulitis
Symptomatic bradycardia
Secondary
=======
Paroxysmal atrial fibrillation
Chronic bilateral leg edema
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. ___,
___ was a pleasure caring for you at ___
___. You were admitted with a skin infection that was
not getting better on oral antibiotics. We started you on IV
antibiotics (vancomycin) and by your second hospital day your
rash showed marked improvement. You were transitioned to an oral
antibiotic on discharge. You were also found to be
supratherapeutic with your coumadin levels (your INR). We think
this is in part due to your taking flaxseed as these two agents
interact. Please do not take flaxseed while taking warfarin.
You also had an episode of chest pain, nausea, and slow heart
rate. We think this is due to your atenolol, and reduced your
dose. Please follow up with your cardiologist.
Please take all of your medications as detailed in this
discharge summary. If you experience any of the danger signs
listed below, please call your primary care physician or come to
the emergency department immediately.
Best Wishes,
Your ___ Care Team
Followup Instructions:
___
|
19789057-DS-20
| 19,789,057 | 23,556,824 |
DS
| 20 |
2157-04-06 00:00:00
|
2157-04-06 22:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cellulitis
Major Surgical or Invasive Procedure:
___ - ___ Placed
History of Present Illness:
This is a ___ yo F with PMH atrial fibrillation, basal cell
carcinoma, melanoma, osteoarthritis, peripheral neuropathy,
sleep apnea, osteoporosis c/b compression fractures,
hyperglycemia, back pain coming in for eval of L anterior leg
wound.
She fell ___ at home and and developed a left leg laceration
which was complicated by an infection and surrounding
cellulitis. She failed outpatient management with Bactrim/Keflex
and was admitted to the ___ on ___ with severe pain and
extension of her cellititis. She was successfully treated with
vancomycin with significant improvment. During that admission a
DVT and abscess were excluded. She ws discharged on ___ with 10
day course of doxycycline and cephalexin which ended on ___.
Despite completing her course, her leg swelling redness and and
pain did not resolve. She presented this time due to increasing
redness involving her foot inferiorly and approaching her knee
superiorly. The patient denied fever, discharge, and loss of
sensation.
In the ED, initial vitals were: 97 51 158/74 16 99% RA
- Exam notable for: LLE edematous from upper calf down to toes
brick red erythema surrounding a 3 cm wound with a scab. No
drainage. No fluctuance. very tender and warm to touch over
anterior shin wrapping around to the medial/lateral calf.
erythema extends down to the foot, up to the knee.
- imaging of the left legs showed No fracture is detected in
the tibia or fibula. No suspicious lytic lesion, sclerotic
lesion, or periosteal new bone formation is detected. No soft
tissue calcification or radio-opaque foreign body is detected.
Limited assessment of the knee and ankle joint is unremarkable.
There is diffuse soft tissue swelling, with no subcutaneous gas.
- Labs notable for: INR 2.0, normal WBC and h/h, new metabolic
acidsosis with a gap of 18 but lactate is 1.3.
- Patient was given: 1500mg of Vancomycin x1
She was admitted for continuation of IV abx. Upon arrival to the
floor, patient reports pain and tenderness over the left calf.
This morning, the patient only reports pain to deep palpation of
the L calf. Otherwise, she is concerned for the worsening
swelling and redness. Denies chest pain and shortness of breath.
Past Medical History:
Atrial fibrillation, basal cell carcinoma, melanoma,
osteoarthritis, peripheral neuropathy, sleep apnea,
osteoporosis, compression fractures, hyperglycemia, back pain.
Social History:
___
Family History:
Positive for mother with hearing loss and heart disease, father
with diabetes. The patient also reports history of DM,
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 97.3 PO 177 / 98 54 18 97
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding GU: No foley
Ext: asymmetric swelling Lt>Rt. there is a 2cm wound healing
edges with eschar at the base. surrounding the wound is a large
area of erythema and beefy cellulitis which is tender to touch.
The prior methylin blue marker from her last admission is still
seen and the current redness extends well beyond the old ink
line. Otherwise the lower limbs are well perfused, 2+ pulses, no
clubbing, cyanosis Neuro: CNII-XII intact, ___ strength
upper/lower extremities, grossly normal sensation, 2+ reflexes
bilaterally, gait deferred.
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: 97.5 PO 148 / 74 54 18 98 Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds
present,
Ext: asymmetric swelling L>R. there is a 2cm wound healing.
surrounding the wound, there is a large area of erythema,
receding from skin marking. Otherwise the lower limbs are well
perfused, 2+ pulses
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, normal gait.
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 10:25PM BLOOD WBC-8.4 RBC-3.89* Hgb-12.7 Hct-38.7
MCV-100* MCH-32.6* MCHC-32.8 RDW-13.0 RDWSD-47.0* Plt ___
___ 10:25PM BLOOD Neuts-58.2 ___ Monos-8.1 Eos-1.3
Baso-0.7 Im ___ AbsNeut-4.91# AbsLymp-2.61 AbsMono-0.68
AbsEos-0.11 AbsBaso-0.06
___ 09:32PM BLOOD ___ PTT-35.1 ___
___ 09:15PM BLOOD Glucose-95 UreaN-26* Creat-1.2* Na-137
K-5.0 Cl-102 HCO3-17* AnGap-23*
___ 09:15PM BLOOD Calcium-8.8 Phos-4.1 Mg-2.0
DISCHARGE LAB RESULTS
=====================
___ 04:12AM BLOOD WBC-6.8 RBC-3.53* Hgb-11.7 Hct-34.7
MCV-98 MCH-33.1* MCHC-33.7 RDW-13.1 RDWSD-46.8* Plt ___
___ 04:12AM BLOOD Plt ___
___ 10:25PM BLOOD Neuts-58.2 ___ Monos-8.1 Eos-1.3
Baso-0.7 Im ___ AbsNeut-4.91# AbsLymp-2.61 AbsMono-0.68
AbsEos-0.11 AbsBaso-0.06
___ 04:12AM BLOOD ___ PTT-33.9 ___
___ 04:12AM BLOOD Glucose-97 UreaN-22* Creat-0.9 Na-141
K-4.0 Cl-104 HCO3-25 AnGap-16
___ 04:12AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1
IMAGING/STUDIES
===============
___ XRay of Tibia/Fibula:
Diffuse soft tissue swelling, with no subcutaneous gas.
___ Lower Extremity Ultrasound:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins, although assessment of the left calf veins is limited.
MICROBIOLOGY
============
___ Blood culture: pending
Brief Hospital Course:
Ms. ___ is a ___ yo F with history of AF on warfarin, and
HTN who was admitted due to unresolving cellulitis. Because of
slow clinical response, a PICC line was inserted, and she was
discharged on a regimen of IV vancomycin and ceftriaxone.
# Cellulitis: The patient presented with cellulitis complicated
by a left anterior leg wound she had after a fall. The
cellulitis was initially managed as an outpatient. She failed
Bactrim/Keflex, so she was treated with IV vancomycin and 5 days
of doxycycline. The redness recurred, so she re-presented to the
hospital for this admission. CRP was not elevated, and imaging
did not suggest any evidence of osteomyelitis. She was started
on IV vancomycin. Due to slow clinical improved, Ceftriaxone was
added on ___. The wound care team also dressed the wound while
she was in the hospital. The plan was to discharge with PICC and
IV home infusion with plan for 7 day total course of Vancomycin
and Ceftriaxone (D1 ___, D7 ___. She will follow up with
her PCP ___ on ___ to evaluate progression of
disease.
# Atrial fibrillation. She was continued on her home amiodarone,
and warfarin. Her atenolol was held for heart rates in the ___.
She has had tachy-brady events in the past and is going to f/u
with Dr. ___ a pacemaker placement.
# Chronic bilateral lower limb edema: This is thought to be
related to amlodipine usage. She was continued on her home
Lasix.
# Hypertension: Amlodipine was recently discontinued due to
peripheral edema. Her home atenolol was held given relative
bradycardia. Consider outpatient initiation of an ACE-I for
better blood pressure control.
# Osteoporosis: Continued home vitamin d and calcium
supplementation. Held home denosumab while inpatient.
#Allergic rhinitis. Continued home fluticasone nasal spray.
TRANSITIONAL ISSUES
===================
#Cellulitis
- She will need a Vancomycin level checked on ___ at home and
sent to ___ labs. To be followed up by Dr. ___.
- Continue antibiotics through ___
#Afib
- Holding atenolol given HR 50-60.
- She should follow-up with Dr. ___ a pacemaker for
tachy/brady syndrome
- Patient may benefit from initiation of ACE-inhibitor for
better blood pressure control if she remains hypertensive
- Per endocrine, OK to reduce calcium tablets as long as she
gets 1200 mg daily from diet and vitamin supplementation
# CODE: full (presumed)
# CONTACT: daughter ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Estrogens Conjugated 0.5 gm VG DAILY
5. Furosemide 20 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8. Warfarin 2.5 mg PO 6X/WEEK (___)
9. Warfarin 5 mg PO 1X/WEEK (WE)
10. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral TID
11. Denosumab (Prolia) 60 mg SC 1X / 6MONTHS
12. Fluticasone Propionate NASAL 1 SPRY NU BID
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. urea 40 % topical QHS
15. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. CefTRIAXone 1 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 1 gram/50 mL 1 g IV q24 hr
Disp #*5 Intravenous Bag Refills:*0
2. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 1 gram 1000 mg IV q12 hr Disp #*11 Vial
Refills:*0
3. Amiodarone 200 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. Calcitrate-Vitamin D (calcium citrate-vitamin D3) 315-250
mg-unit oral TID
6. Denosumab (Prolia) 60 mg SC 1X / 6MONTHS
7. Estrogens Conjugated 0.5 gm VG DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Furosemide 20 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. TraZODone 50 mg PO QHS:PRN insomnia
13. urea 40 % topical QHS
14. Vitamin D 400 UNIT PO DAILY
15. Warfarin 2.5 mg PO 6X/WEEK (___)
16. Warfarin 5 mg PO 1X/WEEK (WE)
17. HELD- Atenolol 25 mg PO DAILY This medication was held. Do
not restart Atenolol until you see your primary care physician
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Left lower extremity cellulitis
Secondary diagnosis:
- Afib
- Chronic bilateral lower extremity edema
- Hypertension
- Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___.
Why did you come to the hospital?
================================
- You came to the hospital because of a worsening infection of
the skin in your leg (cellulitis).
What did we do for you?
=======================
- We started you on IV antibiotics (vancomycin and ceftriaxone).
What do you need to do?
=======================
- It is very important that you take your medications as
prescribed.
- You should follow-up with your primary care doctor.
It was a pleasure taking care of you. We wish you the best!
Followup Instructions:
___
|
19789057-DS-22
| 19,789,057 | 28,084,728 |
DS
| 22 |
2158-08-07 00:00:00
|
2158-08-07 19:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / chlorthalidone
Attending: ___.
Chief Complaint:
weakness, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with HTN, AF
(Coumadin), OSA, and osteoporosis presenting with generalized
weakness and hypotension.
Her recent outpatient notes describe labile blood pressures and
unsteady gait as active issues. In terms of her BPs, she was
seen
in ___ clinic earlier this month where she reported home SBPs in
the 140-160s. Her Lasix was discontinued and chlorthalidone
12.5mg QD started. She was continued on hydralazine 25mg TID and
losartan 25mg QD. Additionally, she was seen in neurology clinic
in ___ due to concerns about unsteady gait and frequent falls
and
was referred to ___, which she has been attending.
Since starting Chlorthalidone, pt reports progressively
worsening
fatigue and weakness. She also reports large volume urine
output
with no c/o dysuria. Today she reports that she awoke feeling
fatigued to the point that she was unable to sit up in bed. She
took her BP and her SBP was in the ___. She drank 3 glasses of
water, felt somewhat better, and rechecked her BP and found SBP
110. However, given this episode she presented to the ED for
evaluation.
ED Course:
Initial Vitals: HR 96, BP 128/78, RR 16, SpO2 95% on RA
Data: Na 126, Cr 1.1 (baseline), lactate 1.0
Interventions: None
Course:
Orthostatics checked - supine 81, 115/60; sitting 98, 106/74,
standing 100, ___
Admitted for hyponatremia and unsteadiness
When seen on the floor, pt reports feeling much better overall.
Denies any recent fevers, chills, cough, SOB, abdominal pain,
n/v, or infectious symptoms.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
Atrial fibrillation on coumadin
osteoarthritis
peripheral neuropathy
osteoporosis c/b compression fractures,
OSA on CPAP
Social History:
___
Family History:
Positive for mother with hearing loss and heart disease, father
with diabetes. The patient also reports history of DM,
Physical Exam:
ADMISSION
VITALS: 98.4PO 125 / 80 95 18 95 ra
GENERAL: Well appearing, in no distress
EYES: Anicteric, pupils equally round, normal hearing
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3/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.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs, trace pitting edema
SKIN: No rashes or ulcerations noted on examined skin
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
VS: ___ ___ Temp: 97.9 PO BP: 145/70 HR: 62 RR: 18 O2 sat:
95% O2 delivery: RA
Gen - sitting up in bed, comfortable
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normal bowel sounds
Ext - no edema; point tenderness over sternum improved from day
prior
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 11:47AM BLOOD WBC-5.3 RBC-4.06 Hgb-12.9 Hct-37.6 MCV-93
MCH-31.8 MCHC-34.3 RDW-12.8 RDWSD-43.6 Plt ___
___ 03:04PM BLOOD ___ PTT-34.5 ___
___ 11:47AM BLOOD Glucose-113* UreaN-20 Creat-1.1 Na-126*
K-3.5 Cl-87* HCO3-26 AnGap-13
___ 06:35AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.9
WORKUP
___ 10:45AM BLOOD CK-MB-1 cTropnT-<0.01
___ 11:47AM BLOOD cTropnT-<0.01
___ 05:35AM BLOOD TSH-3.0
___ 06:35AM BLOOD Cortsol-17.2
DISCHARGE
___ 07:05AM BLOOD WBC-5.2 RBC-3.81* Hgb-12.3 Hct-36.1
MCV-95 MCH-32.3* MCHC-34.1 RDW-13.2 RDWSD-46.0 Plt ___
___ 06:00AM BLOOD ___ PTT-35.0 ___
___ 06:00AM BLOOD Glucose-94 UreaN-18 Creat-1.0 Na-135
K-4.3 Cl-97 HCO3-26 AnGap-12
CXR - ___
No acute cardiopulmonary abnormality.
CXR - ___
No acute displaced rib fracture identified. New opacities in
the right lower
lung likely reflect atelectasis.
Brief Hospital Course:
This is a ___ year old female with past medical history of
osteoporosis, OSA on CPAP, atrial fibrillation on Coumadin and
hypertension, recently initiated on chlorthalidone admitted
___ with hypotension and hyponatremia, course complicated
by syncopal episode, hyponatremia resolving with holding
chlorthalidone, course further complicated by elevated INR, able
to be discharged home.
# Hyponatremia
Patient who recently was started on chlorthalidone who presented
with Na 126. Urine electrolytes were indicative of dehydration
(appropriate ADH). Na improved with IV fluid resuscitation and
holding chlorthalidone. Over subsequent 96 hours, sodium
improved to normal. Did not restart chlorthalidone.
# Hypotension
Patient also presented with hypotension and subjective weakness;
neurologic exam was nonfocal; weakness was felt to relate to
hypotension, which was felt to be secondary to dehydration from
chlorthalidone. Hospital course was complicated by syncopal
episode as below. Initially all antihypertensives were held.
With improvement in blood pressure, losartan was restarted
without issue. Discontinued chlorthalidone as above. Held
hydralazine at discharge--would consider potentially restarting
at follow-up
# Syncope
On hospital day 1, following micturition, patient reported
feeling lightheaded and then had an observed syncopal episode.
Given concern she had lost a pulse she received 3 chest
compressions before waking up. Subsequent EKG, telemetry were
unremarkable. Syncope was felt to have been vasovagal (given
following micturition) vs orthostatic (in setting of dehydration
as above). Patient subsequently seen by ___, ambulated without
recurrent symptoms.
# Sternal pain
Following receiving chest compressions, patient had sternal pain
reproducible on exam. CXR did not reveal signs of broken ribs.
Pain was felt to be likely bruising from attempted compressions.
Patient started on tylenol and trial of Lidoderm patch, prn
oxycodone with good effect. She was discharged with
prescription for limited supply of Lidoderm patch and oxycodone.
# Persistent Atrial fibrillation
# Supratherapeutic ___
___ hospital course was notable for rising INR to 3.9 in
setting of poor PO intake while she was acutely ill. Discussed
with ___ clinic. Held Coumadin dosing on ___
and ___. Per ___ clinic, instructed patient to
check INR on ___ (she has home monitoring device) and to call
___ clinic to receive additional instructions.
Continued Amiodarone
# Hyperlipidemia
Continued statin
# Depression
Fluoxetine held initially in setting of hyponatremia of unclear
cause, then restarted without issue.
Transitional issues
- Discharged home with ___ services
- INR 3.8 on day of discharge; per discussion with ___
___ clinic, Coumadin was held; patient given
instructions to have INR checked day following discharge and to
call ___ clinic for further recommendations
- Discharge Na = 135; consider recheck at follow-up
- Requested patient hold her cyclobenzaprine while she is on
the oxycodone
- given normotension, held hydralazine, would consider
restarting at follow-up appointment
> 30 minutes spent on this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 25 mg PO DAILY
2. solifenacin 10 mg oral DAILY
3. Denosumab (Prolia) 60 mg SC EVERY 6 MONTHS
4. Cyclobenzaprine 2.5 mg PO HS
5. Amiodarone 200 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Warfarin 2.5 mg PO 6X/WEEK (___)
8. Warfarin 5 mg PO 1X/WEEK (WE,FR)
9. HydrALAZINE 25 mg PO TID
10. Estrogens Conjugated 1 gm VG 2X/WEEK (MO,FR)
11. Ranitidine 150 mg PO BID:PRN heartburn
12. Atorvastatin 20 mg PO QPM
13. urea 40 % topical QPM
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
16. Cal-Citrate (calcium citrate-vitamin D2) 315-200 mg oral TID
17. FLUoxetine 20 mg PO DAILY
18. Chlorthalidone 12.5 mg PO DAILY
19. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*25 Tablet Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % apply to sternum daily Disp #*7
Patch Refills:*0
3. OxyCODONE (Immediate Release) 2.5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every eight
(8) hours Disp #*6 Tablet Refills:*0
4. Amiodarone 200 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. Cal-Citrate (calcium citrate-vitamin D2) 315-200 mg oral TID
7. Denosumab (Prolia) 60 mg SC EVERY 6 MONTHS
8. Estrogens Conjugated 1 gm VG 2X/WEEK (MO,FR)
9. FLUoxetine 20 mg PO DAILY
10. Fluticasone Propionate NASAL 1 SPRY NU BID
11. Losartan Potassium 25 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Ranitidine 150 mg PO BID:PRN heartburn
15. solifenacin 10 mg oral DAILY
16. urea 40 % topical QPM
17. Vitamin D 400 UNIT PO DAILY
18. HELD- Cyclobenzaprine 2.5 mg PO HS This medication was
held. Do not restart Cyclobenzaprine until you are no longer
taking oxycodone
19. HELD- HydrALAZINE 25 mg PO TID This medication was held. Do
not restart HydrALAZINE until you see your primary care doctor
20. HELD- Warfarin 2.5 mg PO 6X/WEEK (___) This
medication was held. Do not restart Warfarin until you speak to
the ___ clinic tomorrow (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# Hyponatremia
# Hypotension secondary to dehydration
# Syncope
# Sternal pain
# Persistent Atrial fibrillation
# Supratherapeutic INR
# Hyperlipidemia
# 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:
Ms ___:
It was a pleasure caring for you at ___. You were admitted
with low blood pressure and low sodium. This was caused by one
of your medications: chlorthalidone. This medication was
stopped and your sodium returned to normal.
During your hospital stay, you developed a high INR. We
discussed this with your ___ clinic. They recommended not
taking any Coumadin today (___). Please check your INR
tomorrow and call the ___ clinic--they will give you
instructions on what to do about your next Coumadin dose.
You are now ready for discharge home.
Followup Instructions:
___
|
19789057-DS-23
| 19,789,057 | 25,527,200 |
DS
| 23 |
2158-12-24 00:00:00
|
2158-12-25 14:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / chlorthalidone
Attending: ___
Chief Complaint:
Hypokalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ year old lady with a history of pAFib, HTN,
melanoma, presenting with nausea/vomiting and weakness. She had
nausea and vomiting the day prior to admission, with poor PO
intake. She hadn't been able to eat for the past 24h, which led
to generalized weakness and fatigue. Per her daughter, she was
hypotensive this morning with BP 65/49, which prompted call to
her PCP. She had been in the PCP's office and gotten routine
labwork. Her symptoms, combined with labs showing hypokalemia
and
Hyponatremia, led to patient's referral to the ED.
Of note, patient recently had furosemide, losartan stopped and
started on indapamide (another loop diuretic). She had also had
a
fall two weeks ago with CT head showing 1.0 cm left frontal
subgaleal hematoma. Lastly, she had an insidious weight loss of
40 lb over the past year.
In the ED:
Initial vital signs: T 98.4, HR 86, BP 141/86, RR 18, O2 sat 96%
RA.
Exam notable for: Irregular rhythm, normal rate, otherwise wnl.
EKG: AFib, QTc 505, minimal ST depression in inferior and
lateral
leads.
Labs were notable for: Whole blood K 2.8, trop < 0.01
Patient was given: KCl 40 mEq PO, KCl 10 mEq IV, 1L NS.
Upon arrival to the floor, the patient is really nauseous and
feels lightheaded. She denied fever/chills, headache, chest
pain,
palpitations, abdominal pain, loose stools, or dysuria.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
Atrial fibrillation on coumadin
osteoarthritis
peripheral neuropathy
osteoporosis c/b compression fractures,
OSA on CPAP
Social History:
___
Family History:
Positive for mother with hearing loss and heart disease, father
with diabetes. The patient also reports history of DM,
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.8, BP 103/65, HR 56, RR 16, O2 sat 95 RA.
GENERAL: Uncomfortable appearing.
HEENT: PERRL, EOMI, sclera anicteric, dry mucous membranes,
wearing dentures.
NECK: No cervical lymphadenopathy. No evidence of JVD.
CARDIAC: Bradycardic, no murmurs/gallops/rubs.
LUNGS: CTAB, no crackles/wheezing/rhonchi.
ABDOMEN: Soft, non tender non distended.
EXTREMITIES: No ___ edema, bandage around right ankle. Faint
pedal
pulses.
SKIN: No rashes.
NEUROLOGIC: A&Ox3, CN II-XII, motor and sensation grossly
intact.
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 833)
Temp: 98.1 (Tm 98.4), BP: 132/74 (108-132/62-74), HR: 59
(57-61), RR: 20 (___), O2 sat: 97% (95-97), O2 delivery: Ra
General: awake, alert, well-oriented and well developed. Lying
in
bed resting, NAD
HEENT: large ecchymosis around left eye with yellowing and
purple
areas. Dry mucous membranes.
CVD: RRR S1 S2 no m/r/g. No JVD, no peripheral edema.
Pulm: CTAB
Abd: +bs, nt/nd
Ext: warm and well perfused, +turgor. bandage around R ankle.
Pertinent Results:
ADMISSION LABS
___ 04:30PM BLOOD WBC-6.1 RBC-4.22 Hgb-13.6 Hct-38.6 MCV-92
MCH-32.2* MCHC-35.2 RDW-12.7 RDWSD-42.5 Plt ___
___ 04:30PM BLOOD Neuts-71.2* Lymphs-18.9* Monos-9.1
Eos-0.0* Baso-0.3 Im ___ AbsNeut-4.37 AbsLymp-1.16*
AbsMono-0.56 AbsEos-0.00* AbsBaso-0.02
___ 05:04PM BLOOD ___ PTT-21.8* ___
___ 03:20PM BLOOD UreaN-17 Creat-1.0 Na-130* K-3.5 Cl-86*
HCO3-26 AnGap-18
___ 05:04PM BLOOD Albumin-4.1 Calcium-8.6 Phos-3.2 Mg-1.9
___ 05:04PM BLOOD ALT-255* AST-220* AlkPhos-90 TotBili-0.7
___ 05:04PM BLOOD Lipase-25
___ 05:04PM BLOOD cTropnT-<0.01
___ 10:00PM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:30AM BLOOD Triglyc-44 HDL-79 CHOL/HD-2.3 LDLcalc-90
___ 05:30AM BLOOD TSH-2.6
___ 05:30AM BLOOD Cortsol-12.0
___ 05:04PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 05:13PM BLOOD Lactate-1.2 K-2.8*
___ 08:10PM BLOOD K-3.0*
___ 10:48PM BLOOD Lactate-1.1 K-5.2*
___ 03:40PM BLOOD Na-124* K-3.9
___ 05:12PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:12PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-SM*
___ 05:12PM URINE RBC-0 WBC-1 Bacteri-MANY* Yeast-NONE
Epi-<1 TransE-<1
___ 01:25AM URINE Hours-RANDOM UreaN-316 Creat-53 Na-45
K-31 Cl-37 Uric Ac-24.9
___ 01:25AM URINE Osmolal-285
PERTINENT STUDIES
___ 03:20PM BLOOD UreaN-17 Creat-1.0 Na-130* K-3.5 Cl-86*
HCO3-26 AnGap-18
___ 05:04PM BLOOD Glucose-100 UreaN-14 Creat-0.9 Na-125*
K-3.3* Cl-83* HCO3-25 AnGap-17
___ 10:00PM BLOOD Glucose-111* UreaN-13 Creat-1.0 Na-125*
K-4.2 Cl-87* HCO3-20* AnGap-18
___ 05:30AM BLOOD Glucose-106* UreaN-13 Creat-1.0 Na-125*
K-3.3* Cl-88* HCO3-27 AnGap-10
___ 05:20AM BLOOD Glucose-100 UreaN-15 Creat-0.9 Na-128*
K-3.7 Cl-94* HCO3-26 AnGap-8*
___ 03:10PM BLOOD Na-132* K-4.8
___ 07:43AM BLOOD Glucose-101* UreaN-18 Creat-0.9 Na-136
K-4.4 Cl-100 HCO3-23 AnGap-13
___ 07:57AM BLOOD Glucose-98 UreaN-14 Creat-0.9 Na-138
K-4.2 Cl-101 HCO3-26 AnGap-11
___ 05:13PM BLOOD Lactate-1.2 K-2.8*
___ 08:10PM BLOOD K-3.0*
___ 10:48PM BLOOD Lactate-1.1 K-5.2*
___ 03:40PM BLOOD Na-124* K-3.9
CHEST XRAY ___
IMPRESSION:
Subtle nodular opacity projecting over the left lung base is
indeterminate
though new from prior. Recommend nonemergent CT of the chest to
further
assess.
CT CHEST/ABDOMEN/PELVIS ___
FINDINGS:
Included views of the thyroid are within normal limits.
There is no axillary, mediastinal, or hilar lymphadenopathy.
The heart size is normal. There is no pericardial effusion. No
significant
coronary atherosclerotic calcifications are seen.
The great vessels are patent and normal in caliber. There is
minimal
atherosclerotic calcification along the aortic arch. There is
no dissection.
The main pulmonary arteries are normal in caliber. No pulmonary
embolus is
detected to the proximal segmental levels.
There is no pneumothorax, focal consolidation, or pleural
effusion. There is
mild dependent atelectasis a low the bilateral lower lobes.
There is no
concerning nodule or mass.
The liver density is within normal limits. There is mild
periportal edema.
There is no intra extrahepatic bile duct dilation. The
gallbladder is normal.
No radiopaque ductal stones are detected.
The pancreas demonstrates normal density and bulk, without duct
dilation or
focal lesion.
The spleen size within normal limits. There are no focal
splenic lesions.
The adrenal glands are normal in size and shape.
The kidneys are normal in size and enhance symmetrically,
without
hydronephrosis. There is a 5 mm exophytic fat containing lesion
arising from
the interpolar aspect of the right kidney, most compatible with
an
angiomyolipoma (series 2, image 58). A 3 mm hypodensity along
the periphery
of the posterior interpolar aspect of the right kidney is
indeterminate,
statistically likely a benign cyst (series 2, image 59).
The stomach and intra-abdominal and intrapelvic loops of small
and large bowel
are normal in caliber. The appendix is normal (series 601,
image 22). There
is no focal gastrointestinal lesion. The sigmoid colon is
moderately
redundant (series 601, image 15).
The bladder is decompressed, and appears grossly normal. The
uterus is not
visualized, likely post hysterectomy. No concerning adnexal
lesions are
detected.
There is no mesenteric, retroperitoneal, inguinal, or
intrapelvic
lymphadenopathy, and no ascites.
The abdominal aorta, celiac trunk, SMA, renal arteries, ___, and
iliac
branches are patent and normal in caliber. The portal and
hepatic veins are
patent.
There are no osseous lesions concerning for malignancy or
infection. There is
been interval T12 kyphoplasty since the ___
examination. T8 and T9
kyphoplasty changes are again demonstrated, unchanged from
prior. Moderate
compression deformity of T11 appears stable. Kyphoplasty
changes at L4 are
present. There is a moderate compression deformity of L2.
IMPRESSION:
1. No concerning pulmonary nodule or mass correlating to the
focal opacity
seen on the recent chest radiograph. No acute intrathoracic
process.
2. No intrathoracic or abdominopelvic malignancy identified. No
lymphadenopathy.
3. Mild periportal edema.
4. 5 mm right interpolar renal angiomyolipoma.
ABDOMEN/PELVIS
FINDINGS:
Included views of the thyroid are within normal limits.
There is no axillary, mediastinal, or hilar lymphadenopathy.
The heart size is normal. There is no pericardial effusion. No
significant
coronary atherosclerotic calcifications are seen.
The great vessels are patent and normal in caliber. There is
minimal
atherosclerotic calcification along the aortic arch. There is
no dissection.
The main pulmonary arteries are normal in caliber. No pulmonary
embolus is
detected to the proximal segmental levels.
There is no pneumothorax, focal consolidation, or pleural
effusion. There is
mild dependent atelectasis a low the bilateral lower lobes.
There is no
concerning nodule or mass.
The liver density is within normal limits. There is mild
periportal edema.
There is no intra extrahepatic bile duct dilation. The
gallbladder is normal.
No radiopaque ductal stones are detected.
The pancreas demonstrates normal density and bulk, without duct
dilation or
focal lesion.
The spleen size within normal limits. There are no focal
splenic lesions.
The adrenal glands are normal in size and shape.
The kidneys are normal in size and enhance symmetrically,
without
hydronephrosis. There is a 5 mm exophytic fat containing lesion
arising from
the interpolar aspect of the right kidney, most compatible with
an
angiomyolipoma (series 2, image 58). A 3 mm hypodensity along
the periphery
of the posterior interpolar aspect of the right kidney is
indeterminate,
statistically likely a benign cyst (series 2, image 59).
The stomach and intra-abdominal and intrapelvic loops of small
and large bowel
are normal in caliber. The appendix is normal (series 601,
image 22). There
is no focal gastrointestinal lesion. The sigmoid colon is
moderately
redundant (series 601, image 15).
The bladder is decompressed, and appears grossly normal. The
uterus is not
visualized, likely post hysterectomy. No concerning adnexal
lesions are
detected.
There is no mesenteric, retroperitoneal, inguinal, or
intrapelvic
lymphadenopathy, and no ascites.
The abdominal aorta, celiac trunk, SMA, renal arteries, ___, and
iliac
branches are patent and normal in caliber. The portal and
hepatic veins are
patent.
There are no osseous lesions concerning for malignancy or
infection. There is
been interval T12 kyphoplasty since the ___
examination. T8 and T9
kyphoplasty changes are again demonstrated, unchanged from
prior. Moderate
compression deformity of T11 appears stable. Kyphoplasty
changes at L4 are
present. There is a moderate compression deformity of L2.
IMPRESSION:
1. No concerning pulmonary nodule or mass correlating to the
focal opacity
seen on the recent chest radiograph. No acute intrathoracic
process.
2. No intrathoracic or abdominopelvic malignancy identified. No
lymphadenopathy.
3. Mild periportal edema.
4. 5 mm right interpolar renal angiomyolipoma.
DISCHARGE LABS
___ 05:20AM BLOOD WBC-6.2 RBC-3.44* Hgb-11.3 Hct-32.1*
MCV-93 MCH-32.8* MCHC-35.2 RDW-12.9 RDWSD-44.2 Plt ___
___ 07:57AM BLOOD Glucose-98 UreaN-14 Creat-0.9 Na-138
K-4.2 Cl-101 HCO3-26 AnGap-11
___ 07:57AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.0
___ 07:57AM BLOOD ALT-175* AST-105* AlkPhos-86
Brief Hospital Course:
SUMMARY STATEMENT:
====================
___ female with past medical history of A. fib,
hypertension, melanoma status post treatment, presenting with 1
day of nausea/vomiting and weakness. She was found to have
hyponatremia, hypokalemia, transaminitis, and hypertension.
Attributed to home medications indapamide, amiodarone, and
atorvastatin; these were were held due to
hyponatremia/hypovolemia and transaminitis, respectively. She
received IV fluids briefly in the emergency department, and was
transferred to the floor where she was allowed to eat and drink
liberally. Her electrolytes and transaminases were trended and
all trended towards normal prior to discharge.
ACTIVE ISSUES:
==============
___
Transferred to the hospital due to hypotension in ___ ___.
Determine likely secondary to overdiuresis with home indapamide.
She was fluid responsive, and blood pressure returned to normal
with fluids and resumption of liberal p.o. intake of food and
drink.
#Hyponatremia
Hyponatremia was thought to be multifactorial on admission. The
patient had a history of poor p.o. intake in recent months. She
also reported nausea and vomiting which could have caused GI
losses. She also was on diuretics that could have caused sodium
wasting, as they had in the past with this patient. Urine
studies were consistent with SIADH, but were difficult to
interpret in the setting of receiving IV fluids as well as being
on diuretics prior to admission. With resumption of oral intake
as well as allowing patient to drink to thirst, hyponatremia
slowly improved to normal on discharge.
#Hypokalemia
Hypokalemia deemed secondary to side effect of home diuretic.
Indapamide was held as noted above, and potassium was
replenished as needed.
#Transaminitis
Patient noted to have elevated transaminases, which was not a
new issue for her but acutely more elevated than prior. In the
past her transaminitis has been attributed to transient viral
infections. On this admission, amiodarone and atorvastatin were
held due to concern for drug-induced liver toxicity. LFTs were
downtrending on discharge.
#Weight loss/early satiety/anorexia
Patient reported several months of decreased appetite, eating
only 2 meals a day instead of 3. While in the hospital, she has
good p.o. intake, but still only ate 2 meals a day. She also
reported early satiety, and an unclear amount of weight loss in
the past 3 months. She had a CT scan of the abdomen and pelvis
which did not identify any malignancy or cause of her weight
loss.
#Lung nodule
She was found to have a lung nodule on chest x-ray, but this was
exonerated on CT.
CHRONIC ISSUES:
===============
#Atrial fibrillation
Patient remained in sinus throughout the admission with a mean
ventricular rate of around 60 bpm. She was not under any rate
control, especially given concern for vasovagal syncope in the
past. She continue her apixaban, but amiodarone was held due to
concern for liver toxicity and SIADH.
#Coronary artery disease/hypertension/hyperlipidemia
Patient had recently started losartan prior to admission. She
was not on any antihypertensives during this admission.
TRANSITIONAL ISSUES:
====================
[ ] Home diuretic (indapamide) was held this admission due to
concern that it was causing her hypotension and hyponatremia,
and concern that she was hypovolemic on admission. Notably, it
also seems that she has a past history of intolerance to both
loop diuretics and thiazide diuretics. It seems that the
indication for her being on a diuretic in the past was
hypertension, so we will hold all diuretics until follow-up with
primary care physician/blood pressure pharmacy clinic.
[ ] Home amiodarone was held due to concern for amiodarone
induced liver toxicity. Consider restarting for rhythm control
of atrial fibrillation. On discharge, the patient was in sinus
rhythm with a rate of around 60 bpm.
[ ] Home atorvastatin was held due to concern for liver
toxicity. Consider restarting a statin as outpatient to minimize
ASCVD risk.
[ ] 5 mm right interpolar renal angiomyolipoma seen on CT of the
abdomen. Also seen was 3 mm hypodensity along the periphery of
the posterior interpolar aspect of the right kidney,
statistically likely a benign cyst.
[ ] Mild periportal edema noted on CT of the abdomen.
[ ] Patient is scheduled for endoscopy on ___, the day
after discharge for further workup of her recent weight loss.
Per notes from Hepatology Dr. ___, plan is for endoscopy,
gastric emptying study, and potentially liver biopsy or MRCP for
further workup of elevated LFTs and recent weight loss.
[ ] No restrictions to diet or fluid intake.
[ ] Discharge Cr: 1.0
CONTACT:
Name of health care proxy: ___
Relationship: Daughter
Phone number: ___
Alternate: ___: ___
CODE STATUS: full
>30 minutes spent on discharge planning and coordination
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Apixaban 5 mg PO BID
4. Denosumab (Prolia) 60 mg SC Q6MONTHS
5. FLUoxetine 20 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Indapamide 0.0625 mg PO BID
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
9. Ranitidine 150 mg PO BID
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Denosumab (Prolia) 60 mg SC Q6MONTHS
3. FLUoxetine 20 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
6. Ranitidine 150 mg PO BID
7. HELD- Amiodarone 200 mg PO DAILY This medication was held.
Do not restart Amiodarone until instructed to do so by a
physician
8. HELD- Atorvastatin 20 mg PO QPM This medication was held. Do
not restart Atorvastatin until instructed to do so by a
physician
9. HELD- Indapamide 0.0625 mg PO BID This medication was held.
Do not restart Indapamide until instructed to do so by a
physician
___:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Hyponatremia
Hypokalemia
Hypovolemic hypotension
Drug-induced transaminitis
SECONDARY DIAGNOSES:
Atrial fibrillation
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 to the hospital because you were feeling
nauseous, had vomiting, and low blood pressure.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, you were found to have a low sodium and
potassium level, likely due to your vomiting, poor oral intake,
and your home diuretic (indapamide).
- You were given some intravenous fluids and some of your home
medications were held. Your sodium level improved back to
normal. You were also given supplemental potassium and
phosphate.
- You had elevated liver enzymes, which improved once we stopped
your amiodarone and atorvastatin.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your follow-up appointments listed below.
- Your indapamide, atorvastatin, and amiodarone were held. Do
not restart these until you follow-up with a primary care
physician.
- You have no restrictions to your diet or fluid intake.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19789057-DS-24
| 19,789,057 | 28,196,195 |
DS
| 24 |
2159-12-20 00:00:00
|
2159-12-20 18:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / chlorthalidone / amiodarone
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
==============
___ 12:54PM BLOOD WBC-5.9 RBC-3.90 Hgb-12.8 Hct-38.3 MCV-98
MCH-32.8* MCHC-33.4 RDW-12.6 RDWSD-45.2 Plt ___
___ 12:54PM BLOOD Neuts-43.1 ___ Monos-9.1 Eos-0.8*
Baso-0.5 Im ___ AbsNeut-2.55 AbsLymp-2.74 AbsMono-0.54
AbsEos-0.05 AbsBaso-0.03
___ 12:54PM BLOOD ___ PTT-32.3 ___
___ 12:54PM BLOOD Glucose-99 UreaN-19 Creat-1.0 Na-131*
K-6.8* Cl-99 HCO3-21* AnGap-11
___ 12:54PM BLOOD cTropnT-<0.01
___ 12:54PM BLOOD Calcium-8.6 Phos-3.9 Mg-2.3
___ 01:02PM BLOOD %HbA1c-5.5 eAG-111
___ 01:13PM BLOOD Lactate-1.6 K-4.3
___ 04:07PM URINE Color-Colorless Appear-CLEAR Sp
___
___ 04:07PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-7.0
Leuks-NEG
___ 07:18AM URINE Osmolal-264
___ 07:18AM URINE Hours-RANDOM Creat-45 Na-47
DISCHARGE LABS:
==============
___ 07:10AM BLOOD WBC-5.9 RBC-3.84* Hgb-12.5 Hct-37.7
MCV-98 MCH-32.6* MCHC-33.2 RDW-12.5 RDWSD-44.9 Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:10AM BLOOD Glucose-91 UreaN-17 Creat-1.0 Na-140
K-5.0 Cl-105 HCO3-25 AnGap-10
___ 07:10AM BLOOD ALT-9 AST-16 LD(LDH)-166 AlkPhos-58
TotBili-0.5
___ 07:10AM BLOOD Albumin-4.0 Calcium-8.7 Phos-3.5 Mg-2.2
___ 07:10AM BLOOD Osmolal-293
IMAGING:
=======
CXR (___):
IMPRESSION: No focal consolidation to suggest pneumonia.
Brief Hospital Course:
HOSPITAL SUMMARY:
=================
___ female with PMH pAFib, HTN, and HLD, presented on
___ with palpitations, and was found to be in AFib with RVR.
She was treated with IV and PO diltiazem in the ED, with
improvement in her HR. Pt was then started on standing
metoprolol upon admission. A TEE/DCCV was planned for the
morning of ___, but patient spontaneously converted to NSR
prior to the procedure. She was continued on her home apixaban
5mg BID, and was started on metoprolol succinate 50mg daily.
TRANSITIONAL ISSUES:
====================
#AFib:
[]Patient was started on metoprolol succinate 50mg daily
[]Consider flecainide or dofetilide as an alternative to
amiodarone, as patient has a history of hepatotoxicity ___
amiodarone use
# CODE STATUS: Full Code, confirmed
# CONTACT: ___ (daughter) ___
ACTIVE ISSUES:
==============
#AFib w/ RVR:
Patient w/ hx pAFib, previously treated with amiodarone, which
was discontinued in ___ when she developed elevated LFTs.
Not previously on rate control as outpt. She presented to the ED
with palpitations, found to be in AFib with RVR. Was
hemodynamically stable and without chest pain. Pt was treated w/
IV diltiazem
x3 and PO diltiazem x1 in the ED, then started on metoprolol
tartrate 12.5mg Q6H on admission to the floor. A TEE/DCCV was
planned for the morning of ___, since patient was symptomatic
(palpitations), but she spontaneously converted to NSR (HR ___
prior to the procedure. There was no clear impetus for patient's
AFib w/ RVR. Trop <0.01 and EKG without acute ischemic changes.
No signs or symptoms of infection. TSH 1.8. The metoprolol
tartrate was consolidated to metoprolol succinate 50mg daily on
discharge.
#HTN
Patient was treated with losartan as an inpatient, in place of
her home Irbesartan, as Irbesartan was non-formulary. Irbesartan
was decreased from 75mg BID to 75mg daily on discharge, as she
was found to have soft BPs overnight (90s). She was started on
metoprolol as per above.
CHRONIC ISSUES:
===============
#HLD
- continued home pravastatin 20mg daily
#Depression
- continued home fluoxetine 20mg daily
#Osteoporosis
- continued home Vit D
- treated with calcium carbonate in place of home calcium
citrate(non-formulary)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. irbesartan 75 mg oral BID
2. Denosumab (Prolia) 60 mg SC Q6MONTHS
3. Apixaban 5 mg PO BID
4. ipratropium bromide 42 mcg (0.06 %) nasal TID:PRN runny nose
5. linaCLOtide 145 mcg oral daily prn
6. Pravastatin 20 mg PO QPM
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral daily
10. FLUoxetine 20 mg oral daily
11. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
2. irbesartan 75 mg oral DAILY
3. Apixaban 5 mg PO BID
4. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral daily
5. Denosumab (Prolia) 60 mg SC Q6MONTHS
6. FLUoxetine 20 mg oral DAILY
7. ipratropium bromide 42 mcg (0.06 %) nasal TID:PRN runny nose
8. linaCLOtide 145 mcg oral daily prn
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Pravastatin 20 mg PO QPM
12. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Atrial fibrillation with rapid ventricular response
SECONDARY DIAGNOSES
===================
Hypertension
Hyperlipidemia
Depression
Osteoporosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because your heart rate was very fast
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were treated with medications through the IV to help lower
your heart rate
- You were started on a new medication, called metoprolol, to
help prevent your heart rate from increasing again
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below.
- If you experience new palpitations or chest pain, please call
the heartline at ___
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19789197-DS-25
| 19,789,197 | 20,567,817 |
DS
| 25 |
2137-07-31 00:00:00
|
2137-07-31 16:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
IV Dye, Iodine Containing Contrast Media / ranolazine /
Ezetimibe
Attending: ___.
Chief Complaint:
right leg pain and swelling
Major Surgical or Invasive Procedure:
right femoral artery thrombin injection
History of Present Illness:
Mr. ___ is a ___ y/o male with a past medical history of CAD
s/p CABG, multiple PCIs with stent placement (approximately 15
stents per patient report), also with a history of HTN and HLD
who presented to the ED with right leg pain. Patient was
recently admitted to ___ from ___ with chest pain and
underwent a LHC via a right femoral approach which showed areas
of CAD but he did not undergo stent placement. The decision was
made to medically manage his CAD and continue with risk
reduction. Following the cardiac catheterization the patient was
discharged home however started to complain of right leg
pain/swelling. He thought that this was normal following a
cardiac catheterization but mentioned it to his doctor today at
a f/u appointment. His doctor ended up getting a RLE US which
showed evidence of a DVT in the common femoral vein and a 3.8 cm
pseudoaneurysm arisin off the common femoral artery. He was sent
to the ED for vascular evaluation.
In the ED, initial vitals were: 98.7, HR 58, BP 104/52, RR 20,
96% RA. Imaging notable for: repeat US which showed the common
femoral vein DVT and common femoral artery pseudoaneurysm.
Patient given: ceftriaxone 1 g, morphine 5 mg IV x1, zofran 4 mg
IV x1, 1000cc IVF, prednisone 60 mg PO x1 (pre-medication for
CTA)
Patient had an episode of CP. EKG was reportedly unchanged.
Lasted for 5 minutes and resolved spontaneously. Vascular
surgery was consulted and recommended starting anticoagulation
for DVT. Also recommended CTA to determine if patient should
have a vascular v. ___ procedure.
On the floor, T 98.1, BP 138/55, HR 70, RR 20, 95% RA. Patient
complained of mild right leg pain. Also had one episode of chest
pain that occurred at rest and was relieved by NTG.
Review of systems:
Denies fevers, chills, sob, nausea, vomiting, abdominal pain.
+penile ecchymosis. No cough or hemoptysis. Patient reports
having chest pain with exertion at baseline.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: 3-vessel ___ [LIMA-LAD, SVG-OM, SVG-PDA]
-PERCUTANEOUS CORONARY INTERVENTIONS:
-___: Admitted with angina and a positive ETT-Echo, Cypher
stent to the SVG supplying the OM was placed
-___: Presented with atypical chest pain. Attempts at a MIBI
ETT failed due to a vasovagal reaction. At cath, there was
instent restenosis of the SVG stent. This was successfully
restented with a 3.5x23mm CYPHER stent.
-___: Admitted to ___ w/ ___. Transferred to ___.
___. SVG to RCA totally occluded. SVG to OM stent had both
___ and distal in-stent stenosis. DES placed to OM. Attempt at
opening a 95% distal RCA stenosis resulted in a dissection
requiring 6 Drug eluting Stents.
-___: Elective admit because of angina. In stent
restenosis of RCA. 5 ___ placed to RCA (___)
-___: MIBI (___): perinfarct ischemia in LCx
distribution. Fix defect in LAD distribution.
-___: admitted to ___ with angina. RCA in stent ___
stenosis treated with POBA (cutting and noncutting).
-He has known occluded SVG to RCA, patent LIMA to LAD. He is on
indefinite dual antiplatelet therapy.
3. OTHER PAST MEDICAL HISTORY:
ANEMIA, UNSPEC
URINARY RETENTION. Self-catheterizes routinely.
TMJ PAIN
DIABETES MELLITUS
B12 deficiency
Peripheral vascular disease, unspecified
Laparoscopic right hemicolectomy for endoscopically unresectable
cecal polyp
SBO s/p laparoscopic lysis of adhesions ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
========================
ON ADMISSION:
========================
General: T 98.1, BP 138/55, HR 70, RR 20, 95% RA
Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
at LUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley, +penile ecchymosis, +right femoral
bruit/ecchymosis
Ext: Warm, well perfused, dopplerable pulses (not palpable), no
clubbing, cyanosis, 1+ pitting edema of RLE, no edema on left
Neuro: CNII-XII intact, moving arms/legs spontaneously.
========================
ON DISCHARGE:
========================
Vitals: T 98, BP 122/64 (105-120s/40-60s), HR 50-70s, RR 18,
95-98% RA
General: well appearing man, alert, oriented, no acute distress,
lying comfortably in bed, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
at LUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley, +penile ecchymosis, no femoral bruit noted, some
ecchymosis that is resolving, nontender to palpation
Ext: Warm, well perfused, dopplerable pulses (not palpable), no
clubbing, cyanosis, trace pitting edema of RLE, no edema on
left. right leg significantly larger than left.
Neuro: CNII-XII intact, moving arms/legs spontaneously
Pertinent Results:
====================
ADMISSION LABS:
====================
___ 06:25PM WBC-9.0# RBC-4.17* HGB-12.6* HCT-37.1* MCV-89
MCH-30.2 MCHC-34.0 RDW-13.6
___ 06:25PM NEUTS-70.2* ___ MONOS-9.1 EOS-1.2
BASOS-0.3
___ 06:15PM URINE RBC-1 WBC-63* BACTERIA-MANY YEAST-NONE
EPI-2
___ 06:15PM URINE BLOOD-NEG NITRITE-POS PROTEIN-TR
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 06:25PM cTropnT-<0.01
___ 06:25PM GLUCOSE-122* UREA N-29* CREAT-1.2 SODIUM-138
POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-24 ANION GAP-20
=====================
DISCHARGE LABS:
=====================
___ 06:06AM BLOOD WBC-7.5 RBC-3.58* Hgb-10.8* Hct-32.3*
MCV-90 MCH-30.3 MCHC-33.5 RDW-13.6 Plt ___
___ 06:06AM BLOOD ___ PTT-23.3* ___
___ 06:06AM BLOOD Glucose-142* UreaN-26* Creat-1.0 Na-142
K-4.2 Cl-107 HCO3-26 AnGap-13
___ 06:06AM BLOOD Calcium-9.2 Phos-2.6* Mg-2.2
=====================
STUDIES:
=====================
US RIGHT LEG: IMPRESSION: 4.8 cm pseudoaneurysm arising off the
common femoral artery. Deep vein thrombosis involving the right
common femoral vein extending down to the posterior tibial
veins. Proximal extent of thrombus is not definitively seen and
could extend into the pelvis. Peroneal veins not visualized.
CTA RIGHT LEG: IMPRESSION:
1. A 4.7 x 3.2 x 3.6 cm pseudoaneurysm arises from the right
common femoral artery, in the region of recent groin vascular
access. Significant fat stranding and a small amount of
hemorrhagic density material is seen adjacent to the
pseudoaneurysm and tracking up into the retroperitoneal fat in
the right pelvis.
2. The superficial femoral artery at its origin appears
diminutive, and is occluded in the upper mid thigh. The
popliteal artery reconstitutes from collaterals from the deep
femoral artery.
EKG: Sinus rhythm. A-V conduction delay. Left atrial
abnormality.
Intraventricular conduction delay. Compared to the previous
tracing of ___ no diagnostic interim change.
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a past medical history of CAD
s/p CABG, multiple PCIs with stent placement (approximately 15
stents per patient report), recent C.Cath via right femoral
approach ___ also with a history of HTN and HLD who presented
to the ED with right leg pain and swelling.
# Right femoral DVT
# Right femoral pseudoaneurysm:
Ultrasound showed right femoral DVT and right femoral
pseudoaneurysm. Likely caused by recent cardiac catheterization.
Confirmed by CTA. Started on heparin drip for DVT, which was
cleared by vascular surgery in the setting of pseudoaneurysm.
H/H trended down slightly, but stabilized. CTA showed little
blood seen in retroperitoneum, but remained hemodynamically
stable. Underwent thrombin injection to pseudoaneurysm, which
stabilized the vessel. Procedure uncomplicated. Switched to
apixaban 10mg BID for 1 week for loading dose (D1 evening
___, will transition to 5mg BID for duration of treatment
on evening of ___. There was evidence of a diminutive
femoral artery which vascular was aware of, recommended
outpatient follow up with repeat imaging on ___. Patient made
aware of this recommendation and will follow up post discharge
# Klebsiella UTI:
Acute bacterial UTI growing pan-sensitive Klebsiella.
Asymptomatic, but patient has recurrent infections in the past.
Treated with 2 days of ceftriaxone then transitioned to oral
ciprofloxacin. Plan to treat for 7 days. D1 ___, end date
___.
# Acute blood loss anemia
Drop in Hct while on Heparin though not significantly, thought
related to femoral hematoma and mild blood in retroperitoneum.
Remained HD stable and Hct remained stable for duration of
admission.
# CAD s/p CABG and multiple PCIs most recently C.Cath ___:
Chronic stable angina at baseline. One episode of chest pain
during admission without EKG changes and Troponins negative.
Thought it was brought on by cold air and anxiety. Resolved.
CHRONIC ISSUES
# HTN: continued home amlodipine, atenolool, isosorbide
dinitrite, lisinopril
# Urinary retention: straight cath. Held methemaine while being
treated for UTI.
# DM: Chronic non-insulin dependent DM II, well controlle,d not
complicated. HISS while in patient
=========================
TRANSITIONAL ISSUES:
=========================
- Ddx: right femoral DVT, right femoral pseudoaneurysm
- Procedure: right femoral thrombin injection
- Transitioned for heparin to apixaban for anticoagulation. 10mg
BID for 7 days (D1 evening ___. Transition to 5mg BID on
evening of ___.
- Klebsiella UTI, Day 1 abx ___. Dicharged on ciprofloxacin
500mg BID. End date ___. Total duration of treatment: 7
days.
- On CTA of right leg, incidental finding of diminuitive
superficial femoral artery, occluded in the upper mid thigh.
Vascular aware of diagnosis. Discussed with patient who will
follow up as an outpatient and have repeat vascular imaging.
- Repeat vascular imaging to be done on ___
- Unable to palpate distal pulses in right foot. Able to assess
via doppler.
- H/H at discharge: 10.___.3
- No changes made to home medications
- FULL CODE
- wife HCP ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atenolol 12.5 mg PO DAILY
4. cilostazol 50 mg oral BID
5. Clopidogrel 75 mg PO DAILY
6. fenofibrate 200 mg oral DAILY
7. Isosorbide Dinitrate 60 mg PO TID
8. Lisinopril 30 mg PO DAILY
9. methenamine hippurate 1 gram oral DAILY
10. Rosuvastatin Calcium 40 mg PO QPM
11. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
12. Cyanocobalamin 1000 mcg IM/SC MONTHLY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Atenolol 12.5 mg PO DAILY
4. cilostazol 50 mg oral BID
5. Clopidogrel 75 mg PO DAILY
6. Isosorbide Dinitrate 60 mg PO TID
7. Lisinopril 30 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Rosuvastatin Calcium 40 mg PO QPM
10. Apixaban 10 mg PO BID Duration: 7 Days
RX *apixaban [Eliquis] 5 mg ___ tablet(s) by mouth twice a day
Disp #*72 Tablet Refills:*0
11. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*7 Tablet Refills:*0
12. Cyanocobalamin 1000 mcg IM/SC MONTHLY
13. Fenofibrate 200 mg ORAL DAILY
14. methenamine hippurate 1 gram ORAL DAILY
Start taking when ciprofloxacin finishes
15. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Right femoral deep vein thrombosis
Right femoral artery pseudoaneurysm
Urinary Tract infection
SECONDARY DIAGNOSIS:
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 taking of ___ at ___. ___
came to the hospital for right leg swelling. ___ were found to
have a clot in your femoral vein, which was causing your
swelling. An ultrasound also showed an pseudoaneurysm, which is
a dilation of your femoral artery. Vascular surgery injected a
material into your artery to help strengthen it. The procedure
went well. ___ were started on a blood thinner to treat the clot
in your leg. ___ will take this medication for at least 3
months.
For the blood thinner, ___ will take 10mg twice a day for 6 more
days, then 5mg twice a day for the duration of your treatment.
___ were also found to have a urinary tract infection that we
treated with antibiotics. ___ will take oral antibiotics for 4
days after discharge. While ___ are on the ciprofloxacin for the
UTI, ___ should not take the methenamine. Restart it as directed
by your primary care doctor after finishing ciprofloxacin.
We wish ___ the best of health,
Your medical team at ___
Followup Instructions:
___
|
19789450-DS-11
| 19,789,450 | 22,714,316 |
DS
| 11 |
2181-04-02 00:00:00
|
2181-04-03 13:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
aspirin / Nsaids / mercaptopurine
Attending: ___
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Intubation
Lumbar puncture
History of Present Illness:
___ w/ PMH EtOH use disorder, UC on humira, esophageal
strictures, HTN and HLD presents with headache and 4 seizures on
day of presentation. No PMH of seizures.
Per friend, day of presentation patient had an episode where he
"blacked out" in the car, followed by a severe frontal headache
on awakening. He was able to drive home after this episode. Had
a glass of wine, was talking to friend, patient was witnessed to
lose consciousness, "foaming at the mouth" with arms flexed,
returning to baseline after each episode. He again had another
seizure in our ED waiting room. Semiology: ___ minutes in
length, L head turn followed by tonic extension of arms,
associated w/ desat, tachycardia.
ROS notable for headache 3 days ago as well that had resolved.
denies fever, chills.
In the ED, VS notable for SBP 178, HR 108, TMax102.8. Labs
notable for WBC 5.6, lactate 16.8, ALT/AST: 193/109, lipase 113,
blood alcohol 68, UTox positive for Benzos (but UTox done after
received lorazepam). Pan-cultures, including LP were sent.
Dispensed IV thiamine, 2L IVF, 4mg Lorazepam, then had another
seizure in ED, was altered thereafter, was intubated for airway
protection given AMS and concern for status epilepticus. Also
started on CTX, Vancomycin, Ampicillin and Acyclovir for empiric
meningitis tx, loaded with Keppra. CSF clear w/o 3 total
nucleated cells, no WBCs/RBCs, protein 65 ,normal glucose.
NCHCT-no acute intracranial process
CXR- L basilar atelectasis
Evaluated by Neurology, who thought presentation most consistent
w/ infection vs structural lesion. Less likely EtOH withdrawal
given time course and localization factors. Recommend cEEG, MRI,
cont. Ativan, Keppra, empiric meningitis drugs till gram stain
results.
On arrival to the MICU, febrile to 100.8F, HD stable, intubated
and sedated after propofol bolus.
Past Medical History:
Ulcerative Colitis/IBD
HTN
HLD
Alcohol Use Disorder
Esophageal strictures s/p balloon dilatation
Social History:
___
Family History:
Father deceased from prostate cancer. Mother unknown.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: Sedated, intubated
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Warm, dry
NEURO: Sedated, intubated
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 07:45PM BLOOD WBC-5.6 RBC-3.71* Hgb-13.4* Hct-41.4
MCV-112* MCH-36.1* MCHC-32.4 RDW-14.3 RDWSD-59.1* Plt ___
___ 08:04PM BLOOD ___ PTT-23.8* ___
___ 07:45PM BLOOD Glucose-109* UreaN-10 Creat-1.1 Na-144
K-4.8 Cl-96 HCO3-15* AnGap-33*
___ 07:45PM BLOOD ALT-108* AST-193* AlkPhos-92 TotBili-0.6
___ 07:45PM BLOOD Lipase-113*
___ 07:45PM BLOOD cTropnT-<0.01
___ 07:45PM BLOOD CK-MB-8
___ 07:45PM BLOOD Albumin-4.8 Calcium-10.4* Phos-3.5 Mg-2.1
___ 04:08AM BLOOD VitB12-601 Folate-6
___ 07:45PM BLOOD ASA-NEG Ethanol-68* Acetmnp-NEG
Tricycl-NEG
___ 12:04AM BLOOD Type-ART Temp-37 ___ Tidal V-500
PEEP-5 FiO2-40 pO2-97 pCO2-33* pH-7.43 calTCO2-23 Base XS-0
As/Ctrl-ASSIST/CON Intubat-INTUBATED
___ 07:45PM BLOOD Lactate-16.8*
IMAGING:
=========
Brain MRI IMPRESSION:
1. Gyriform pattern of FLAIR high-signal intensity identified in
the right
occipital, right parietal, left occipital parietal and left
temporal regions as described detail above, which is
nonspecific, this type of findings can be seen in patients with
posterior reversal encephalopathy (PRES), however post ictal
changes may have similar appearance, if clinically warranted,
MRI could
be repeated in few days to demonstrate resolution of this
findings.
2. There is no evidence of diffusion abnormalities to indicate
acute or
subacute ischemic changes
3. Numerous scattered foci of high signal intensity identified
in the
subcortical and periventricular white matter are nonspecific and
may reflect
changes due to small vessel disease, however unusual for the
patient's age,
therefore demyelinating changes cannot be completely rule out.
4. There is minimal mucosal thickening in the ethmoidal air
cells bilaterally
and patchy mucosal thickening the mastoid air cells.
CT HEAD ___: No acute intracranial process.
Brief Hospital Course:
Mr. ___ is a ___ yo man with history of ulcerative
colitis(self dc'd Humira ~1 month ago), EtOH use disorder and
actively using alcohol, who was admitted to the neurology
service after multiple first time seizures in the setting of
days of headache and visual floaters. They were characterized by
left head turning, bilateral arm stiffening, and non
responsiveness. He had at least 4 observed seizures by the time
he arrived in the ED. He received Ativan and had a desaturation
event and subsequently required intubation. He was in the ICU
for one day, extubated on ___ and transferred to the Neurology
floor. In the ICU, he was started on Keppra for seizures and
they resolved by hospital day 1. He had an LP that did not show
signs of infection and his HSV PCR was negative (he received
about 36h of acyclovir until PCR negative). His MRI showed FLAIR
hyperintensities predominantly posterior region which was
suggestive of posterior reversible encephalopathy syndrome
(PRES) which clinically fit with his presentation and history of
hypertension but recently off medications. He was monitored on
the neurology floor and had no further seizures. Additional
hospital issues are described below
#EtOH use disorder- Presented with EtOH 68 and per medical
records, patient drinks 4 drinks/a day. Folic acid/B12 levels
were normal, and the patient was dispensed Thiamine, Folic Acid
throughout his hospitalization. He was started on CIWA protocol
for withdrawal, after extubation.
#Failure to Thrive-Per patient and family, recent 10#
unintentional weight loss and MSM demographic. HIV test was
consented through the patient and pending on transfer.
#Anion Gap/Elevated Lactate-Presented with anion gap 33, lactate
18, with normal pH. Lactate normalized and anion gap closed on
hospital day #2, and were attributed to seizures.
#Elevated AST/ALT, lipase-Admitted with AST/ALT 193/108, and
lipase 130 which were noted to be chronic at least since ___. He had already been evaluated by ___ hepatology as an
outpatient, and thought to be toxo-metabolic, non-cirrhotic.
LFTs were monitored throughout his hospitalization and were
stable.
#HTN-The patient reported that he was discontinued from
___ for hypertension since switching to new PCP in ___,
___. He was reinitiated on ___ on HD#2. Blood pressure
was gradually lowered for hypertensive emergency, and SBP were
140-160 by the day of discharge on valsartan 320mg daily.
#HLD-Atorvastatin was restarted, he had previously taken it and
has history of HLD.
#Ulcerative Colitis-Humira was held given the fact that he had
self dc'd approx. 1 month ago.
#ID-admission blood culture grew micrococcus in one bottle.
Repeat blood cultures negative x5 days. He was initially treated
with vancomycin pending speciation. He remained afebrile,
without leukocytosis and without infectious symptoms. This was
therefore strongly favored to represent contaminant and he was
discharged without antibiotic therapy.
================================
Transitional Issues:
[ ] Neurology: f/u MRI brain to be performed in ___ weeks.
[ ] PCP: please continue to titrate antihypertensives to achieve
goal normotension.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ValACYclovir 500 mg PO Q24H
2. Propranolol 10 mg PO Q8H:PRN Tremors
3. Atorvastatin 40mg PO QD
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. FoLIC Acid 1 mg PO DAILY
3. LevETIRAcetam 1000 mg PO BID
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Valsartan 320 mg PO DAILY
6. Propranolol 10 mg PO Q8H:PRN Tremors
7. ValACYclovir 500 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Posterior reversible encephalopathy syndrome
focal-onset epilepsy, not intractable, without status
epilepticus
Hypertension
Hypertensive emergency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ were admitted to the general neurology service at ___
after having multiple seizures. ___ were briefly in the ICU
because ___ needed a breathing tube since ___ became so sleepy
from the medications we gave ___ to stop the seizures. ___
recovered well and did not have any further seizures. We started
a medicine, Keppra (aka levetiracetam), to prevent seizures and
___ will need to continue taking this. We believe ___ had
seizures because of something called "posterior reversible
encephalopathy syndrome" or "PRES" which can occur when blood
pressure suddenly becomes too high. It is why ___ had seizures.
We expect that ___ will gradually get better. Your outpatient
neurologist will work with ___ to determine if and when ___ can
come off of the Keppra.
Get another MRI in the next ___ weeks, this is to make sure that
these changes in your brain are improving.
SEIZURE PRECAUTIONS:
Helpful Websites: epilepsyfoundation.org
epilepsy.com
In case of seizure: 1. Stay Calm. 2 Keep Safe, place on side.
3. Call ___ if seizure is greater than 5 minutes or if there are
other concerns.
By ___ Law - no driving for six months following
altered consciousness - also avoid active participation in
traffic
Avoid bathing/swimming alone
Avoid climbing
Avoid using sharp moving objects
Avoid unsupervised exposure to heat sources (open fires, stoves)
Wear protective gear for sports
Avoid being alone in locked setting
Avoid situations where altered consciousness could prove to be
dangerous
Sincerely,
___ Neurology Service
Followup Instructions:
___
|
19789613-DS-13
| 19,789,613 | 24,764,713 |
DS
| 13 |
2156-05-04 00:00:00
|
2156-05-05 19:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
TEE ___
PPM Explant ___
History of Present Illness:
Mr. ___ is a ___ year old male with heart block s/p PPM
placement in ___ recurrent sepsis following generator change in
___, referred in by his ___ cardiologist Dr. ___
semi urgent evaluation for pacemaker extraction in the setting
of recurrent bacteremia.
The patient has a SJM pacemaker implanted in ___ for
("slow heart," records pending), and had a generator change in
___. In ___, he felt unwell with fatigue and
was found to have coagulase negative staph bacteremia. He was
treated with 4 weeks of IV daptomycin completed in early ___
and improved clinically. He was then transitioned to oral
doxycycline but did not tolerate this so was switched to Keflex.
Patient was seen by Dr. ___ at ___ on ___. CRP
was elevated at that time, and patient was having night sweats.
His dose of cephalexin was increased from 250mg to 500mg TID. At
some point in the last month, the patient discontinued
antibiotics as it was felt the infection was under control. His
ID doctor drew surveillance cultures.
Blood cultures on ___ demonstrated recurrent bacteremia
despite increasing Keflex. Dr. ___ admission to
___ for ID consult, TEE, and to discuss the timing and need
for possible pacemaker extraction.
In the ED, the patient denied chest pain, SOB, fevers, cough, or
other infectious symptoms.
- In the ED, initial VS were 99.8 78 127/55 18 97% RA
- Exam notable for being well appearing on exam, A&Ox3, CTAB, no
___ edema
- EKG w/ 1' AVB, LAD, RBBB LAFB, no STE
- Labs showed Lactate 1.2, WBC 11.0, INR 1.2 UA clean
- CXR showing left pectoral pacemaker with 2 intact leads. No
evidence for acute cardiopulmonary process.
- Transfer VS were 98.1 84 118/59 16 97% RA
On arrival to the floor, patient reports the story as above. He
feels generally well, with his only symptoms being fatigue and
night sweats. Denies dyspnea, chest pain, cough, urinary
symptoms, rash.
Past Medical History:
SSS (sick sinus syndrome)
Second degree AV block s/p PPM ___
OSTEOARTHROSIS, GENERALIZED
Hypertension
Hyperthyroidism
Osteoporosis on Reclast
Primary testicular hypogonadism
Bilateral edema of lower extremity
Lower lumbar pain on chronic opioids
Left sacroiliac pain, chronic, s/p spinal cord stimulator ___
Neuropathy, peripheral
Dry eyes
Urinary frequency
ARMD (age related macular degeneration)
PVD (posterior vitreous detachment)
Mild stage glaucoma
Pseudophakia
Exotropia, left eye
Choroidal nevus
Keratosis
Hearing loss
Edema extremities
Social History:
___
Family History:
Mother - ___
Sister - ___ - Depression
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: 98.4PO 165/70 81 18 96RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, dentures
HEART: RRR, S1/S2, ___ systolic murmur
CHEST: left upper chest PPM pocket without
edema/erythema/warmth, non-tender to palpation
LUNGS: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: No cyanosis; chronic venous statis changes
bilaterally; trace 1+ non-pitting edema to ankles
NEURO: CN II-XII intact, MAE
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
==========================
VS: Tmax=98.3 F T=98.5F ___ BP=148/61-168/56 mmHg RR=18x'
SpO2=95% on RA
GENERAL: Well-appearing man in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP non visible at 30 degrees.
CARDIAC: Systolic murmur ___ best heard at the apex. 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. Dressing in place left shoulder, c/d/i
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, or xanthomas. Has
erythematous rash with scratch marks on anterior chest wall in
relation to his hair follicles. No significant erythema around
surgical incision.
Pertinent Results:
ADMISSION LABS:
=================
___ 12:55PM BLOOD WBC-11.0* RBC-4.54* Hgb-11.3* Hct-37.1*
MCV-82 MCH-24.9* MCHC-30.5* RDW-15.3 RDWSD-45.7 Plt ___
___ 12:55PM BLOOD Neuts-81.4* Lymphs-10.2* Monos-7.6
Eos-0.0* Baso-0.3 Im ___ AbsNeut-8.95* AbsLymp-1.12*
AbsMono-0.83* AbsEos-0.00* AbsBaso-0.03
___ 12:55PM BLOOD ___ PTT-32.0 ___
___ 12:55PM BLOOD Glucose-93 UreaN-25* Creat-1.2 Na-135
K-4.0 Cl-92* HCO3-31 AnGap-16
___ 12:55PM BLOOD cTropnT-<0.01
___ 12:55PM BLOOD Calcium-8.9 Phos-3.4 Mg-2.4
___ 01:13PM BLOOD Lactate-1.2
MICRO:
=================
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)}; Aerobic
Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)}; Anaerobic
Bottle Gram Stain-FINAL EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {GRAM POSITIVE COCCUS(COCCI)}; Anaerobic
Bottle Gram Stain-FINAL; Aerobic Bottle Gram Stain-FINAL
EMERGENCY WARD
STUDIES:
=================
___ Imaging CHEST (PA & LAT)
Left pectoral pacemaker with 2 intact leads. No evidence for
acute
cardiopulmonary process.
___ Cardiovascular ECHO
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. A thrombus/vegetation measuring
0.6cm by 0.5cm associated with the right ventricular pacing lead
is seen in the right atrium (clip 77, 83, 84). No atrial septal
defect is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets are moderately thickened. No masses or vegetations are
seen on the aortic valve. Moderate (2+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
small mobile echodensity on the left atrial side of the mitral
valve measuring 4mm by 3mm most consistent with vegetation. No
mitral valve abscess is seen. An eccentric jet of mild to
moderate (___) eccentric mitral regurgitation is seen directed
anteriorly. The tricuspid valve leaflets are mildly thickened.
IMPRESSION: Small echodensity on the mitral valve consistent
with vegetation with mild to moderate mitral regurgitation.
Thrombus versus vegetation on the ventricular pacing lead in the
right atrium. Moderate aortic regurgitation without focal
vegetation.
DISCHARGE LABS:
=================
___ 06:50AM BLOOD WBC-7.6 RBC-4.05* Hgb-9.9* Hct-33.3*
MCV-82 MCH-24.4* MCHC-29.7* RDW-15.8* RDWSD-47.5* Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-93 UreaN-23* Creat-1.0 Na-143
K-4.4 Cl-103 HCO3-27 AnGap-17
___ 06:50AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0
Brief Hospital Course:
Mr. ___ is an ___ y/o man with history of heart block s/p PPM
placement in ___ with sepsis following generator change in ___, referred in by his ___ cardiologist Dr. ___
pacemaker extraction in the setting of recurrent bacteremia.
Patient underwent TEE, which showed vegetation on RV lead as
well as on mitral valve. Blood cultures grew Staph epidermidis.
Infectious disease was consulted, and the patient was started on
vancomycin. He underwent PPM explant on ___. He will
continue vancomycin for an aniticipated course of ___ weeks (Day
1: ___ Projected End Date: ___, to be determined in
Infectious Disease clinic. Following explant of the PPM, he
remained afebrile and hemodynamically stable. He had some
episodes of asymptomatic bradycardia at night only. He will be
mailed an event monitor, and will follow up with his
cardiologist to discuss when it will be safe to implant another
PPM.
======================
TRANSITIONAL ISSUES:
======================
- Patient to continue vancomycin 1000 mg daily for anticipated
course of ___ weeks (Day 1: ___ Projected End Date:
___. Course to be determined in ___ clinic.
-- Please obtain weekly labs: CBC with differential, BMP, ESR,
CRP, vancomycin trough and FAX to: **ATTN: ___ CLINIC -
FAX: ___
- Patient had several episodes of asymptomatic bradycardia at
night
-- He will be mailed a Lifewatch event monitor to be followed up
by his cardiologist Dr. ___ for any daytime severe
bradycardia.
- His dressing over the former pacemaker site may be taken down
on ___.
- He should discuss with Infectious Disease and with his
cardiologist when it will be safe to replace his PPM.
- He developed a dermatitis on his chest, likely related to
telemetry leads. Please ensure resolution of this rash.
- Contact: ___ (Niece/HCP): ___
- Code: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Methadone 5 mg PO TID
2. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate
3. Sertraline 50 mg PO DAILY
4. Torsemide 10 mg PO DAILY
5. testosterone enanthate 200 mg/mL injection Q21days
6. Omeprazole 20 mg PO DAILY
7. Reclast (zoledronic acid-mannitol-water) 5 mg/100 mL
injection Yearly
8. Xalatan (latanoprost) 0.005 % ophthalmic QHS
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN nasal
congestion
10. calcium citrate-vitamin D3 1250 calcium - 800 units oral
DAILY
11. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram
oral DAILY
12. Vitamin D 1000 UNIT PO BID
13. Polyethylene Glycol 17 g PO BID
Discharge Medications:
1. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
2. Vancomycin 1000 mg IV Q 24H
RX *vancomycin 1 gram 1000 mg IV Daily Disp #*30 Vial Refills:*1
3. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram
oral DAILY
4. calcium citrate-vitamin D3 1250 calcium - 800 units oral
DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN nasal
congestion
6. Methadone 5 mg PO TID
7. Omeprazole 20 mg PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
9. Polyethylene Glycol 17 g PO BID
10. Sertraline 50 mg PO DAILY
11. testosterone enanthate 200 mg/mL injection Q21days
12. Torsemide 10 mg PO DAILY
13. Vitamin D 1000 UNIT PO BID
14. Xalatan (latanoprost) 0.005 % ophthalmic QHS
15. Zoledronic Acid (Reclast) (zoledronic acid-mannitol-water)
5 mg/100 mL injection YEARLY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- Endocarditis secondary to pacemaker lead infection
- Acute blood stream infection
Secondary diagnoses:
- Heart block
- Osteoarthritis
- Peripheral neuropathy
- 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 taking care of you. You were admitted to the
hospital because you were feeling very tired. We thought that
your symptoms may have been caused by bacteria in your blood,
which has been very hard to treat with antibiotics. We were
concerned that the difficulty treating your infection may have
been caused by areas of infection that were stuck to your
pacemaker. We started you on antibiotics and removed your
pacemaker, and you felt better.
You will continue to take antibiotics for several weeks. You
will see an infectious disease specialist to help with this.
Please follow up with your cardiologist to talk about when it
would be safe to put in another pacemaker.
It was a pleasure caring for you!
Your ___ Care Team
Followup Instructions:
___
|
19789642-DS-7
| 19,789,642 | 24,298,005 |
DS
| 7 |
2146-05-30 00:00:00
|
2146-06-01 21:46:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___
Chief Complaint:
Headache, neck stiffness
Major Surgical or Invasive Procedure:
lumbar puncture
History of Present Illness:
Ms. ___ is a ___ yo F with no significant PMH who
presents with 1.5 days of occipital headache and neck stiffness.
These symptoms began at 11PM on ___ and have progressively
gotten worse until arrival at the ___ ED. She described her HA
as "throbbing, pounding" and "as if someone stabbed me in the
back of the head." Her HA has spread from the back to front,
right above her eyes. Aggravated by: walking, coughing,
movement. Relieved by: nothing including ten 200mg Advil. Said
she had stomach pain due to taking the Advil, but has since
improved.
She endorsed symptoms of photophobia, pain on upward gaze,
nausea (w/o vomiting), chills and subjective fever. She denied
night sweats, cough, SOB, CP, palpitations, V/D, hematochezia,
melena, arthralgias, myalgias, and excessive fatigue.
Last weekend, had two days of viral gastroenteritis, which
involved profuse diarrhea, but felt much better by ___.
Said that one of her co-workers had similar symptoms, but she
does not spend much time with her.
Two weekends ago, she was her sister's home in ___ when she
was bitten by an insect and developed a lesion that was itchy
and swollen. She used a cream that helped the itchness and it
has not bothered her since. She also endorsed traveling to
___ two months ago, stayed for one week.
In the ED, initial vitals were: T 99.6 P 96 BP 136/74 RR 18 SaO2
95% RA Pain ___. Patient had an LP performed in ED. She
received IV vancomycin, ceftriaxone, doxycycline, ampicillin, IV
dexamethasone, and metoclopramide. She was transferred to ___ in
stable condition.
Past Medical History:
PAST MEDICAL HISTORY:
Anxiety
Detached retina
R chest hemangioma
L lower chest superficial BCC s/p currettage
L anterior tibial tendinopathy
MVA in ___ with diffuse joint pain
MVA in ___
Chronic constipation
Social History:
___
Family History:
Mother died at ___ of glioblastoma
Father died at ___ of Hodgkin's disease
Sister is alive and healthy
Physical Exam:
PHYSICAL EXAM ON ADMISSION
Vitals: Tc: 98.7 Tm: 98.7 BP: 120/80 P:92 R:22 O2:98% RA Pain
___
General: pleasant, slightly tired-appearing, AOx3, no acute
distress
HEENT: NC/AT, PERRL, EOM difficult to assess due to pt's pain
and photophobia, MMM, clear oropharynx
Neck: mild, non-tender LAD, neck stiffness
CV: RRR, normal S1&S2, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: +BS, ND, tenderness to deep palp in LLQ, no masses or
HSM
GU: deferred
Ext: no edema, clubbing or cyanosis, 2+ pulses distally
Neuro: CN V, VII-XII intact (difficult to assess II,III,IV,VI
___ eye pain), unsteady gait, unsteady heel-toe maneuver, neg
Romberg, neg Kernig, neg Brudzinski's sign
Skin: erythematous annular blanching lesion on posterior neck
PHYSICAL EXAM ON DISCHARGE
VS: Tc:97.9 Tm:98.7 BP:107/50 P:83 RR:18 O2: 98% RA Pain ___
GENERAL: NAD, alert, pleasant, comfortable, interactive
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM
LUNGS: Clear to auscultation bilaterally, no w/r/r
HEART: RRR, normal S1&S2, no r/m/g
Abdomen: +BS, NTND, no guarding or rebound tenderness, no masses
or HSM
Ext: no edema, clubbing or cyanosis, 2+ distal pulses
Neuro: CN II-XII intact, no focal deficits
Pertinent Results:
___ 01:10PM BLOOD WBC-8.4# RBC-4.62 Hgb-14.4 Hct-40.4
MCV-88 MCH-31.2 MCHC-35.7* RDW-12.2 Plt ___
___ 01:10PM BLOOD Neuts-81.2* Lymphs-13.4* Monos-4.2
Eos-0.6 Baso-0.6
___ 01:10PM BLOOD Plt ___
___ 01:10PM BLOOD Glucose-98 UreaN-16 Creat-0.8 Na-140
K-3.9 Cl-103 HCO3-25 AnGap-16
___ 01:27PM BLOOD Lactate-1.1
___ 05:15PM URINE Color-Straw Appear-Hazy Sp ___
___ 05:15PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 05:15PM URINE RBC-6* WBC-103* Bacteri-FEW Yeast-NONE
Epi-1 TransE-1
___ 02:08PM CEREBROSPINAL FLUID (CSF) WBC-90 RBC-0 Polys-28
___ ___ 02:08PM CEREBROSPINAL FLUID (CSF) WBC-180 RBC-4*
Polys-9 ___ ___ 02:08PM CEREBROSPINAL FLUID (CSF) TotProt-66*
Glucose-58
MICROBIOLOGY
___ URINE CULTURE (Final ___: GRAM POSITIVE BACTERIA.
10,000-100,000 ORGANISMS/ML.. Alpha hemolytic colonies
consistent with alpha streptococcus or Lactobacillus sp.
___ LYME SEROLOGY (Final ___: NO ANTIBODY TO B.
___ DETECTED BY EIA.
___ CSF Culture
GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
VIRAL CULTURE (Preliminary):
___ Blood Culture, Routine (Pending):
IMAGING
___ CT Head w/o Contrast
1. No acute intracranial hemorrhage.
2. Bilateral deep/subcortical white matter hypodensities are
nonspecific and, while they can be seen with small vessel
ischemic disease, given patient age and that the findings are
not completely typical for this, demyelinating processes (such
as Lyme disease, MS, or other inflammatory processes) are not
excluded. If symptoms persist, suggest MR ___
___.
___ EKG
Normal EKG, no ST/T-wave changes, QTc 413 ms
DISCHARGE LABS
PENDING STUDIES
___ 02:08PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
___ 02:08PM CEREBROSPINAL FLUID (CSF) ARBOVIRUS ANTIBODY
IGM AND IGG-PND
___ 03:16PM CEREBROSPINAL FLUID (CSF) BORRELIA BURG___
ANTIBODY INDEX FOR CNS INFECTION-PND
Brief Hospital Course:
___ yo previously healthy female with 1.5 days of headache and
neck stiffness with labs most consistent with aseptic
meningitis.
ACTIVE ISSUES
# Aseptic meningitis: The patient's mild fever (highest was 99.8
F in PCP's office), headache, stiff neck, and photophobia are
suggestive of meningitis. Her lack of focal neurologic deficits
and normal mental status makes encephalitis less likely. CSF
showing 66 protein and 58 glucose, WBC 90 & 180 with lymphocytic
predominance is most consistent with an aseptic (viral)
meningitis. However, her CSF pressure of 26 cm H2O is c/f a
possible bacterial etiology, so we will cover with
broad-spectrum abx prophylactically. Broad spectrum coverage
with IV vanco 1000mg BID, ceftriaxone 2g BID, ampicillin 2g IV
q4hr was used until CSF, blood cx return neg x 72hours). IV
Ayclovir 700mg TID was also used to cover for HSV. Her pain and
nausea was controlled with PRN medications and her symptoms
gradually improved with time.
# Pyuria: Patient has 103 WBC's in urine with few bacteria
noted. Leuk esterase large, nitrites neg. Unclear etiology, but
our broad spectrum abx coverage for meningitis should cover a
possible UTI. 10 ketones also seen in urine, likely due to lack
of appetite and relative dehydration the past 1.5 days. Urine cx
pos for gram pos bacteria (alpha hemolytic colonies consistent
with alpha streptococcus or Lactobacillus sp-Urine cx pos for
gram pos bacteria), likely to be contamination. Repeat UA ___,
small leukocytes, neg nitrites, small bacteria.
# Stomach ache: Likely due to patient taking 10 200mg Advil past
1.5 days. Currently asymptomatic, but will give PPI to help
stomach lining recover. No clear indication for continuing PPI
as an outpatient.
CHRONIC ISSUES
# Constipation: patient was continued on home bowel regimen
TRANSITIONAL ISSUES
# Cultures negative x 72 hours final results pending please
follow up cultures and viral studies
# Was placed on pantoprazole for abdominal pain due to excess
NSAID use. Patient will not be discharged on pantoprazole.
Please re-evaluate as needed.
# Please f/u non-specific findings on CT (Bilateral
deep/subcortical white matter hypodensities)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Senna 2 TAB PO DAILY
2. Vitamin D 400 UNIT PO DAILY
3. Ibuprofen 200 mg PO Q8H:PRN pain
Discharge Medications:
1. Senna 2 TAB PO DAILY
2. Vitamin D 400 UNIT PO DAILY
3. Ibuprofen 200 mg PO Q8H:PRN pain
Please do not take more than 3200mg in one day.
4. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: aseptic meningitis
secondary diagnosis: abdominal pain secondary to excess NSAID
use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted to the general medicine inpatient service for
headache and neck stiffness. ___ had a lumbar puncture in the
Emergency Department which was concerning for meningitis,
inflammation of the coverings of your spine and brain. Cultures
were taken of your cerebrospinal fluid and ___ were started on
intravenous antibiotics and anti-viral medications. Antibiotics
were continued until your cultures continued to show no growth
of bacteria even after three days. It is thought ___ had a
condition called aseptic meningitis, that is meningitis due to a
virus. There is no recommendations for continuing treatment for
aseptic meningitis and the symptoms should gradually reverse in
time. ___ will be taken off of the antibiotics and have already
had improvements in your symptoms. ___ are stable enough to
continue the rest of your recovery at home.
Please continue all of your home medications as prescribed.
Please call your primary care doctor or come to the Emergency
Department if ___ have worsening headache, or any neurological
changes such as blurry vision, dizziness, and inability to move
or feel part of your body.
Thank ___ for allowing us to participate in your care!
Followup Instructions:
___
|
19789921-DS-15
| 19,789,921 | 22,420,138 |
DS
| 15 |
2178-09-12 00:00:00
|
2178-09-12 16:17:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old non-verbal man with Down Syndrome, VSD s/p
repair and dysphagia who presented to the ED due to nausea and a
rash. The history was obtained from his family, who is
___, as the patient is non verbal.
His family reports that since 3 days ago, he has had a rash on
his right neck which now appears more prominent. He seems
nauseated this morning. He has not been using his neck as much
as normal. He is nonverbal at baseline. No fevers per family. He
has otherwise been acting like himself.
His family is unsure if he has had chicken pox before.
In the ED, initial vitals were: T97.2, HR 74, BP 82/43, RR 16,
SpO2 98% RA. Later spiked a fever to 102.1 while being observed
overnight.
- Exam notable for: rash on the right neck and shoulder
- Labs notable for: normal CBC, coags, chemistries. AST 45. UA
bland with 30 protein. Trop negative x2. Lactate was 3.1 and
then normalized on multiple rechecks after IVF.
- Imaging was notable for: CT abd/pelvis with no acute
findings, CT neck with contrast without mass or abscess. CT head
without acute process. CXR with low lung volumes with mild
bibasilar patchy opacities, likely atelectasis.
- Patient was given: valacyclovir 1g Q8H, morphine, diazepam,
Tylenol and 5 liters of IVF
Upon arrival to the floor, patient is nonverbal. Above history
is confirmed with family.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- Down's syndrome
- Dysphagia (on pureed solids, ground/moist foods, and thin
liquids
- VSD s/p repair with Gore-Tex patch
- 1+ TR
- Seborrheic dermatitis
- Hypothyroidism
Social History:
___
Family History:
(According to outpatient notes): Father died of stomach cancer
in his ___. Mother is alive, age ___ years old, with
hypertension. He has two sisters. No family history of stroke,
hyperlipidemia, diabetes mellitus, early coronary artery disease
or sudden cardiac death.
Physical Exam:
PHYSICAL EXAM:
Vitals: 99.5 100 / 63 98 18 96 RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, bounding carotid pulse observed 1cm above clavicle
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Derm: Vesicular rash noted on the right back. Does not cross
midline. The superior portion of the rash follows a dermatomal
distribution, but there are extra lesions lower down on the back
and wrapping around to the chest. There is no obvious area of
erythema concerning for superinfection.
Pertinent Results:
==============
ADMISSION LABS
===============
___ 07:30AM BLOOD WBC-10.0 RBC-4.46* Hgb-15.4 Hct-43.6
MCV-98 MCH-34.5* MCHC-35.3 RDW-13.7 RDWSD-49.8* Plt ___
___ 07:30AM BLOOD WBC-10.0 RBC-4.46* Hgb-15.4 Hct-43.6
MCV-98 MCH-34.5* MCHC-35.3 RDW-13.7 RDWSD-49.8* Plt ___
___ 07:30AM BLOOD Neuts-64.2 ___ Monos-9.5 Eos-1.0
Baso-0.8 Im ___ AbsNeut-6.44* AbsLymp-2.34 AbsMono-0.95*
AbsEos-0.10 AbsBaso-0.08
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD ___ PTT-26.2 ___
___ 07:30AM BLOOD Glucose-130* UreaN-15 Creat-1.1 Na-140
K-5.0 Cl-103 HCO3-22 AnGap-20
___ 07:30AM BLOOD ALT-29 AST-45* AlkPhos-64 TotBili-0.7
___ 03:55PM BLOOD cTropnT-<0.01
___ 07:30AM BLOOD cTropnT-<0.01
___ 07:30AM BLOOD Lipase-26
___ 07:30AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.0 Mg-2.2
___ 08:22AM BLOOD Lactate-3.1*
==============
DISCHARGE LABS
==============
___ 06:45AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0
___ 02:42PM BLOOD Lactate-1.5
___ 06:45AM BLOOD WBC-8.1 RBC-3.92* Hgb-13.4* Hct-39.4*
MCV-101* MCH-34.2* MCHC-34.0 RDW-14.2 RDWSD-51.8* Plt ___
___ 06:45AM BLOOD Plt ___
___ 06:45AM BLOOD Glucose-88 UreaN-10 Creat-0.9 Na-141
K-3.9 Cl-105 HCO3-25 AnGap-15
___ 06:45AM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0
============
IMAGING
============
CT Abd/Pelvis ___: 1. Normal appendix.
2. Top-normal heart size.
3. Bibasilar atelectasis
4. Small fat and fluid containing right inguinal hernia.
CT Neck ___: Posterior hypopharyngeal and retropharyngeal
soft tissue fullness at the C3-4
level. No evidence of discrete mass or abscess. Further
assessment with
endoscopy is suggested given the history of dysphagia.
RECOMMENDATION(S): Recommend further evaluation with endoscopy
given history
of dysphagia.
CT Head ___: 1. No acute intracranial process.
2. Global atrophy, advanced for age.
3. Prominent extra-axial CSF density spaces within the anterior
middle cranial fossa bilaterally suggestive of arachnoid cysts
or focal temporal lobe atrophy.
Brief Hospital Course:
SUMMARY: ___ year old man non-verbal man with Down's Syndrome,
VSD s/p repair and hypothyroidism presenting with acute painful
vesicular rash consistent with localized herpes zoster.
ACUTE ISSUES:
# Herpes Zoster: Patient presented with vesicular rash most
consistent with zoster. Appears to involve more than one
dermatome but does not cross midline and no evidence of
dissemination of superinfection. Patient was started on
valacyclovir 1g q8h for 70day course (last day ___.
# Fever: patient febrile to 102.1F in the ED. Thought to be
likely related to herpes zoster infection. An extensive
infectious work-up (UA, CXR, CT neck, CT abd/pelvis) was pursued
which was unremarkable. Patient was monitored overnight with no
further fevers.
# Hypotension: patient found to have relatively low BPs in the
ED (82-112/43-61). Recorded outpatient BPs in the ___, so
this is not far from his baseline. Likely due to dehydration in
the setting of illness as evidenced by lactate 3.1 on arrival
which resolved after 3L IV fluid.
# Dysphagia: continued home diet of soft, ground moist foods,
and pureed solids with thin liquids.
TRANSITIONAL ISSUES:
- Complete 7-day course of valacyclovir 1gm q8h (last day ___
- CT on ___ showed no mass but soft tissue fullness at C3-4,
recommend EGD in the future for evaluation of dysphagia.
# CONTACT:
Next of Kin: ___
Relationship: SISTER
Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Medications:
1. ValACYclovir 1000 mg PO Q8H
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every 8 hours
Disp #*17 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Herpes Zoster
SECONDARY DIAGNOSIS:
Down's syndrome
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___:
You were admitted for fever and rash. We thought this was zoster
(also called shingles). You will be treated with one week of a
medication called Valtrex. We did many tests for other types of
infections that did not show anything else.
Please continue taking Valtrex (last day ___.
We wish you all the best!
- Your ___ care team
Followup Instructions:
___
|
19789939-DS-5
| 19,789,939 | 25,670,037 |
DS
| 5 |
2142-06-08 00:00:00
|
2142-06-08 14:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left-sided numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ Stroke Scale score was : 1 1a. Level of Consciousness: 0 1b.
LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual
fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 0 5b. Motor
arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7.
Limb Ataxia: 0 8. Sensory: 1 9. Language: 0 10. Dysarthria: 0
11. Extinction and Neglect: 0 REASON FOR CONSULTATION: Code
stroke/or stroke HPI: Ms. ___ is a ___ year old woman with
history of right parietal anaplastic astrocytoma s/p resection
(___) followed by radiation and chemotherapy (completed ___
in remission by repeat imaging, HLD, hypothyroidism who presents
with left sided sensory changes. History provided by patient and
collateral from husband, who is an excellent historian.
Ms. ___ was last known well at 6:30am this morning. Prior to
that she had woken up at 5 AM and felt well, moved around a
little bit and then went to bed again at 6:30 AM. When she awoke
at 9:00 AM, she felt generally unwell but had difficulty
pinpointing why. She then tried to get out of bed and noticed
that when she moved her left leg, the entire leg felt numb and
heavy, circumferentially. She denies any weakness of the leg.
Around the same time, she noticed that her left arm also felt
numb and heavy, but to a lesser degree than the leg. She did
have some numbness of the face on the left side as well, but she
has had this intermittently chronically since treatment of her
tumor. Torso is spared.
She notes that when walking around the house, she frequently
bumped into objects around the house, and at one point slammed
the left leg into the garage door when entering the house. When
she went out to get the mail, she felt the left leg give out and
began to fall forward. She is not sure whether this is related
to sensory loss, weakness, or difficulty using the leg in
general. Throughout this whole time, she denied any new visual
changes, denied difficulty understanding or expressing speech,
denies dysarthria, denies focal weakness or numbness.
Notably, patient underwent routine colonoscopy yesterday. Prior
to that, her home aspirin 81 mg daily was held for the last
week. Otherwise, prior to her acute change this morning, patient
reports she has been in her usual state of health recently. She
did have low back pain for the last week without bowel or
bladder symptoms. She denies any recent trauma, new or missed
medications, or recent illnesses.
Regarding her oncologic history, this began in ___ when she
developed headache in the vertex suddenly. Her husband found her
home confused and incontinent. She was found to have a large 5 x
6 cm right parietal mass with some enhancement. Ultimately
underwent pathology which revealed a grade 3 oligo astrocytoma.
She underwent resection and ___ by neurosurgery. She
then underwent radiation and chemotherapy between ___ and ___.
Since then, the tumor has been followed with serial exams which
has been stable. As a result of her tumor, she has a baseline
left inferior quadrantanopsia.
Husband notes that in ___, she developed transient sensory
symptoms- bilateral facial numbness and tingling in both hands.
This lasted about one hour. She was worked up at ___
___. Cardiac workup was negative. She was diagnosed with a
possible TIA and started on aspirin.
Past Medical History:
-right parietal anaplastic astrocytoma s/p resection (___)
followed by radiation and chemotherapy (completed ___ in
remission by repeat imaging
-ADHD
-Hyperlipidemia
-Depression
-Hypothyroidism
Social History:
___
Family History:
Denies family history of early stroke or premature CAD
Physical Exam:
ADMISSION
Vitals: Temperature 98.5, heart rate 72, blood pressure 133/77,
respiratory rate 18, oxygen percent on room air
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
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. 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. Baseline left inferior
quadrantanopsia.
V: Facial sensation reduced to pinprick in V1 to V3 distribution
to 70% of normal.
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 5
-Sensory: Reduced to pinprick in the left arm and leg,
circumferentially, ranging from 50-70% of normal. There is also
reduced proprioception to small amplitude movements of the index
finger and great toe on the left. No graphesthesia. 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 extensor on the left, flexor on right
-Coordination: Mild left upper extremity dysmetria with
finger-nose-finger. No ataxia on HKS bilaterally. No truncal
ataxia.
-Gait: Good initiation. Mildly unsteady, which is baseline per
husband, but gait is narrow-based, normal stride and arm swing.
Able to walk in tandem without difficulty.
===============
DISCHARGE
Notable for persistent mild left-sided neglect and left inferior
quadrantanopia. No sensory deficits.
Pertinent Results:
___ 05:10AM BLOOD WBC-5.1 RBC-3.86* Hgb-12.2 Hct-37.0
MCV-96 MCH-31.6 MCHC-33.0 RDW-12.4 RDWSD-43.4 Plt ___
___ 05:10AM BLOOD Neuts-62.1 ___ Monos-9.4 Eos-2.7
Baso-0.6 Im ___ AbsNeut-3.19 AbsLymp-1.28 AbsMono-0.48
AbsEos-0.14 AbsBaso-0.03
___ 05:10AM BLOOD ___ PTT-32.2 ___
___ 05:10AM BLOOD Glucose-88 UreaN-15 Creat-0.9 Na-142
K-3.9 Cl-104 HCO3-25 AnGap-13
___ 05:10AM BLOOD ALT-21 AST-19 LD(LDH)-165 AlkPhos-67
TotBili-0.3
___ 05:10AM BLOOD Albumin-4.4 Calcium-8.7 Phos-5.4* Mg-2.1
___ 12:38PM BLOOD %HbA1c-5.3 eAG-105
___ 12:30PM BLOOD Triglyc-95 HDL-68 CHOL/HD-2.2 LDLcalc-65
IMAGING
CTA HEAD/NECK
IMPRESSION: 1. No acute abnormalities on a noncontrast head CT.
2. Status post right temporoparietal craniotomy and tumor
resection with similar posttreatment changes. 3. Mild
atherosclerosis, but otherwise normal CTA of the head and neck
without evidence of high-grade stenosis or large vessel
occlusion. No internal carotid artery stenosis by NASCET
criteria.
MRI BRAIN
IMPRESSION:
Unchanged MRI appearance of the brain. Persistent enhancement at
the surgical margin with no findings to suggest tumor
progression.
TTE
CONCLUSION: The left atrial volume index is normal. There is
premature appearance of a large (>30 microbubbles) of agitated
saline in the left heart at rest c/w a small atrial septal
defect or stretched patent foramen ovale. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and global left ventricular
systolic function. Quantitative biplane left ventricular
ejection fraction is 60 %. Left ventricular cardiac index is
normal (>2.5 L/min/m2). There is no resting left ventricular
outflow tract gradient. Normal right ventricular cavity size
with normal free wall motion. Tricuspid annular plane systolic
excursion (TAPSE) is normal. The aortic sinus diameter is normal
for gender with normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets (3) appear structurally normal. No
masses or vegetations are seen on the aortic valve. There is no
aortic valve stenosis. There is a centrally directed jet of
trace aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve. There is trivial
mitral regurgitation. The pulmonic valve leaflets are normal.
The tricuspid valve leaflets appear structurally normal. No
mass/vegetation are seen on the tricuspid valve. There is
physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is high normal. There is no pericardial
effusion.
IMPRESSION: Small atrial septal defect/stretched patent foramen
ovale with a large number of microbubbles in the left heart at
rest. Mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global biventricular systolic function.
Brief Hospital Course:
___ with PMH right parietal oligo-astrocytoma s/p resection and
chemotherapy and radiation in ___ presents with worsening
left-sided numbness.
#Left sided numbness
Present at baseline, has had one similar episode previously in
___ concerning for TIA and was started on ASA and atorvastatin
for secondary prevention. Work-up was done at ___, and holtor
monitor was placed for 30 days, but they never got a report. Due
to the transient nature of this episode, TIA is possible, but
other differentials include seizure or meningeal irritation in
the setting of symptoms plus headache. EEG and AED not
considered at this time as this is only the second episode over
a span of ___ years. Will repeat holter monitoring and TTE
outpatient. Continue ASA and atorvastatin. Follow-up with Dr.
___. After discharge, TTE results were communicated and she was
found to have a PFO with microbubbles seen in the LA at rest
concerning for right to left shunt. These results were
communicated with the patient, her husband, and PCP ___ ___
at 1415. She will need lower extremity dopplers and a cardiology
consultation outpatient.
The significance of this finding is not entirely clear. There
will need to be a complete workup, including Ziopatch and
possibly a TEE to further characterize. Given that the nature of
this event as TIA is not clear and full stroke workup has not
been completed, there is no clear/stroke indication for closure
urgently.
#Right parietal oligo-astrocytoma s/p resection ___
Also received chemotherapy and radiation. Residual deficits of
left-sided numbness, neglect, left inferior quadrantanopia.
Follows with Dr. ___ and has yearly scans which have
been stable
#Hypothyroidism
Continued on home levothyroxine
#ADHD
Continued on home methylphenidate
#Depression
Continued on home venlafaxine
==================
Transitional Issues:
-New dx of PFO, with concern for right->left shunt. Will need
lower extremity dopplers and cardiology follow-up.
-Follow-up results of ziopatch with either PCP or Dr. ___
==================
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 =65 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MethylPHENIDATE (Ritalin) 20 mg PO BID
2. Ferrous Sulfate 325 mg PO DAILY
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Venlafaxine 150 mg PO DAILY
7. calcium citrate (bulk) 100 % miscellaneous DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. calcium citrate (bulk) 100 % miscellaneous DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Levothyroxine Sodium 125 mcg PO DAILY
6. MethylPHENIDATE (Ritalin) 20 mg PO BID
7. Venlafaxine 150 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
TIA
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for feelings of left sided
numbness that improved during your hospital stay. This may
represent a transient ischemic attack (TIA), similar to what you
experienced in ___. Therefore, we recommend you continue on
your aspirin and atorvastatin for secondary stroke/TIA
prevention. You will wear a patch that monitors your heart rate
for 30 days to look for any irregular heart rhythms as a
potential cause for this event. We have also ordered for you to
get an ECHO, or imaging of your heart. You will follow-up with
Dr. ___.
Thank you for allowing us to participate in your care.
Sincerely,
___ Neurology
Followup Instructions:
___
|
19790164-DS-5
| 19,790,164 | 22,992,582 |
DS
| 5 |
2140-02-27 00:00:00
|
2140-02-27 17:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
persistent cough, trouble sleeping
Major Surgical or Invasive Procedure:
___ - Upper endoscopy
History of Present Illness:
This is a ___ old Male with PMH significant for metastatic
esophageal adenocarcinoma (s/p esophagectomy with gastric pull
through and chemoradiation - surgery complicated by ___ with
laparoscopic reduction of hiatal hernia and J-tube placement,
___ now presenting with hypoxia and persistent cough.
The patient was recently admitted ___ to ___ thoracic
surgery service with gastric outlet obstruction - of unclear
etiology per Dr. ___ (? longstanding pyloric spasm).
EGD ___ was without evidence of esophageal obstruction -
biopsies were negative for malignancy. Repeat EGD was performed
___ and he underwent dilation of the pylorus to improve
gastric emptying. Trialed with metoclopramide dosing. Given his
ongoing symptoms he underwent hiatal hernia repair and J-tube
placement for these symptoms this admission (___). Tube feeds
were tolerated post-op. He had noted pulmonary nodules on
imaging that admission with CT-guided biopsy on ___ positive
for metastatic disease. He also required a Foley catheter for
urinary retention - which was maintained at discharge. In
addition, he was treated with a 5-day course of ciprofloxacin.
He was discharged home with ___ on ___.
On ___ he was tolerating oral feeds and Ensure well and
discontinued J-tube feeds. At follow-up with Dr. ___
thoracic surgery on ___ a CXR demonstrated a very dilated
conduit with large PTX and effusion? but the patient was not
symptomatic. On ___ had a PET-CT ___ ___ had MRI of
the head, both at the mobile imgaging unit at ___,
to evaluate his malignancy burden. Results are not yet
available.
The patient then notified the thoracic surgery team on ___
in the evening with complaints of persistent productive cough
and trouble sleeping. He stated that the symptoms had been
present for several weeks. Pt tried nyquil with little effect.
Pt also reports nausea/vomiting as a result of coughing. Per
patient, he was referred to clinic or ___ ED for earlier
evaluation and chose earlier evaluation because he was coughing
violently every night with extensive sputum production that
looks like a combination of mucus and his feeding material.
On arrival to the ED today, oxygen saturation was 96%, but then
he
desaturated in the ED to 88%, and started receiving oxygen by
nasal canula. He remained asymptomatic, denying SOB. CXR
significant for RML collapse and moderate right pleural effusion
and CT PE protocol was negative for pneumothorax or PE, but also
suggested that the dilated conduit is causing compression of the
right lung, per preliminary reads for both.
ED course:
- initial VS 98.9 95 97/70 19 96% RA (desats to 88% on RA)
- Labs notable for WBC 16.7, Hgb 13.6, platelets 363
- Creatinine 0.6, lactate 1.2; INR 1.1
- LFTs: AST 41, ALT 21, AP 89 and albumen 3.4
- CXR and CTA chest obtained
- Blood cultures obtained
- Received 1L LR
- Evaluated by thoracic surgery
REVIEW OF SYSTEMS: See HPI for pertinent details.
Denies fevers or chills; no nightsweats. No headaches or visual
changes. No chest pain or difficulty breathing. Denies abdominal
pain. No changes in bowel habits. No dysuria or hematuria. Mild
extremity swelling after standing for prolonged period. Has lost
over 80lbs since the diagnosis of esophageal adenocarcinoma.
Past Medical History:
PAST MEDICAL HISTORY:
Metastatic esophageal adenocarcinoma, s/p esophagectomy with
gastric pull through and chemoradiation - surgery complicated by
GOO with pyloric dilatation, then laparoscopic reduction of
hiatal hernia and J-tube placement
PAST SURGICAL HISTORY:
- Laparoscopic reduction of hiatal hernia and J-tube insertion,
___
- Laparoscopic colon polypectomy, ___
- Esophagectomy and gastric pull through, ___
Social History:
___
Family History:
Mother HTN
Father Died of MI ___
Uncle with leukemia
Physical Exam:
ADMISSION EXAM
===============
Vitals: 98.9 97/70 95 16 92%RA
General: NAD. Appears stated age. Non-toxic appearing.
HEENT: PERRL. EOMI. Nares clear. Oropharynx with white exudate
on hard palate and poor dentition. Neck supple. No
lymphadenopathy.
___: RRR. No murmurs, audible rubs. S1 and S2 noted.
Respiratory: Mild increase in work of breathing. Reduced airway
sounds on the R with good air movement on the L and rub noted in
L base. No rhonchi or rales appreciated.
Abdomen: Soft, NTND with normoactive bowel sounds; no
hepatosplenomegaly or palpable masses; J-tube intact in LLQ.
Extremities: Warm, well-perfused distally; 2+ distal pulses
bilaterally with no cyanosis, clubbing or peripheral edema.
Derm: Skin appears intact with no significant rashes or lesions
Neuro: AOx3. Cranial nerves II-XII are intact. Normal bulk and
tone. Motor and sensory function are grossly normal. Gait
deferred.
DISCHARGE EXAM
===============
Vitals: 98.3 101/62 72 18 92% RA (amb sat 88% yesterday)
I/Os: TFs 1820 | IV 550 | 1470 | 175 from NGT
General: NAD. Appears stated age. Non-toxic appearing.
HEENT: PERRL. EOMI. MMM. OP clear. NGT with brownish food debris
and liquid material consistent with stomach contents.
___: RRR. No murmurs.
Respiratory: Some decreased breath sounds and faint inspiratory
crackles at left base, right lung with bowel sounds. No wheezes.
Abdomen: soft, NTND with normoactive bowel sounds; J-tube intact
in LLQ without erythema. TFs leaking around site mildly.
Extremities: WWP with no c/c/e. 2+ distal pulses b/l.
Neuro: Motor, and sensory functions all grossly normal. Gait
deferred.
Pertinent Results:
ADMISSION LABS
===============
___ 11:35AM LACTATE-1.2
___ 11:20AM GLUCOSE-130* UREA N-17 CREAT-0.6 SODIUM-140
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-35* ANION GAP-12
___ 11:20AM ALT(SGPT)-21 AST(SGOT)-41* ALK PHOS-89 TOT
BILI-0.6
___ 11:20AM LIPASE-36
___ 11:20AM ALBUMIN-3.4* CALCIUM-9.5 PHOSPHATE-2.9
MAGNESIUM-2.3
___ 11:20AM WBC-16.7* RBC-4.67 HGB-13.6* HCT-41.0 MCV-88
MCH-29.1 MCHC-33.1 RDW-14.4
___ 11:20AM NEUTS-85.3* LYMPHS-5.7* MONOS-6.1 EOS-1.5
BASOS-1.4
___ 11:20AM PLT COUNT-363
___ 11:20AM ___ PTT-30.2 ___
DISCHARGE LABS
===============
___ 07:00AM BLOOD WBC-8.8 RBC-4.08* Hgb-11.8* Hct-36.0*
MCV-88 MCH-28.9 MCHC-32.8 RDW-14.4 Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-127* UreaN-16 Creat-0.6 Na-143
K-3.8 Cl-105 HCO3-33* AnGap-9
___ 07:00AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.1
MICROBIOLOGIC DATA
===================
___ Urine culture - pending
___ Blood culture - pending
IMAGING STUDIES
================
CXR ___:
1. Right lower lobe collapse and small-to-moderate right
pleural effusion.
2. Mild left basilar atelectasis, new from prior.
3. No definite pneumothorax, although evaluation is limited due
to esophageal conduit on the right.
CTA Chest ___:
1. No acute aortic abnormality or pulmonary embolus.
2. Several bilateral pulmonary nodules, similar in appearance
to ___ compatible with metastatic disease.
3. Hazy ground-glass opacity in the left lower lobe with
adjacent small pleural effusion is unchanged since ___. Ground-glass opacity is nonspecific but may represent
focal edema.
4. Status post esophagectomy with gastric pull-up with
prominent distention of the intrathoracic stomach, similar in
degree ___ suggestive of outlet obstruction.
5. Distended gastric pullup as well as the large bowel loops
and associated fat herniating into the thoracic cavity causes
significant mass effect upon and contributes to the
atelectasis/collapse of the lungs.
6. Unchanged right thyroid nodule measuring 1.8 cm.
7. Large left central diaphraghmatic hernia, unchanged.
8. Coronary artery calcifications.
EGD ___
Esophagitis was seen in the upper third of the esophagus.
Evidence of an esophago-gastric anastomosis was seen at 23 cm
from the incisors.
Stomach: Gastric deformity was noted, with massive dilation of
the proximal stomach. There was excessive fluid and food debris
in the proximal stomach. The distal stomach was less dilated and
without much fluid or food debris. There was no discrete
intrinsic lesion or extrinsic compression visualized to account
for this discrepancy. There appeared to be a twist in the lumen
at the level of the pylorus/gastric outlet. This could be
traversed with the gastroscope into the duodenum, which appeared
normal. There was again no discrete intrinsic lesion or
extrinsic compression visualized at this level. Excavated
Lesions A few large, irregular, superficial, ischemic-appearing
ulcers were found in the stomach body. Cold forceps biopsies
were performed for histology at the stomach ulcer, to rule-out
malignancy.
Brief Hospital Course:
___ with PMH significant for metastatic esophageal
adenocarcinoma (s/p esophagectomy with gastric pull through and
chemoradiation - surgery complicated by GOO with pyloric
dilation and laparoscopic reduction of hiatal hernia then J-tube
placement, ___ who presented with hypoxia and persistent
cough.
# Likely chronic aspiration, leading to hypoxia with persistent
productive cough - Imaging suggestive of impaired lung function
in the setting of markedly dilated gastric conduit (with
evidence of air-fluid level and food material in the thorax -
suggesting chronic gastric outlet obstruction). Patient
presented complaining of productive cough attributed to chronic
aspiration and GERD. CTA chest showed no pulmonary embolism or
PTX but severe dilated of the intrathoracic stomach. No evidence
of consolidation. Thoracic surgery was consulted, relaying he
was not a surgical candidate given his metastatic disease. He
was placed on aspiration precautions and GI was consulted who
performed an EGD on ___ which demonstrated gastric volvulus
that was managed with NG tube decompression. We recommended
strict NPO and only sips for comfort - using a J-tube for
primary nutrition. He was also discharged on home oxygen given
some ambulatory desaturations.
# Gastric outlet obstruction - Patient developed gastric
obstruction after total esophagectomy with gastric pull through.
Etiology unclear to primary surgeon, but there is a suggestion
of longstanding pyloric spasm. Attempts to improve the
obstruction with pyloric dilatation and hiatal hernia reduction
have not provided relief and he now has a J-tube for nutrition.
Imaging on admission revealed significant distention of gastric
conduit, as patient had been eating food recently. Of note, he
enjoys eating and expressed desire to keep eating. He was placed
on aspiration precautions and GI was consulted who performed an
EGD on ___ which demonstrated gastric volvulus that was
managed with NG tube decompression. We recommended strict NPO
and only sips for comfort - using a J-tube for primary
nutrition. He continued on once daily PPI therapy. Thoracic
surgery did mention that aggressive head of bed elevation to
___ degrees will be important to prevent GERD and aspiration -
thus a hospital bed was requested for home.
# Leukocytosis - WBC elevated to 16.7 on admission with
neutrophilia, but resolved spontaneously without intervention.
He had no localizing symptoms and imaging (CXR and CT) without
consolidation. Urine culture with coagulase negative Staph and
he had no symptoms - antibiotics were deferred.
# Metastatic esophageal adenocarcinoma - Patient is s/p
esophagectomy with gastric pull through with chemoradiation in
___. Esophageal adenocarcinoma found to be Her 2+ and recently
with bilateral pulmonary lung nodules also found to be Her 2+,
supporting metastatic disease. Dr. ___ (primary
oncologist from ___ was made aware of his hospitalization and
is planning for palliative chemotherapy after hospitalization
with follow-up scheduled the week of his discharge.
TRANSITIONAL ISSUES:
- strict NPO recommended with head of bed elevation, ongoing PPI
use. No surgical options. Maintain J-tube for primary nutrition.
Will need hospital bed going forward.
- follow-up with outpatient oncologist, Dr. ___ at ___,
scheduled for this ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Metoclopramide 10 mg PO QID
3. Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Tamsulosin 0.4 mg PO HS
2. Metoclopramide 10 mg PO QID
3. Omeprazole 20 mg PO DAILY
we recommend that you take this medication twice daily.
4. Oxygen
Home oxygen @ 2 LPM continuous via nasal cannula, conserving
device for portability.
5. Hospital bed
Please provide with hospital bed to allow for head of bed
elevation to 40-degrees given chronic aspiration concerns.
ICD-9 code: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Chronic aspiration
- Gastric outlet obstruction
- Metastatic esophageal adenocarcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for complaints of persistent
nightly cough productive of sputum and food material that was
keeping you from sleeping. You were found to have low oxygen
levels on presentation to the emergency department with oxygen
saturations in the 80's on room air. Imaging revealed
compression of your lungs by a dilated conduit concerning for
persistent outlet obstruction. Our advanced GI endoscopy team
performed an upper endoscopy and noted twisting of your
intrathoracic stomach. Unfortunately, there is no surgical
correction for this. Continue the PPI therapy and keep your head
of bed elevated. We would encourage you to avoid eating by mouth
going forward and only take liquids for comofort - utilizing
your J-tube for tube feeding as your dominant form of nutrition.
It was pleasure taking care you.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19790220-DS-12
| 19,790,220 | 21,104,527 |
DS
| 12 |
2141-09-28 00:00:00
|
2141-09-28 20:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
all fish / bee sting / amlodipine / Cialis
Attending: ___.
Chief Complaint:
headache, thrombocytopenia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a very pleasant ___ male with pmhx
of obesity, HTN, HLD, GERD, OA, probable undiagnosed OSA, who
presents to ___ with worsening thrombyctopenia, headache, fatigue
and malaise. He has first found to have low platelets when
seeing
his PCP ___ on ___, ~1 week after returning from a 2 month
work trip to ___. At that time plt were 34. He had been
referred
to hematology, saw Dr. ___ on ___ and at that appointment plt
were up to 122. He was having intermittent sharp pains in his
head at that time. HCV, HIV negative, no e/o hemolysis, he was
told he may have ITP and planned to check his platelets in the
lab periodically given spontaneous improvement. However, had
increased bruising on worsening sharp, non-radiating
intermittent
headache over the next ___ weeks, and PCP referred him to
___ where plt were noted to be 16. Transferred to ___ ___, were
they were 17.
While in ___, he reports that he did walk through the woods
occasionally, but doesn't remember any tick or mosquito bites
(or
while here, for that matter). Was having some unusual bruising
during his trip there, but did not seek any medical attention
until he returned to the ___. He has traveled to ___ a
few times in the past year for work (spends 2 months there at a
time) and also has had a few similarly lengthed trips to ___
___ and ___).
Endorsing mild photophobia, no phonohobia. Denies fevers/chills.
No spontaneous bleeding (no nosebleed, no gum bleeding).
He was recently treated for otitis w/ amoxicillin (prescribed on
___ for WBC elevated to 17, and ear complaints to PCP.
In the ___, triage vital signs T 97.4 HR 54, BP 173/89 RR 16 Sat
95% on room air. He was given Benadryl and prochlorperazine for
headache, and home omeprazole and simvastatin.
Past Medical History:
COLONIC POLYPS
BORDERLINE DIABETES
GASTROESOPHAGEAL REFLUX
HEALTH MAINTENANCE
HYPERLIPIDEMIA
HYPERTENSION
OBESITY
OSA
OSTEOARTHRITIS
___ ESOPHAGUS
ACTINIC KERATOSIS
BEE STING ALLERGY
COLONIC ADENOMA
LUNG NODULE
Social History:
___
Family History:
2 sisters alive and well. Sister and mother
(deceased) with peripheral vascular disease. Father with gastric
cancer (deceased at age ___. 1 brother with coronary artery
disease. No family history of hematologic malignancy, bleeding
or
thrombotic disorders.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.6 BP 186/97 HR 53 RR 18 O2 sat 96% on room air
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round. Mild photophobia
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 without meningismus, moves all extremities,
strength grossly full and symmetric bilaterally in all limbs. No
pitting edema
SKIN: Bilateral mild linear petechiae on shins
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 PHYSICAL EXAM:
VITALS: 97.7 PO 97/59 R Sitting HR67 RR16 95%RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round. No photophobia
ENT: Mild rhinorrhea. Oropharynx without 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 without meningismus, strength ___ in upper and
lower extremities bilaterally, sensation grossly intact. AOx3.
No pitting edema
SKIN: Bilateral mild linear petechiae on shins
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:
LABS ON ADMISSION:
___ 09:00AM WBC-9.1 RBC-4.92 HGB-14.9 HCT-44.8 MCV-91
MCH-30.3 MCHC-33.3 RDW-13.1 RDWSD-43.5
___ 09:00AM NEUTS-75.2* LYMPHS-15.5* MONOS-6.7 EOS-1.9
BASOS-0.2 IM ___ AbsNeut-6.84* AbsLymp-1.41 AbsMono-0.61
AbsEos-0.17 AbsBaso-0.02
___ 09:00AM PLT COUNT-15*
___ 09:00AM ___ PTT-27.9 ___
___ 12:48AM POIKILOCY-1+* ECHINO-1+* RBCM-SLIDE REVI
___ 12:48AM PARST SMR-NEGATIVE
___ 09:00AM ALT(SGPT)-18 AST(SGOT)-19 LD(LDH)-302* ALK
PHOS-66 TOT BILI-0.7
___ 09:00AM CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-2.0
___ 09:00AM HAPTOGLOB-108
___ 09:00AM GLUCOSE-86 UREA N-12 CREAT-0.7 SODIUM-140
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-25 ANION GAP-10
___ 03:24PM ___
Peripheral smear: per heme/onc fellow, notable for some
large/giant platelets, no schistocytes or e/o hemolysis.
Specifics of case and smear results discussed directly over the
phone with fellow
CT Head at ___ ___ no acute intracranial process
Chest x-ray:
No evidence of appreciable vascular congestion or acute focal
pneumonia.
CT Abdomen/Pelvis W/ CO: FINDINGS:
LOWER CHEST: Bibasilar atelectasis. 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 surgically absent.
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 solid renal lesions or
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops
demonstrate normal caliber, wall thickness, and enhancement
throughout. Mild diverticulosis of the sigmoid colon is noted,
without evidence of wall thickening or fat stranding. The
appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate gland is at the upper limit of
normal. Prostatic calcifications are noted.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute
fracture.There is mild anterolisthesis L5 over S1, unchanged
from
prior. A L4 vertebral body Schmorl's node is noted.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION: No finding to explain the patient's symptoms.
LABS ON DISCHARGE:
___ 06:00AM BLOOD WBC-14.5* RBC-5.00 Hgb-15.0 Hct-44.6
MCV-89 MCH-30.0 MCHC-33.6 RDW-13.2 RDWSD-42.7 Plt Ct-77*
___ 06:00AM BLOOD Glucose-101* UreaN-15 Creat-0.7 Na-144
K-3.7 Cl-105 HCO3-28 AnGap-11
___ 06:00AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.1
___ 08:24AM BLOOD %HbA1c-5.9 eAG-123
Brief Hospital Course:
Mr. ___ is a ___ male with h/o obesity, HTN, HLD,
GERD, OA, probable undiagnosed OSA, who presented to ___ with
ongoing headache and malaise, with worsening thrombocytopenia,
found to have ITP. He was started on prednisone 120 mg daily
with improvement in platelet count. His headache improved with
symptomatic management.
TRANSITIONAL ISSUES:
[] H. pylori stool Ag was ordered but patient was unable to
provide sample in-house. Please collect outpatient. Of note,
there is a high false negative rate of test with patients taking
PPI. Serum H. pylori IgG was sent due to high negative
predictive value, pending at discharge
[] Follow up cough/rhinorrhea
# Contacts/HCP/Surrogate and Communication: HCP is wife ___
___ ___
# Code Status/Advance Care Planning: FULL - presumed (please
also see current POE order)
[X] I spent more than 30 minutes in discharge planning and
coordination of care.
ACUTE/ACTIVE PROBLEMS:
#Severe Thrombocytopenia:
#Likely ITP:
Patient presented with ~2 weeks of worsening headache and
malaise and fluctuating but overall decreasing platelet count.
Dr. ___ in clinic suspected patient has new ITP, however plt
were 122 at the time he went to clinic, so no treatment
initiated at that time. At time of presentation to the ___
platelets were at a nadir of 15. Patient was evaluated by
Heme/Onc who reviewed smear and found it most consistent with
ITP (giant platelets were noted and no evidence of hemolysis).
Labs also not c/w hemolysis. Parasite smear was negative, as
were ___ anaplasma IgG/IgM, HIV, HCV, SPEP. Patient was started
on prednisone 120 mg daily with improvement in platelet count to
77 at discharge. He was continued on home PPI. FSBGs were
checked due to concern for hyperglycemia with prednisone, but
his sugars were <200 thus no insulin was initiated. A1c was
checked and was 5.9%. Patient had insomnia secondary to the
steroids and was given rx for trazodone for sleep.
#Headache:
#Fatigue:
Headache with photophobia but no fevers, AMS, focal neurologic
signs or meningismus. CT head at ___ was negative for bleed.
Headache was though to be secondary to the general
malaise/discomfort people feel
when they have low platelets v migraine-type headache. Treated
with migraine cocktail in the ___ (IVF, iv Compazine and
Benadryl) to good effect and prn Tylenol/tramadol on the floor.
Neuro exam remained normal and symptoms improved while in-house.
#Cough
#Rhinorrea, likely viral URI
Patient developed rhinorrhea with post-nasal drip and reactive
cough while in-house. No fevers, chills. Oropharynx was clear
and cough dry and non-productive. Lung exam was clear and CXR
was unremarkable. Flonase was started with improvement of
symptoms.
#Likely OSA:
Patient noted to desat while sleeping, and his PCP has inkling
that he has OSA due to hemoglobin being high/normal. He is meant
to have a home sleep study in the near future. No issues
in-house
#Iron deficiency: discontinued iron sulfate as not currently
deficient, per H/O recs
#Hypertension: continued home losartan, HCTZ, amlodipine
#GERD: continued omeprazole
#Hyperlipidemia: continued simvastatin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
4. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY
5. Simvastatin 10 mg PO QPM
6. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 2 SPRY NU BID
RX *fluticasone propionate [24 Hour Allergy Relief] 50
mcg/actuation 2 SPRY IN twice a day Disp #*1 Spray Refills:*0
2. PredniSONE 120 mg PO DAILY
RX *prednisone 20 mg 6 tablet(s) by mouth once a day Disp #*180
Tablet Refills:*0
3. TraZODone 50 mg PO QHS:PRN insomnia
RX *trazodone 50 mg ___ tablet(s) by mouth every night as needed
Disp #*30 Tablet Refills:*0
4. amLODIPine 5 mg PO DAILY
5. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 allergic reaction
6. losartan-hydrochlorothiazide 100-12.5 mg oral DAILY
7. Omeprazole 20 mg PO DAILY
8. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
immune thrombocytopenia
migraine headache
rhinorrhea, viral URI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___!
Why were you hospitalized?
- You came to the hospital because your platelets were very low
and you were having a bad headache.
What happened while you were in the hospital/
- You were diagnosed with a condition called ITP (Immune
thrombocytopenia)
- You were started on treatment with prednisone, and your
platelets responded beautifully.
- We scanned your head as ITP predisposes you to bleeding but
the scan was normal. You headache improved. It had features of a
migraine (sensitivity to light), and migraine medications
helped.
- You developed a runny nose and cough for which you had an
x-ray. Xray was normal.
What should you do after you leave the hospital?
- Please continue to take the prednisone and omeprazole. Do not
take any ibuprofen, motrin, aspirin, naproxen or aleve as they
increase your risk of bleeding when on prednisone.
- Please do not engage in any tackle sports or similar physical
activity as your platelets are still below the normal range.
- Follow up with Dr. ___ on ___ 8:30 am
- Monitor your headache symptoms. you can take up to 1g of
Tylenol 3 times a day for it.
- Monitor your cough and runny nose. If you notice sore throat,
trouble swallowing, shortness of breath or fevers, please call
your PCP right away.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19790357-DS-12
| 19,790,357 | 23,122,368 |
DS
| 12 |
2156-04-09 00:00:00
|
2156-04-19 13:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Sudafed / Norvasc / Bactrim
Attending: ___.
Chief Complaint:
double vision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a past medical
history of atrial flutter on rivaroxiban, HTN, HLD, PVD,
subclavian steal s/p stent, who presents with diplopia.
He states that at 11am yesterday (___) he developed
sudden onset of double vision while driving (was just getting to
the house). This was diagonal at times, vertical at times,
seemingly with different directions of gaze but not clear which.
It would go away if he closed one eye. This lasted minutes at a
time, coming and going while he was resting sitting on the
couch.
It eventually became constant. He then went to ___
ED
and got an MRI brain with MRA which showed an old stroke in the
pons.
His blood pressure was high and they gave him an increased dose
of his home MTP (50mg). Over his course in the ED his symptoms
got better, and they discharged them home and told him to follow
up with his vascular surgeon who is here at ___. Then, this
morning he woke up with the double vision, and it has been there
since (constant), so he was told to come to the ED.
He denies any numbness, weakness, speech difficulty, no
difficulty with walking except for because of the double vision.
Of note, he underwent a cardiac catheterization on ___
(no interventions performed, was part of a heartburn workup). He
held his dose of rivaroxiban ___ night and ___ morning
in
anticipation of the catheterization.
He recently got a subclavian stent placed - prior to this he was
having fatiguing weakness in his left arm which is now gone.
He has had several prior strokes. On New years day of this year
he was sitting watching Star Wars with his daughter, and
developed numbness in his left arm. He had planned to go to ___ so he got in his car anyways and drove to ___. Then his wife made him go to the ER there. MRI was done
and there was a stroke (he does not know where), but our review
of
his old MRI indicates that it was a right parapontine median
infarct.
Symptoms lastedin the order of days and are now gone, there was
no
weakness. He was taken off ASA at that time, kept just on Plavix
and
xarelto.
On neuro ROS, the pt denies headache, loss of vision,
dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention. Denies difficulty with
gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
PMH:
- HTN
- PVD
- HLD
- COPD
- Lyme Dz
- Tobacco abuse
PSH:
- Right common iliac stent
- Left to right fem-fem bypass (occluded)
- Left Iliac Stent (___)
- Left SFA to popliteal artery bypass graft with greater
saphenous vein (___).
- Left fem-pop stenting (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Physical Exam:
Vitals: 97.8 50 147/88 18 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Breathing comfortably
Cardiac: regular, mildly bradycardic
Abdomen: soft
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive to examiner. Language is fluent
with intact repetition and comprehension. Normal prosody. No
paraphasic errors. Naming intact to both high and low frequency
objects. Reads without difficulty. Speech was not dysarthric.
Able to follow both midline and appendicular commands. Good
knowledge of current events. No apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: Eyes appear conjugate in primary gaze. Left eye
does
not fully abduct.
He reports strictly vertical double vision when looking straight
ahead. This becomes diagonal looking down with second image down
and to the right. The bottom/right imagegoes away when covering
the left eye. No double vision looking up or to the right. No
double vision with head tilt to the left.
V: Facial sensation intact to light touch.
VII: Slight L NLFF, activates symmetrically.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5- ___ 5 5 5
R 5 ___ ___ 5- ___ 5 5 5
-Sensory: Decreased sensation to cold to past the knees
bilaterally. Slightly decreased vibratory sensation bilateral
toes. Sensation to light touch intact throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 3 1
Plantar response was extensor on the right, flexor on the left.
-Coordination: No dysmetria b/l upper or lower extremities. No
nystagmus.
-Sensation: Stocking distribution decreased cold sensation to
past knees. Decreased vibratorty sensation toes. Sensation
intact
to light touch bilaterally.
-Gait: Deferred
On discharge: exam unchanged from admission
Pertinent Results:
___ 06:20AM BLOOD TSH-2.4
___ 06:20AM BLOOD Triglyc-122 HDL-60 CHOL/HD-2.0 LDLcalc-33
___ 06:20AM BLOOD %HbA1c-5.5 ___ CTA head/neck:
1. No evidence of hemorrhage or acute infarct.
2. Occlusion of the left vertebral artery at its origin with
intermittent
opacification and ultimately reconstitution distally possibly
from collaterals
or retrograde flow.
3. Scattered internal carotid artery calcifications bilaterally
without
evidence of stenosis by NASCET criteria.
4. Severe emphysema.
5. 4 mm left upper lobe pulmonary nodule.
___ TTE: No echocardiographic evidence of cardiac embolus nor
PFO. Normal biventricular regional/global systolic function.
Type II pattern diastolic dysfunction with elevated left atrial
pressure
___ abdominal XR: 1. Bi-iliac stents and surgical clips in the
left upper abdomen and right inguinal region.
2. Nonspecific nonobstructive bowel gas pattern with a moderate
amount of
stool in the low pelvis.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a past medical
history of atrial flutter on rivaroxiban, HTN, HLD, PVD,
subclavian steal s/p stent, R paramedian pontine stroke who
presents with diplopia. Appears to have a left CN IV palsy on
exam. However, he has multiple other risk factors for stroke,
including aflutter with missed anticoagulation, recent cardiac
cath, HTN, HLD, and severe peripheral vascular disease. He
reports his symptoms are now stable. OSH MRI did not show an
obvious new stroke. CTA head/neck showed occlusion of the L
vertebral artery at its origin with intermittent opacification
and ultimately reconstitution distally likely from collaterals.
His diplopia & exam rapidly improved after his admission. We
attempted to repeat his brain MRI to assess for a possible new
small brainstem infarct not seen on initial MRI. However, MRI
head was unable to be done here as pt had a colonoscopy within
30 days and had metal clips in place. Our Radiology dept. felt
that it was unsafe to do MRI at this time. We intended to
consult Neuroophthalmology. However, Mr. ___ was upset
because we could not repeat his MRI & elected to leave. He was
already on aspirin, plavix, and rivaroxaban. We were concerned
about increased risk of bleeding. After speaking to his primary
vascular surgeon, okay to stop Plavix and continue xarelto. He
was discharged home on his home medications except for Plavix
with instructions to follow up with his neurologist in ___
and NeuroOphthalmology.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Metoprolol Tartrate 37.5 mg PO BID
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Flecainide Acetate 150 mg PO Q12H
5. Losartan Potassium 50 mg PO DAILY
6. Oxybutynin 10 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
8. Finasteride 5 mg PO DAILY
9. Rivaroxaban 20 mg PO DAILY
10. Gabapentin 300 mg PO BID
11. Creon (lipase-protease-amylase) 24,000-76,000 -120,000 unit
oral 2 capsules prior to meals
12. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. Oxybutynin 10 mg PO DAILY
7. Rivaroxaban 20 mg PO DAILY
8. Tamsulosin 0.4 mg PO QHS
9. Cyanocobalamin 3000 mcg PO DAILY
10. Creon (lipase-protease-amylase) 24,000-76,000 -120,000 unit
oral 2 capsules prior to meals
11. Flecainide Acetate 150 mg PO Q12H
12. Losartan Potassium 50 mg PO DAILY
13. Metoprolol Tartrate 12.5 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Diplopia
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 symptoms of diplopia. Unfortunately, we
were unable to obtain a better MRI to image this better.
Certainly symptoms of diplopia can be caused by a small stroke,
and you have multiple risk factors including peripheral vascular
disease, high blood pressure, high cholesterol, and atrial
fibrillation.
Please follow up with Dr. ___ in vascular surgery &
Neuroophthalmology.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19790357-DS-8
| 19,790,357 | 25,873,687 |
DS
| 8 |
2154-05-24 00:00:00
|
2154-05-25 00:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sudafed / Norvasc / Bactrim
Attending: ___.
Chief Complaint:
Right foot pain
Major Surgical or Invasive Procedure:
___
Aortobifemoral bypass with 14 mm x 7 mm Dacron graft.
___
1. Exploratory laparotomy.
2. Abdominal washout.
3. Repair of proximal suture line leak.
History of Present Illness:
Mr. ___ is a ___ man well-known to the
Vascular Surgery service at ___ including for history of
occluded PTFE fem-fem bypass graft who was discharged 2 days
prior to present admission after conservative inpatient
management of chronic right lower extremity ischemia; he was
discharged on lovenox bridge to warfarin. His pain never fully
resolved and now he returns for evaluation and management. At
time of presentation to the ED, patient's clinical appearance
was not acutely concerning for immediate threat to RLE and
patient's pulse exam was slightly improved over exam on
discharge 2 days ago but toes did appear slightly more dusky
than on discharge.
Past Medical History:
PMH:
- HTN
- PVD
- HLD
- COPD
- Lyme Dz
- Tobacco abuse
PSH:
- Right common iliac stent
- Left to right fem-fem bypass (occluded)
- Left Iliac Stent (___)
- Left SFA to popliteal artery bypass graft with greater
saphenous vein (___).
- Left fem-pop stenting (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
VS: 98.2 50 143/53 16 98% RA
Gen: NAD, AAOx3, pleasant
CV: RRR no m/r/g
Pulm: CTAB no w/r/r
Abd: Soft, NT/ND
Ext: Slightly cool RLE, mild-to-moderate duskiness to plantar
surface of R great toe, no mottling of skin. Motor function
intact, SILT.
Pulses:
Fem DP ___
Left P D D
Right P D D
On discharge:
VS: 98 69 161/66 16 94% RA
Gen: NAD, AAOx3
CV: RRR, normal S1/S2
Pulm: CTAB
Abd: Soft, minimal midline incisional tenderness, well-healing
midline surgical
Ext: Groin incisions healing well, c/d/i. Extremities warm and
well-perfused. Duskiness in right foot improving
Pulses:
Fem DP ___
Left P P D
Right P P D
Brief Hospital Course:
Mr. ___ was admitted to the Vascular Surgery service
with HPI as stated above and was started on a heparin drip on
the floor. On hospital day 2 he was continued on the drip and
underwent lower extremity arterial duplex which demonstrated
patent right femoropopliteal and tibial vessels with monophasic
flow throughout. All imaging was reviewed and it was decided to
take the patient to the OR for an aorto-bifem bypass graft the
following day. He was cleared for surgery by cardiology prior
to the procedure.
He went to the OR on ___ for the bypass. For full details
please see the dictated operative report. There was significant
blood loss in the OR and the patient received 3 liters of
crystalloid fluid, additional albumin, 3 units of packed red
blood cells, 4 units of FFP, 1 unit of platelets, and 1.4 L by
cellsaver. The patient was transferred to the CVICU intubated.
The night of the procedure, the patient became increasingly
hypotensive with increasing pressor requirement, increasing
lactate, and increasing acidosis. In the morning of POD1, he
underwent exploratory laparatomy. He was found to have bleeding
from the proximal anastamosis which was controlled. He was
heavily resuscitated with blood products. Following the
procedure, his hematocrit was at 30 from a pre-op hematocrit of
10. He was transferred back to the CVICU in stable condition. On
POD0 and POD1 from the exploration, the patient was kept
intubated and sedated. He remained hemodynamically stable, his
hematocrit remained stable, and his acidosis normalized and his
lactate trended down.
On POD2, the patient was extubated. Upon extubation, the patient
experienced pulmonary edema and was maintained on O2 via
facemask as he was diuresed. IV lasix was given for diuresis and
the patient's respiratory status steadily improved. At the time
of discharge, the patient's respiratory status was at baseline
and he was saturating well on room air. From a vascular
perspective, the patient improved dramatically following the
procedure. On POD3, the patient had palpable DP pulses
bilaterally. His feet were warm and well-perfused and the
duskiness present on admission in his right toes improved
throughout the remainder of his admission. The day prior to
admission, the patient experienced an episode of narrow complex
tachycardia in the 140s. He was asymptomatic and hemodynamically
stable. He received one dose of 5 mg IV metoprolol and converted
back into normal sinus rhythm. EKG following this episode was
normal and the same as pre-op. He remained in normal sinus
rhythm for the remainder of the admission. Upon discharge, his
metoprolol was increased from 50 bid to 50 tid.
The biggest issue experienced following the re-operation was the
patient's mental status. Upon extubation, the patient became
extremely confused and agitated. Discussion with the patient's
wife revealed an significant history of daily alcohol use,
significantly more than disclosed by the patient preoperatively.
He was started on a CIWA scale with ativan for withdrawal. He
was also started on haldol to control his confusion and
agitation. On POD3, the patient's mental status slowly began to
improve. However, he remained oriented to self at best with
frequent agitation, especially at night. Therefore, psychiatry
was consulted on POD5. Psychiatry recommended minimizing use of
benzodiazapenes, increasing the haldol dose, and stressing
reorientation techniques. On POD6, the patient's mental status
began to improve more rapidly. He became alert and oriented x3.
He was seen by speech and swallow who cleared him for pureed
diet with thickened liquids. He was transferred out of the ICU.
On POD7, the patient returned to his baseline mental status. He
tolerated diet and was advanced to thin liquids and soft diet.
He ambulated well with ___. On POD8, he was discharged home with
___ for home ___ and wound/pulse monitoring. He will follow-up in
the clinic with Dr. ___ in 2 weeks for his post-op visit and
staple removal.
Medications on Admission:
Meds at time of discharge ___:
- Acetaminophen 325-650 mg PO Q4H:PRN pain
- Aspirin 325 mg PO DAILY
- Atorvastatin 80 mg PO DAILY
- Clopidogrel 75 mg PO DAILY
- Lisinopril 20 mg PO DAILY
- Metoprolol Tartrate 50 mg PO BID
- Enoxaparin Sodium 60 mg SC BID
- OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
- Warfarin 5 mg PO DAILY16
- Docusate Sodium 100 mg PO BID Constipation
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*2
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Peripheral Vascular Disease s/p Aorto Bifemoral Bypass Graft
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
WHAT TO EXPECT:
1. It is normal to feel weak and tired, this will last for ___
weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
Wear loose fitting pants/clothing (this will be less irritating
to incision)
Elevate your legs above the level of your heart with ___
pillows every ___ hours throughout the day and at night
Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
Take all the medications you were taking before surgery, unless
otherwise directed
Take one full strength (325mg) enteric coated aspirin daily.
Take one 75 mg Plavix daily
ACTIVITIES:
No driving until post-op visit and you are no longer taking
pain medications
You should get up every day, get dressed and walk, gradually
increasing your activity
You may up and down stairs, go outside and/or ride in a car
Increase your activities as you can tolerate- do not do too
much right away!
No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
You may shower (let the soapy water run over incision, rinse
and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area
CALL THE OFFICE FOR : ___
Redness that extends away from your incision
A sudden increase in pain that is not controlled with pain
medication
A sudden change in the ability to move or use your leg or the
ability to feel your leg
Temperature greater than 101.5F for 24 hours
Bleeding from incision
New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
___
|
19790743-DS-16
| 19,790,743 | 23,610,233 |
DS
| 16 |
2126-12-31 00:00:00
|
2126-12-31 15:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
s/p ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old female with no significant past
medical history who was an unrestrained passenger in an ___ this
evening. She states that the car was pulling out of a parking
lot
when it hit a patch of ice and struck a pole. HEr air bag did
not
deploy and as above she was not wearing a seatbelt. She reports
she struck her face on ___ dashboard and she was ambulatory at
the scene without difficulty. Imagign at the OSH she was taken
to
showed a C1 veretebral body fracture spanning from the anterior
to the posterior arch on the left side. She was placed in a hard
collar and transferred to ___ for further management and care.
Past Medical History:
Myopia
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact without nystagmus
Neck:Hard Cervical Collar, Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes:
No hoffmans no clonus
Propioception intact
Toes downgoing bilaterally
On discharge:
AVSS
General - Awake and alert. Sitting up in chair. Wearing SOMI
brace.
Mental Status - A&Ox3. Pleasant though quiet.
Cranial Nerves - II - XII grossly intact.
Motor - ___ in bilateral upper & lower extremities.
Sensation - Intact to light touch throughout.
___ absent.
Pertinent Results:
___ CTA neck with and without contrast:
There is a minimally displaced fracture through the left
anterior and
posterior arches of C1. The fracture does not extend through the
transverse foramen. The adjacent left vertebral artery is
without evidence of dissection or active extravasation. The
remainder of the neck vasculature appears normal. Final read
pending 3D reformats.
___ MRI cervical spine without contrast (prelim read):
1. Comminuted fracture of the posterior arch of C1 is better
depicted on prior CT; however, there is associated increased
T2/STIR signal within the left lateral mass of C1.
2. Large prevertebral soft tissue hematoma extending from the
clivus to the inferior aspect of the C4 vertebral body.
3. Abnormal fluid signal between the lateral masses of C1 and
C2, between the occiput and C1, and within the atlantodental
joint -- given the apical ligament is not seen, apical ligament
injury is not excluded.
4. There is an additional defect in the atlanto-occipital
membrane and the anterior arch of C1 appears lower than its
expected position in relation to C2.
5. No clear transverse ligamentous disruption although given
prior CT
findings, including the fracture traversing the insertion site
of the
transverse ligament, the mechanical stability of C1 and C2 is
uncertain 6. No evidence of spinal cord compression, cord
contusion, or cord edema.
Brief Hospital Course:
Ms. ___ was admitted to the Neurosurgery service for further
management of her C1 fracture. She was transferred from the
Emergency Department to the inpatient ward for close
observation. She remained in a hard cervical collar. An MRI
was ordered to further evaluate her injury. Due to concern of C1
and C2 instability secondary to ligamentous injury, a SOMI brace
was ordered. Ms. ___ remained inpatient until the brace
arrived on ___. She was otherwise neurologically
intact during this time.
Ms. ___ remained neurologically intact on ___. She
was placed in a SOMI brace and was instructed to wear it at all
times except while showering during which she may wear a soft
cervical brace and be cognizent of minimizing neck range of
motion. Her pain was controlled on oral pain medications. She
was discharged home with plan for follow up with Dr. ___ in
2 weeks with repeat x-rays.
Medications on Admission:
Birth Control patch, nortryptiline, senna
Discharge Medications:
1. Ortho Evra (norelgestrom-ethinyl estradiol) 150-35 mcg/24 hr
transdermal weekly
2. Senna 17.2 mg PO DAILY
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*168 Tablet Refills:*0
4. Nortriptyline 25 mg PO QHS
5. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
Never exceed 4000 mg in 24 hours.
Discharge Disposition:
Home
Discharge Diagnosis:
Minimally displaced fracture of C1 left anterior and posterior
arches
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Neurosurgery service after you were
found to have a cervical injury of C1. Due to your injury, a
special brace was ordered (Somi brace).
Now that you have your brace, you should wear it at all times
other than during times of hygiene.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting at the neck.
Do not take anti-inflammatory pain medications such as ibuprofen
(Advil, Motrin) or naproxen (Aleve, Naprosyn).
Take your pain medication as instructed; you may find it best if
taken in the morning when you wake-up for morning stiffness, and
before bed for sleeping discomfort.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Senna, while taking narcotic
pain medication.
Clearance to drive and return to work will be addressed at your
follow up office visit with Dr. ___.
Followup Instructions:
___
|
19791178-DS-21
| 19,791,178 | 25,167,868 |
DS
| 21 |
2114-10-28 00:00:00
|
2114-11-08 14:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Isordil
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yr old male with coronary artery disease s/p CABG and
multiple
stents (most recent catheterization ___, no stents placed),
hyperlipidemia and diabetes II presents with chief complaint of
chest pain which began three days prior to admission. He had the
onset of chest pain while walking, and it was relieved by
stopping and sitting down. He describes left-sided chest pain
with a burning quality or a numb quality. It lasts three minutes
at a time and is partially improved by sublingual nitroglycerin
and deep breathing. He does not associate the pain with eating
or with laying down. Associated symptoms include nausea, SOB,
palpitations, lightheadedness, blurry vision, and bilateral arm
weakness/feeling of heat. He had this chest pain three times and
called EMS on the third time, worried about the increased
frequency of pain. He also reports chest pain three days ago at
rest, and sometimes gets chest pain while laying down.
In the ED, initial vitals were 98.3 86 106/67 16 98% RA. Labs
were remarkable for: potassium 5.4, BUN 27, Cr 0.9, glucose 154,
troponin <0.01, proBNP 136, lactate 1.4. WBC 9.1 (80%
neutrophils), H/H 11.7/35.2, plt 283, coags WNL. Received
aspirin 325mg and sublingual nitroglycerin in ED.
ROS
Gen: Weight gain ___ lbs.
HEENT: No rhinorrhea or sore throat
CV/Pulm: As per HPI. Also reports heavy feeling of legs when
walking.
Abd: No nausea/vomiting/diarrhea. +Constipation. Worried about
taking meds that affect liver.
GU: He is worried about his prostate because it has not been
checked in a long time.
MSK: R shoulder pain.
Skin: No rash.
Heme: No LAD. No abnormal bruising/bleeding.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes type 2 (checks BG up to
BID, reports lows of 44-60s in AM), (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG: 3-vessel CABG - records not in ___ system but
apparently had SVG to RCA/LCx and LIMA to LAD
- PERCUTANEOUS CORONARY INTERVENTIONS: Occluded SVG RCA/LCX s/p
PCI to RCA/LCX in ___, s/p staged PCI ___ with DES to OMB
(ISR), LM and RCA (ISR). Most recent cath ___ resulted in no
PCI (see results below)
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Right shoulder problem s/p steroid injection
Patient denies other past medical problems
Social History:
___
Family History:
Sister had heart surgery. Grandfather had MI.
Physical Exam:
ADMISSION
VS: 98.2 63 132/81 20 100% RA 63kg
General: Well-appearing male laying in bed. Awake, alert,
comfortable, conversational.
HEENT: MMM. No scleral icterus. EOMI.
Neck: No JVD.
CV: RRR, no m/g/r.
Lungs: CTA b/l
Abdomen: +BS, soft, nontender, nondistended.
Ext: No peripheral edema. 2+ DP and ___ pulse on right, reduced
pulses on left.
Neuro: CN ___ intact, motor strength UEs and LEs full,
symmetric. Light touch sensation intact on distal UEs and LEs.
Skin: No obvious rashes.
DISCHARGE
VS: 98.1 116/72 74 16 99% RA
max 98.3 ___ 16 ___ 98-100%
BG ___
General: Awake, alert, comfortable appearing
HEENT: MMM. No scleral icterus. EOMI.
Neck: No JVD.
CV: RRR, no m/g/r.
Lungs: CTA b/l.
Abdomen: +BS, soft, nontender, nondistended.
Ext: No peripheral edema. Scaly plaque in between right third
and fourth toes
Pertinent Results:
ADMISSION
___ 02:43AM PLT COUNT-283
___ 02:43AM NEUTS-79.7* LYMPHS-14.3* MONOS-5.1 EOS-0.6
BASOS-0.3
___ 02:43AM WBC-9.1 RBC-3.93* HGB-11.7* HCT-35.2* MCV-90
MCH-29.7 MCHC-33.1 RDW-12.7
___ 02:43AM cTropnT-<0.01 proBNP-136
___ 02:43AM GLUCOSE-154* UREA N-27* CREAT-0.9 SODIUM-134
POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-27 ANION GAP-12
___ 02:54AM LACTATE-1.4 K+-5.0
___ 03:31AM ___ PTT-30.0 ___
___ 10:50AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 10:50AM CALCIUM-9.4 PHOSPHATE-3.2 MAGNESIUM-1.8
___ 10:50AM CK-MB-2 cTropnT-<0.01
___ 10:50AM CK(CPK)-41*
___ 12:41PM URINE MUCOUS-RARE
___ 12:41PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 12:41PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 12:41PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:25PM calTIBC-303 FERRITIN-44 TRF-233
___ 05:25PM IRON-30*
___ 05:25PM CK-MB-3 cTropnT-<0.01
___ 05:25PM CK(CPK)-41*
___ 05:25PM SODIUM-140 POTASSIUM-5.4* CHLORIDE-101
___ 07:20PM PTT-78.5*
___ 11:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
INTERIM LABS / LAB TRENDS
___ 02:43AM BLOOD cTropnT-<0.01 proBNP-136
___ 10:50AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:25PM BLOOD CK-MB-3 cTropnT-<0.01
MICROBIOLOGY
___ 12:41 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 5:00 pm BLOOD CULTURE 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 5:20 pm BLOOD CULTURE 2 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS
___ 07:06AM BLOOD WBC-9.9 RBC-4.28* Hgb-12.4* Hct-37.2*
MCV-87 MCH-29.0 MCHC-33.3 RDW-12.5 Plt ___
___ 07:06AM BLOOD Plt ___
___ 07:06AM BLOOD ___ PTT-29.3 ___
___ 07:06AM BLOOD Glucose-259* UreaN-39* Creat-1.0 Na-136
K-5.2* Cl-100 HCO3-27 AnGap-14
___ 07:06AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.0
STUDIES/IMAGING
CXR PA/lateral ___
FINDINGS: PA and lateral views of the chest. The sternotomy
wires are
intact. Coronary artery stents and/or calcifications are seen.
Mediastinal
clips are seen. There is prominence of epicardial fat on the
left. No focal
consolidation, pleural effusion or pneumothorax. The
cardiomediastinal and
hilar contours are normal.
IMPRESSION: No acute cardiopulmonary process.
TTE ___
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF=60%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size is normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal left ventricular wall thickness and cavity
size with normal global/regional systolic function.
Stress test ___
___ year old man with a history of CAD s/p multiple
cardiac stents and CABG in ___ who presents with angina,
dyspnea on
exertion, and palpitations. The patient completed 8 minutes of a
Gervino protocol representing a poor exercise tolerance; 4.3
METS. The
test was stopped at the patient's request due to shortness of
breath.
No chest, neck, back, or arm discomforts were reported. There
were no
ST changes noted during the procedure. The rhythm was sinus with
no
ectopy noted. The blood pressure response was appropriate. The
heart
rate response was blunted in the presence of beta blocker
therapy.
IMPRESSION: Poor exercise tolerance, limited by exertional
dyspnea. No
anginal symptoms or ischemic ST segment changes at the achieved
level of
work. Nuclear report sent seperately.
NTERPRETATION:
The image quality is adequate.
Left ventricular cavity size is normal, with an end diastolic
volume of 56 ml.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium. There were no perfusion
abnormalities.
Gated images reveal akinesis of the septum, likely due to a
prior CABG. There
are no focal areas of hypokinesis.
The calculated left ventricular ejection fraction is 52%.
No prior studies are available for comparison.
IMPRESSION: 1. Normal myocardial perfusion without perfusion
defects at the
level of exercise achieved. The exercise tolerance was poor.
2. Akinesis of
the septum is likely related to the prior CABG. Wall motion is
otherwise normal
with an ejection fraction of 52%.
Brief Hospital Course:
___ yr old male with coronary artery disease s/p CABG and
multiple
stents (most recent catheterization ___, no stents placed),
hyperlipidemia and diabetes II p/w chief complaint of chest
pain.
ACTIVE DIAGNOSES
# UNSTABLE ANGINA: Known blockages per cardiac cath ___
include RCA origin with 50% stenosis, apical LAD 60-70%
stenosis, occluded mid-LAD, small OM branch 80% stenosis. EKG
did not show any clearly ischemic changes, and troponins were
negative x 3. Urine tox screen was negative for cocaine.
Presentation was consistent with unstable angina. Patient
received IV heparin x 48 hrs, in addition to metoprolol, aspirin
325mg, Plavix, and simvastatin. Metoprolol was uptitrated, and
pt was discharged on 150mg daily (he had experienced some
dizziness while on 200mg, so it was decreased to 150mg daily).
Isosorbide dinitrate was tried but resulted in severe headache,
so it was soon discontinued. His chest pain improved. TTE this
admission revealed LVEF 60% with normal left ventricular wall
thickness and cavity size with normal global/regional systolic
function. Exercise MIBI showed normal myocardial perfusion,
akinesis of the septum consistent with prior CABG, and otherwise
normal wall motion. Consider addition of amlodipine for better
control of anginal symptoms, and consider decreasing aspirin to
81mg daily as outpatient (see "Transitional Issues" below).
# ANEMIA: On admission, hemoglobin and hematocrit were 11.7 and
35.2 respectively. Iron studies were checked and showed a low
iron level at 30; TIBC, ferritin and transferrin were within
normal limits. He was started on an iron supplement. H/H
improved to 12.4/37.2 by the day before discharge.
# HYPERKALEMIA: Potassium was elevated to 5.4 on ___, and ECG
was negative for signs of hyperkalemia. Potassium level
improved to being within normal limits, but on another check was
elevated to 5.2. A low dose of lisinopril had been started this
hospitalization, which was discontinued. He was discharged with
instructions to have a chemistry panel checked on ___ to
monitor potassium.
# HEADACHE: Suspected etiology was initiation of isosorbide
dinitrate, which was soon discontinued. Also considered
temporal arteritis though given history of just starting
nitrate, suspicion for other process was low. Patient denied
vision change or jaw claudication. Headache resolved.
# LEUKOCYTOSIS: Transient elevation in WBC to 14.8, which
resolved by the following day. Suspicion for infection was low.
Urine culture was negative; blood cultures were drawn and have
since returned negative.
# TINEA PEDIS: Patient was started on terbinafine.
CHRONIC DIAGNOSES
# Diabetes type 2: Held home PO medications (metformin and
glimepiride) and replaced with insulin sliding scale. BG was
poorly controlled on insulin sliding scale. Checking of HgbA1c
and titration of diabetes regimen as outpatient is advised.
# HTN: Uptitrated metoprolol tartrate and ultimately discharged
patient on metoprolol succinate 150mg PO daily, increased from
his home dose of 100mg daily. A trial of 200mg daily failed as
pt developed dizziness. Isosorbide dinitrate was also attempted
and resulted in severe headache, so it was stopped. Low-dose
lisinopril was attempted and then stopped due to hyperkalemia.
# HLD: Continued home simvastatin.
# Right shoulder pain: Suspect rotator cuff impingement. He
reported being treated with steroid injections in the past. Pain
was unresponsive to Tylenol, so he was treated with Tramadol
PRN. Right shoulder pain improved.
TRANSITIONAL ISSUES
*Follow-up with Cardiology as an outpatient. Metoprolol
succinate was increased from 100mg daily to 150mg daily (trial
of 200mg daily failed due to dizziness). Advise further
titration as outpatient. Consider addition of amlodipine for
better control of anginal symptoms. Also, patient came in on
aspirin 325mg daily and so was discharged with the same dosage.
Please re-assess and consider decreasing to 81mg daily if
appropriate.
*Follow-up with established orthopedic doctor for management of
right shoulder pain.
*Follow-up with primary care doctor for further diabetes
management. Blood sugar ran high while on insulin sliding scale
this admission.
*Potassium was higher than normal, so trial of lisinopril was
stopped after one dose. Have repeat chemistry checked on ___
at ___'s office to monitor potassium.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Simvastatin 40 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. glimepiride 2 mg Oral daily
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Simvastatin 40 mg PO DAILY
5. 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
6. glimepiride 2 mg ORAL DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Succinate XL 150 mg PO DAILY
RX *metoprolol succinate 100 mg 1.5 tablet extended release 24
hr(s) by mouth daily Disp #*45 Tablet Refills:*0
9. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
10. Terbinafine 1% Cream 1 Appl TP DAILY
11. Outpatient Lab Work
Unstable angina
Lab date: ___
Lab to draw: Sodium, potassium, chloride, bicarbonate, BUN,
creatinine, glucose
Refer to: ___, phone # ___, fax #
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Unstable angina
Secondary: Diabetes Mellitus, hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care at ___
___. As you know, you came to the hospital
due to chest pain, which was not relieved by repeated doses of
nitroglycerin. Your symptoms were concerning for unstable
angina, and you were started on an intravenous blood thinner.
Also, your medications were adjusted to decrease the work of the
heart. You had a bad headache in response to one of those
medications (isosorbide dinitrate), so it was stopped. A
picture of your heart revealed that its pumping function was
normal. An exercise stress test was reassuring against any
blockages of blood flow to the heart muscle.
Please see the attached sheets for changes to your medication
regimen. You were also started on an iron supplement.
Followup Instructions:
___
|
19791816-DS-15
| 19,791,816 | 23,250,735 |
DS
| 15 |
2199-08-30 00:00:00
|
2199-08-30 12:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Aggrenox
Attending: ___
Chief Complaint:
Weakness and numbness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ F w/ PMH b/l SDH, afib on ASA, DLBCL s/p
RCHOP, embolic infarcts, epilepsy who presents with 1 month of
progressive R sided weakness.
Patient states that starting around 1 month ago she began to
notice that her right hand and feet are becoming weaker
progressively. She also reports a tingling feeling in her hands
legs and hip. The tingling feeling is roughly the same
throughout the day and has been getting progressively worse.
She
feels the tingling over her palm and other aspects of her hand,
she does not feel in her fingers is much he also is over the
dorsum of her lower arm up to her elbow level. She reports
tingling in her foot up to the ankle level as well. There are
no
effecting or alleviating factors. She states that she feels
like
she has been getting weaker as well. Her son who lives with her
also has noticed the same. He states that he takes here for
walks in the park and that typically he wheels her on the
wheelchair to the park and then she will walk around the park
before going back. He states that she has had 2 lean on her
wheelchair more often for support than in the past. He also
thinks that she is not able to walk as far as she used to be
able
to she has been holding onto the wall at home occasionally which
is new. She states that she has noticed she has had trouble
covering the same distances as before. She states that
admitting
is harder because of her right hand she states that the right
hand gets tired more easily. She does not have any
incoordination or weakness as initially she has no problems
bending, it is only with continued noting that she has to stop.
She denies any medication changes, falls, head trauma prior to
these changes. She states that she otherwise feels well and
denies any headache, vision changes, double vision, sleep
problems, back pain. No urinary incontinence, bowel
incontinence.
Regarding her seizure history she states that she has had QTCs
in
the past as well as seizures where she could not see anything
and
other subtypes. Her son states that she usually is not aware of
many of her seizure types but that he has not noticed any
seizures for at least one year. She remains on Keppra 500 mg
twice a day as well as phenytoin 50 mg twice a day with no
missed
doses. Her previous seizures have not involved any tingling in
all.
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 numbness, parasthesia. Denies loss of
sensation. Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
DLBCL s/p RCHOP in ___, getting yearly surveillance
b/l SDH ___, did not require surgery
epilepsy (started in ___
embolic infarcts
hernia repair
PAST MEDICAL HISTORY:
- Small bowel lymphoma (dx. ___, s/p chemotherapy last
completed ___
- A-fib (no anticoagulation)
- Epilepsy
- Hypertension
- Hyperlipidemia
- Osteoporosis
- Cardiomyopathy, systolic heart failure
- Moderate to severe MR
- posterior fossa embolic strokes
- Seizures
- Subdural hematoma
- Large B-cell Lymphoma dx ___ s/p 4 cycles of R-CHOP
- Systolic heart failure (EF 30% in ___
PAST SURGICAL HISTORY
- HERNIA REPAIR ___
- ___'S RIGHT FOREHEAD
- RIGHT CATARACT REMOVAL
- GASTRIC RESECTION OF LARGE CELL LYMPHOMAS
- LEFT CATARACT REMOVAL
- LEFT LACUNAR INFARCT
- GASTRIC LARGE CELL LYMPHOMAS
Social History:
___
Family History:
Mother: bone cancer
Father: heart disease, PD
Brother: cancer (unknown type), smoking
Sister: dementia (alive at ___)
Maternal grandfather: cirrhosis
___ grandmother: heart attack
Children:
- daughter with liver transplant (unclear reason)
- daughter with lyme disease
- son with prostate ca s/p resection
- son (deceased) heart disease
Physical Exam:
On admission:
Vitals:
T 98.8 HR 42 BP 135/98 RR 16 Spo2 99% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert. States it is early ___ maybe the ___ or
___, Not sure of year states it is ___ something. States she is
at ___. States that the president is "that jerk.". Able to
state DOWB with some prompting. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt was able to name both high ___ 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 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 finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
voice hypophonic, high pitched
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 ___
R 4 4+ ___ 5 4+ 4 5 5
L 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception throughout. No extinction to DSS.
Hyperesthesia to pinprick over palm, dorsal aspect of hand.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: some dysmetria b/l. no resting tremor
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
=====
On discharge:
Vitals: T97.3 BP 127/77 HR 73 RR 18 O2 sat 96 RA
Neurologic:
-Mental Status: Alert. Oriented to ___, ___. There were no
paraphasic errors. Pt was able to name both high ___ 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 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 finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
voice hypophonic, high pitched
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 ___
R 4+ 5 4+ ___ ___ 4+ 4 5 5
L 5 ___ ___ 5 5 5 5 5 5
-Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception throughout. No extinction to DSS.
Hyperesthesia to pinprick over palm, dorsal aspect of hand.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was mute bilaterally.
-Coordination: some dysmetria b/l. no resting tremor
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
Pertinent Results:
___ 11:52AM BLOOD WBC-6.6 RBC-4.48 Hgb-14.2 Hct-43.4 MCV-97
MCH-31.7 MCHC-32.7 RDW-12.6 RDWSD-45.1 Plt ___
___ 01:48AM BLOOD Neuts-59.6 ___ Monos-15.9*
Eos-2.0 Baso-0.5 Im ___ AbsNeut-5.52 AbsLymp-2.00
AbsMono-1.48* AbsEos-0.19 AbsBaso-0.05
___ 01:47AM BLOOD ALT-16 AST-20 AlkPhos-76 TotBili-0.2
___ 01:47AM BLOOD Lipase-93*
___ 01:47AM BLOOD cTropnT-<0.01
___ 01:47AM BLOOD Phenyto-2.4*
CXR: No definite focal consolidation is seen, however calcified
pleural plaques may limit identification. Possible small right
pleural effusion. Slightly coarsened interstitial markings may
represent mild volume overload. Mild cardiomegaly, similar.
NCHCT:
No acute intracranial process. No evidence of intracranial
hemorrhage.
MRI brain:
No significant interval change compared to prior MR imaging.
No acute intracranial infarct, mass or hemorrhage. No abnormal
enhancing
lesions.
Chronic small bilateral occipital lobe infarcts appear similar
compared to
prior imaging.
Mild white matter microangiopathic changes are fairly stable.
Generalized
cerebral atrophy with ex vacuo dilatation of ventricular system.
MRI C-spine:
No evidence of compromise of the cervical cord in the spinal
canal. No
abnormal cord signal intensity.
No acute vertebral body fractures or dislocations.
Degenerative changes result in multilevel neural foraminal
narrowing most
marked on the right at the C3-4 and left C6-7 levels as
described above.
Brief Hospital Course:
Ms. ___ is a pleasant ___ F w/ PMH b/l SDH, afib on
ASA, DLBCL s/p RCHOP, embolic infarcts, epilepsy who presents
with 1 month of progressive R sided weakness and 10 days of
worsening R sided tingling. The tingling has been happening off
and on for the last ___ years, but this time it is tingling for
longer than usual. On exam, she has a mild UMN pattern weakness
in the 4+ range in both her arm and her leg. There are no
sensory changes on formal testing with pin. Given her stroke
risk factors (ie having afib but only being on ASA given her
bleeding risk in the setting of bilateral SDH), she had an MRI
of her brain looking for a stroke that could have led to her
right sided weakness. There was no change on her MRI from her
prior MRI in ___. Chronic small bilateral occipital lobe
infarcts were noted and similar to that seen in ___ ___s
chronic small vessel changes. She also had an MRI of her
cervical spine, which did not show any abnormal cord signal
intensity. She has some degenerative changes resulting in
multilevel neural foraminal narrowing worse at R C3-C4.
Overall, it is unclear what caused her right sided weakness and
neuropathy. Given that the weakness has been going on for the
last week to 4 weeks, it may have been that she had a small left
sided stroke resulting in a mild right hemiparesis. This would
not be picked up on DWI/ADC if it happened >14 days ago, so
perhaps that could be one explanation. Regardless, she is not
someone who could be safely anticoagulated given her age and
risk of falling in the setting of a history of bilateral
subdural hemorrhages. She will remain on aspirin for the time
being and follow up with outpatient neurology.
Transitional issues:
- EMG as outpatient with neurology
- if symptoms are more bothersome, can start gabapentin 100mg
qhs and uptitrate to 100mg BID in 1 week
- consider increasing losartan given mildly elevated BPs while
in hospital (140s-180/60s-70s)
- cefpodoxime 100mg BID for 5 days for uncomplicated UTI
Medications on Admission:
Dilantin 50 mg BID
keppra 500 mg BID
Digoxin 125 mcg once a day
Losartan 50 mg in the morning 25 mg at night
Metoprolol succinate ER 25 mg daily
Omeprazole 20 mg delayed release once a day
Simvastatin 10 mg at night
Aspirin 81 mg daily
Caltrate 600 milligrams once a day
Zyrtec 10 mg once daily
Latanoprost drops
Brimonidine drops
Discharge Medications:
1. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 5 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice daily Disp
#*10 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q12H
4. Cetirizine 10 mg PO DAILY
5. Digoxin 0.125 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. LevETIRAcetam 500 mg PO Q12H
8. Losartan Potassium 25 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Phenytoin Infatab 50 mg PO BID
12. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Right sided weakness
Neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted because your right arm and leg were weak, and
you were having worsening of the tingling in your hands and
feet. Given your history of subdural hemorrhages, atrial
fibrillation, and prior stroke, we wanted to make sure that you
did not have a new stroke as the cause of your weakness. You had
a MRI of your brain and your cervical spine, which did not show
a new stroke or any problems with your spinal cord. Although we
do not know exactly why your right side is weaker and why the
tingling is worse, it is not because of a new anatomic problem
such as a stroke or a tumor.
As an outpatient, you will need another test called an EMG,
which Dr. ___ order. If the tingling in your hands
worsen, you can also start some gabapentin 100mg at night to see
if that will help.
You were also found to have a urinary tract infection. Please
take cefpodoxime twice per day for an additional 5 days.
It was such a pleasure taking care of you, and we wish you the
best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19791816-DS-9
| 19,791,816 | 25,424,582 |
DS
| 9 |
2195-12-15 00:00:00
|
2195-12-25 22:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Aggrenox
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
intubation
bronchoscopy
lumbar puncture
History of Present Illness:
per Dr. ___ note:
Mrs. ___ is an ___ h/o A-fib/HTN s/p cerebellar stroke and
lymphoma (being treated) now brought from home by her son with
AMS.
She was hospitalized from ___ - ___ after sustaining complex
partial seizures (started left hand) with secondary
generalization. She had several seizures immediately before
admission but responded well to Keppra. She had an MRI and
lumbar puncture but no source of seizure was found. Her hospital
course was prolonged due to respiratory failure ___ volume
overload. She was found to have an LVEF of 30% (previously 35%).
She developed a left pleural effusion which required a
thoracentesis on ___.
Since discharge on ___, she has been staying with one of her
sons. She had a bit of a runny nose over the past couple of days
but no evidence of a substantial infection. She has been taking
all of her medicines and reportedly has not missed any doses of
Keppra. She was last seen well watching television at about 3pm
when her son went to take a nap. When he found her (approx
___, she was still sitting in her chair but was saying
(fluently) that she couldn't see the television because it
wasn't bright enough. Then she knocked over a glass of water
next to her and didn't seem to notice or care. Her son
recognized that her mental status was in flux and called his
brother who arrived ~10 min later, by which time she had to be
helped up (no clear lateralizing weakness). They had to carry
her down the stairs and drove her to the ED.
In the ED, VS were 99.5 167/87 91 18 100% RA. NIHSS was 16,
largely because of her speech deficits precluding various parts
of the examination. Her speech abnormalities aside (she said
only ___ in response to pain), her examination was non-focal.
___ did not show any acute intracranial abnormality.
ROS: Unable to obtain
Past Medical History:
Seizures (recent admission)
Small bowel lymphoma ___ years ago
Large B-cell Lymphoma dx ___ s/p 4 cycles of R-CHOP
Skin cancer
HTN
CHF
AFib
GERD
Cerebellar Stroke
small bowel lymphoma ___ years ago
Large B-cell Lymphoma dx ___ s/p 4 cycles of R-CHOP
Skin cancer
HTN
CHF
AFib
GERD
Cerebellar Stroke
Social History:
___
Family History:
Mother, bone cancer
Physical Exam:
ADMISSION EXAM:
99.5 167/87 91 18 100% RA
GEN: Elderly, thin, NAD
HEENT: No ptosis, NC/AT
NECK: No Kernig, no bruit
CARD: RRR no m/r/g
PULM: CTAB, moving air well at bases b/l
ABD: Soft NT ND NABS
EXTREM: No edema
NEUROLOGIC
- MS: Awake, eyes open without any prompting, attends to both
sides of the room. Does not follow any commands (either verbal
or pantomimed). Says only ___ when pinched in any extremity.
Does not repeat anything.
- CN: PERRL 2 -> 1. No consistent BTT but appears to attend to
stimulus on both sides of the room. Eyes are conjugate and
though does not pursue to command, movements are full
horizontally. Corneals are present. Face is symmetric. Gag is
strong.
- MOTOR/SENSORY: Does not follow any motor commands. Toes down.
Withdraws all extremities equally to pinch.
- REFLEXES: Present, attenuated throughout
- CEREBELLAR: The purposeful movement that is seen in both arms
is without any gross ataxia. The legs withdraw smoothly from
pinch.
- GAIT: Deferred
DISCHARGE EXAM:
Normal neurologic examination.
Pertinent Results:
ADMISSION LABS (___):
7.4 > 13.0/40.1 < 238 MCV 95
Neuts-76.3* Lymphs-13.7* Monos-7.2 Eos-2.5 Baso-0.3
___ PTT-35.0 ___
141 | 104 | 8
--------------< 140
3.0 | 27 | 0.8
ALT-11 AST-25 AlkPhos-75 TotBili-0.6
Albumin-3.4* Calcium-9.1 Phos-1.4*# Mg-1.6
Lipase-61*
Serum/Urine Tox: negative
UA: Bland
Cardiac Labs:
___ 08:15PM BLOOD CK-MB-4 cTropnT-0.13*
___ 03:19AM BLOOD CK-MB-3 cTropnT-0.12*
___ 10:25PM BLOOD cTropnT-0.04*
___ 07:10PM BLOOD cTropnT-0.02*
___ 07:10PM BLOOD Digoxin-1.3
CSF Studies (___)
WBC-1 RBC-0 Polys-20 ___ Macroph-40
TotProt-45 Glucose-68
Cytology: pending
TB PCR: pending
IMAGING:
CTA Head/Neck ___:
FINDINGS:
CTA Head: There is calcification of the carotid siphons but no
stenosis of the intracranial internal carotid arteries. The
anterior and middle cerebral arteries are patent with normal
contrast enhancement and branching pattern. There is a normal
anterior communicating artery complex.
The vertebral and basilar arteries demonstrate normal
enhancement without stenosis or occlusion. The posterior
cerebral arteries have a normal branching pattern. The posterior
communicating arteries are not visualized.
There is no evidence of stenosis, occlusion, aneurysm or
arteriovenous malformation.
The major dural venous sinuses and cerebral veins are patent.
CTA Neck: There is marked calcification of the aortic arch with
moderate calcification of the origins of the major head and neck
vessels.
There is 41% stenosis of the left internal carotid artery by
NASCET criteria.
There is no stenosis of the right internal carotid artery by
NASCET criteria.
The cervical portions of the vertebral arteries demonstrate
normal enhancement. There is no evidence of a stenosis or a
dissection.
There are calcified pleural plaques in the visualized right
hemithorax. There are calcified nodules of both lung apices.
There is a right IJ Port-A-Cath with its tip in the SVC, the
distal extent is not imaged.
IMPRESSION:
1. No stenosis, dissection, or aneurysm greater than 3 mm of
the major intracranial arterial vasculature.
2. Calcific atherosclerosis causing 41% stenosis of the left
internal carotid artery by NASCET criteria. No right internal
carotid artery stenosis by NASCET criteria.
CT Chest ___:
IMPRESSION:
1. Left lower lobe collapse secondary to retained secretions in
the left lower lobe bronchus.
2. Small to moderate nonhemorrhagic left pleural effusion and
small loculated right sided pleural effusion, both decreased in
size.
3. Thickened paraspinal and retroperitoneal soft tissues on the
left worsened since prior study from ___, dedicated
abdominal imaging should be considered for further assessment of
possible lymphoma recurrence.
4. Bilateral calcified pleural plaque, right greater than left,
suggestive of prior asbestos exposure.
5. Improved pulmonary edema, now minimal.
6. Moderate atherosclerosis and fusiform dilation of the
descending aorta.
MRI Head w/wo ___:
IMPRESSION:
1. Two small foci of slow diffusion identified in the right
occipital region as described above, suggesting acute/subacute
ischemic changes, postictal areas of slow diffusion is also a
consideration, there is no evidence of mass effect or
hemorrhagic transformation.
2. No enhancing lesions are identified. Scattered foci of high
signal intensity on T2 and FLAIR sequences history in the
subcortical white matter are nonspecific and may reflect changes
due to small vessel disease
3. Mild mucosal thickening is identified in the mastoid air
cells bilaterally, new since the prior examination.
EEG:
___:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of an abnormal background consisting of burst
suppression in the beginning portion of the recording. This does
improve shortly by 4 a.m. after which the background consists of
a more continuous 4 Hz activity with bilateral frontally
predominant delta activity. However, the burst suppression
pattern resumes by 06:20 until the end of the recording. These
findings are indicative of a severe encephalopathy.
Additionally, right frontal and bilateral frontal sharp and slow
wave discharges are seen infrequently indicative of potentially
epileptogenic cortex in these regions. The generalized
superimposed beta activity is likely medication effect from
agents such as benzodiazepines or barbiturates. There are no
electrographic seizures.
___:
IMPRESSION: This 24 hour EEG telemetry is consistently with a
moderate encephalopathy of toxic, metabolic, or anoxic etiology.
The burst suppression pattern previously seen has improved,
though there are still periods of suppression as well as bursts
of bifrontally predominant rhythmic delta activity which does
not evolve. Bifrontal discharges are again seen, indicative of
epileptogenic cortex in these regions. No definite
electrographic seizures were recorded.
___:
IMPRESSION: This 24 hour EEG telemetry is consistent with a mild
encephalopathy of toxic, metabolic, or anoxic etiology. The
burst suppression pattern previously seen has resolved, with a
return to near normal background in the latter half of the
record, as well as the presence of near normal sleep
architecture. Rare left centroparietal discharges are seen at
the very beginning of the record, indicative of epileptogenic
cortex in these regions, but then dissipate. No electrographic
seizures were recorded. Overall, the record appears
significantly improved from the prior study.
Brief Hospital Course:
Interval Events:
On repeat examination (after exam documented above), she was
found to be unresponsive with eyes deviated left, left-beating
nystagmus, and subtle left head turn. NCSE was suspected and she
was given LZP immediately. Nystagmus continued intermittently
despite 2mg LZP and she was given another 2mg after ___ minutes.
She required intubation shortly thereafter because of airway
protection (dropping SaO2 to ___, secretional) and was started
on propofol which also had the effect of breaking her status
(which by that point had progressed to hand shaking). Home
Keppra dose was increased from 1000 mg BID to ___ BID ___
given in ED) with proposal.
Hospital Course:
___ was admitted to the ICU in guarded condition.
EEG monitoring was initiated after receiving lorazepam,
levetiracetam and propofol; the tracing showed burst suppression
with no evidence of electrographic seizures. She remained
electrographically and clinically free of seizures. A repeat
workup to determine the etiology of her seizures was conducted
and was notable for MRI with two small (3-mm) foci of diffusion
restriction consistent with stroke; cytology was negative and TB
PCR is pending. Her strokes were thought to be secondary to her
known atrial fibrillation, with minimal clinical significance.
No new etiology of her seizures was identified and the most
likely cause remains underlying small vessel disease with
residual abnormalities characterized on MRI.
Her hospital course was complicated by a failure to wean from
the ventilator. Bronchoscopy was performed and secretions were
concerning for pneumonia. Bronchoalveolar lavage was performed
and cultures were positive for MRSA. She underwent a course of
treatment for MRSA pneumonia. Her failure to wean was attributed
to her pneumonia as well as scarring given her history of
pulmonary tuberculosis. With treatment of her pneumonia she was
able to wean from the ventilator. Her oxygen requirement
resolved.
On admission, her troponins were mildly elevated but plateaued
at 0.14. This was attributed to strain in the context of seizure
and acute medical illness. No intervention was performed. For
her atrial fibrillation, her coumadin was held in anticipation
of lumbar puncture and she was started on a heparin drip. Her
anticogaulation was subsequently switched to fondiparinux given
concern for heparin-induced thrombocytopenia. HIT antibodies
were sent and were negative. Her heparin was restarted and her
platelet count recovered without intervention. Her coumadin was
restarted. She was transitioned to a lovenox bridge in
preparation for discharge.
She was evaluated by physical therapy who saw that she was
decondittioned and recommended rehabilitation versus home with
24 hour supervision. The patient and her family strongly
preferred to go home with 24 hour rehabilitation and home
physical therapy.
CT chest showed an incidental finding of soft tissue thickening
in the abdomen, concerning for possible recurrence of GI
lymphoma. Her recent lymphoma recurrence had been located in the
left upper quadrant of the abdomen, per discussion with her
oncologist's fellow, the known location of cancer was consistent
with these new findings. She should follow up with her
oncologist on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 12.5 mg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Caltrate 600 (calcium carbonate) 600 mg (1,500 mg) oral daily
5. LeVETiracetam 1000 mg PO BID
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Magnesium Oxide 500 mg PO DAILY
8. Simvastatin 10 mg PO DAILY
9. Lisinopril 20 mg PO DAILY
10. Warfarin 2 mg PO DAILY16
11. latanoprost 0.005 % ophthalmic QHS
12. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES QHS
3. LeVETiracetam Oral Solution 1500 mg PO BID
RX *levetiracetam 500 mg 3 tabs by mouth twice a day Disp #*180
Tablet Refills:*1
4. Lisinopril 20 mg PO DAILY
5. Simvastatin 10 mg PO DAILY
6. Warfarin 2 mg PO DAILY16
7. Enoxaparin Sodium 50 mg SC BID
Please take until your INR is therapeutic.
RX *enoxaparin 60 mg/0.6 mL 50 mg SC twice a day Disp #*14
Syringe Refills:*1
8. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*8 Tablet Refills:*0
9. Caltrate 600 (calcium carbonate) 600 mg (1,500 mg) oral daily
10. Docusate Sodium 100 mg PO DAILY:PRN constipation
11. latanoprost 0.005 % ophthalmic QHS
12. Magnesium Oxide 500 mg PO DAILY
13. Metoprolol Succinate XL 12.5 mg PO DAILY
14. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Seizure
MRSA Pneumonia
Klebsiella UTI
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ were admitted to the hospital because ___ were having a
seizure. We increased the dose of your anti-seizure medication,
Keppra, and ___ did not have any more seizures. While ___ were
here we did more tests to investigate the cause of your
seizures, including a lumbar puncture and an MRI of your brain.
There was no sign of an infection of your nervous system. Your
MRI did show two very small strokes which we believe were due to
your atrial fibrillation. We do not think that this was the
cause of your seizures. It is important that ___ continue to
take the coumadin to reduce the likelihood of any further
strokes.
While ___ were here ___ were found to have a pneumonia. ___ had
a bronchoscopy to look at your lungs. We treated ___ with
antibiotics for your pneumonia. This pneumonia made it difficult
for ___ to come off of the ventilator.
___ are currently receiving antibiotics for a urinary tract
infection. ___ will complete four more days of treatment.
___ were evaluated by physical therapy who noticed that ___ were
very weak from your stay in the hospital. We recommended that
___ continue to receive physical therapy, and that ___ will need
24 hour assistance while ___ are getting back on your feet. We
will arrange for home physical therapy.
While ___ were in the hospital, ___ missed an appointment with
your oncologist. We have made an appointment for ___ to follow
up with your oncologist. We did not specifically investigate
your lymphoma, but uring your chest CT scans we saw evidence of
your prior lymphoma, and it is important that ___ continue to
follow up to evaluate for any progression.
Finally, we have restarted your coumadin for your atrial
fibrillation. Your INR is not at goal. We have been giving ___
lovenox while your INR rises. ___ should follow up with your
PCP's office this week to find your INR and get guidance
regarding your warfarin dosing.
It has been a pleasure taking care of ___.
Sincerely
- The ___ Deaconess ___ Department
Followup Instructions:
___
|
19791899-DS-21
| 19,791,899 | 29,547,197 |
DS
| 21 |
2173-10-09 00:00:00
|
2173-10-10 22:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pyelonephritis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is reliable historian
___ Female presents with 1 day dizziness, low abdominal
discomfort, dysuria, polyuria. Awoke at 2Am with nausea/vomting
x 1 and lower abdominal discomfort without fever, chills,
sweats. She went to ED and had persistent lower anterior
abdominal pain and costovertebral angle tenderness, leukocytosis
and CT abdomen suggestive of acute pyelnonephritis. In the ER
she was given ibuprofen with good effect, and a dose of
Ciprofloxacin 500mg orally. She had no fever, but decision was
to observe her in hospital given ongoing nausea and vomiting.
ROS: toherwise (-) in 12 pt detail review
Past Medical History:
Ingrown toenail
No prior UTIs
Social History:
___
Family History:
Mo - DM2
Fa - deceased pancreatic/prostate cancer at ___
Physical Exam:
98.1, ___, 61, 18, 100% RA "pain = 0-1/10"
Well in NAD
Anicteric, OP clear and moist, neck supple, no ___ CTA bilat
Cor RRR, nl S1, S2 no MRG
Abd (+)suprapubic tenderness, (+) bilat CVA tenderness, no HSM,
no masses
EXT no C/C/edema
SKIN no rashes lesions
NEURO fluent speech, nl cognition, non-focal exam throughout
Pertinent Results:
___ 04:20AM WBC-16.2* RBC-4.50 HGB-12.9 HCT-40.6 MCV-90
MCH-28.7 MCHC-31.8 RDW-11.7
___ 04:20AM NEUTS-82.2* LYMPHS-12.2* MONOS-4.6 EOS-0.8
BASOS-0.2
___ 04:20AM PLT COUNT-179
___ 04:20AM GLUCOSE-106* UREA N-14 CREAT-1.3* SODIUM-137
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
___ 05:25AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
___ 05:25AM URINE RBC-3* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 05:25AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:25AM URINE UCG-NEGATIVE
___ 5:25 am URINE Site: NOT SPECIFIED
ADDED TO ___ ON ___ AT 14:56.
URINE CULTURE (Pending):
___ PELVIS, NON-OBSTETRIC Clip # ___
Reason: torsion vs ovarian cyst
UNDERLYING MEDICAL CONDITION:
___ year old woman with acute onset suprapubic cramping,
nausea, vomiting
REASON FOR THIS EXAMINATION:
torsion vs ovarian cyst
Final Report
HISTORY: Acute onset suprapubic cramping and nausea.
COMPARISON: None.
LMP: ___.
FINDINGS: Transabdominal pelvic sonography was performed; the
internal
examination was deferred. The uterus measures 8.2 x 2.8 x 5.1
cm. The
endometrium is normal measuring 4 mm. The ovaries are normal
bilaterally with
preserved arterial and venous waveforms. No free fluid is seen.
IMPRESSION: Normal examination.
___ 11:___BD & PELVIS WITH CONTRAST Clip # ___
Reason: eval for appy
Contrast: OMNIPAQUE Amt: 130
UNDERLYING MEDICAL CONDITION:
+PO contrast; History: ___ with RLQ pain and tenderness,
leukocytosis. thin,
needs PO contrast
REASON FOR THIS EXAMINATION:
eval for appy
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: JRke MON ___ 2:18 ___
Acute pyelonephritis.
Wet Read Audit # 1
Final Report
HISTORY: Right lower quadrant pain and tenderness
COMPARISON: None available
TECHNIQUE: Axial helical MDCT images were obtained from the
lung bases to the pubic symphysis after administration of IV and
oral contrast. Coronal and sagittal reformations were
generated.
DLP: 407.31 mGy-cm
FINDINGS: The lung bases are clear and the visualized heart and
pericardium are unremarkable.
CT ABDOMEN: The liver enhances homogeneously, without focal
lesions or
intrahepatic biliary duct dilatation. The gallbladder is
unremarkable and the portal vein is patent. The pancreas,
spleen, adrenal glands are within normal limits.
Diffuse bilateral striated nephrograms are present indicative of
acute severe pyelonephritis. There is no discrete abscess,
however more confluent hypodensity in the right renal upper
(601b: 35) and inter-pole regions could represent phlegmon.
There is no hydronephrosis or perinephric abscess. No
nephrolithiasis is identified.
The small and large bowel are normal, without evidence of wall
thickening or obstruction. The appendix is visualized (601b:20)
and is normal. The aorta and its main branches are patent and
nonaneurysmal. There is no mesenteric or retroperitoneal lymph
node enlargement by CT size criteria. There is no ascites,
abdominal free air or abdominal wall hernia.
CT PELVIS: The urinary bladder and ureters are unremarkable.
There is no pelvic wall or inguinal lymphadenopathy. No pelvic
free fluid is observed.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions
concerning for
malignancy.
IMPRESSION: Acute severe bilateral pyelonephritis. No abscess.
Urine culture
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
___ F with no prior PMHx presents with 1 day suprapubic
discomfort (likely cystitis), polyuria, abd pain, N/V and CVA
tenderness (with ascending pyeloonephritis) with CT findings
suggestive of bilateral pylenopnephritis.
#Pyelonephritis:
-Treated with ciprofloxacin during her hospitalization, and her
symptoms of flank pain improved, as did her nausea. Although
final culture grew out 3 species of bacteria, ___ d/w ___
medical director continuation of antibiotics for now.
Discharged with oral anti-emetics, tylenol and oxycodone prn for
flank pain. She also had pain in her pelvis - ? from cystitis
or menstruation. Prescribed three days of pyridium
# ___: (Cr = 1.3, likely higher than baseline given weight, age,
build)
Creatinine improved to 1.0 on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Orsythia (levonorgestrel-ethinyl estrad) 0.1-20 mg-mcg oral
daily
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*26 Tablet Refills:*0
2. Phenazopyridine 100 mg PO TID Duration: 3 Days
It may turn your urine orange. You can only take this for three
days
RX *phenazopyridine [Uristat] 95 mg 1 tablet(s) by mouth three
times a day Disp #*9 Tablet Refills:*0
3. Orsythia (levonorgestrel-ethinyl estrad) 0.1-20 mg-mcg oral
daily
4. Promethazine 12.5 mg PO Q6H:PRN nausea
RX *promethazine 12.5 mg 1 tablet(s) by mouth three times a day
Disp #*10 Tablet Refills:*0
5. Acetaminophen w/Codeine ___ TAB PO Q6H:PRN pain
It may make you drowsy
RX *acetaminophen-codeine [Tylenol-Codeine #3] 300 mg-30 mg 1
tablet(s) by mouth every 6 hours as needed for pain Disp #*10
Tablet Refills:*0
RX *acetaminophen-codeine [Tylenol-Codeine #3] 300 mg-30 mg ___
tablet(s) by mouth every 6 hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ because of pain in your abdomen and
nausea and vomiting. You were diagnosed with pyelonephritis
(infection of the kidneys that occurs because the urine is
infected). Please finish a 14 day course of antibiotics for
this. Also, you may take the medication pyridium for up to
three days to help with symptoms of bladder spasm. I have also
given you a prescription for medication for nausea in case you
need something. You may also take tylenol with codeine for your
back pain from your kidney infection. Your antibiotics reduce
the efficacy of your birth control pills in their ability to
prevent pregnancy; if you are sexually active for the rest of
this pack of pills make sure that your partner uses a condom.
Followup Instructions:
___
|
19792031-DS-2
| 19,792,031 | 26,194,800 |
DS
| 2 |
2140-01-08 00:00:00
|
2140-01-08 14:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
LLE pain, redness, swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo man with HTN, atrial fibrillation on
warfarin, presenting with worsening cellulitis.
He states his symotoms first began 6 days ago. He had noted
increased bilateral swelling but that his lefty leg was much
larger than his right. His left leg was also very hot, red, and
painful to touch. He was seen by his PCP on ___ and was
prescribed Keflex for cellulitis. He took this and felt the pain
was improving but that the redness was worsening prompting him
to
come to the ED.
Of note he had one prior episode like this with bilateral leg
swelling and infection ___ years ago. At that time he was
admitted
to medicine for several days of IV antibiotics.
In the ED vitals were T97.6, HR 86, BP 127/87, RR18, O2Sat 99%
RA. His exam was c/w cellulitis and he was given vancomycin. He
had ___ which was negative for DVT. He was admitted to
medicine.
On arrival to the floor he is feeling well with minimal pain to
the left lower extremity. He denies any fevers, chills, night
sweats. No sick contacts, no trauma to the leg.
14 point ROS otherwise negative
Past Medical History:
Hypertension
Atrial Fibrillation
Social History:
___
Family History:
Family History: father with CAD
Physical Exam:
Admission exam
VS: ___ Temp: 98.0 PO BP: 162/97 HR: 89 RR: 18 O2
sat:
99% O2 delivery: RA General Appearance: pleasant, comfortable,
no
acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
Extremities: 2+ bilateral pitting edema with large area or
redness on the left shin very hot to touch, outlined with
marker.
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
Pertinent Results:
___ 07:35AM BLOOD WBC-5.3 RBC-4.55* Hgb-13.9 Hct-42.6
MCV-94 MCH-30.5 MCHC-32.6 RDW-13.2 RDWSD-45.5 Plt ___
___ 07:05AM BLOOD WBC-5.1 RBC-4.46* Hgb-13.6* Hct-41.9
MCV-94 MCH-30.5 MCHC-32.5 RDW-13.3 RDWSD-45.6 Plt ___
___ 06:19AM BLOOD WBC-4.8 RBC-4.33* Hgb-13.4* Hct-40.9
MCV-95 MCH-30.9 MCHC-32.8 RDW-13.3 RDWSD-45.9 Plt ___
___ 01:15PM BLOOD WBC-6.1 RBC-4.67 Hgb-14.4 Hct-43.1 MCV-92
MCH-30.8 MCHC-33.4 RDW-13.3 RDWSD-45.2 Plt ___
___ 01:15PM BLOOD Neuts-53.3 ___ Monos-10.4 Eos-2.3
Baso-0.3 Im ___ AbsNeut-3.27 AbsLymp-2.02 AbsMono-0.64
AbsEos-0.14 AbsBaso-0.02
___ 07:35AM BLOOD ___ PTT-37.8* ___
___ 07:05AM BLOOD ___
___ 06:19AM BLOOD ___
___ 01:15PM BLOOD ___ PTT-37.2* ___
___ 07:35AM BLOOD Glucose-99 UreaN-19 Creat-0.8 Na-144
K-4.6 Cl-104 HCO3-25 AnGap-15
___ 07:05AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-142
K-4.5 Cl-103 HCO3-26 AnGap-13
___ 06:19AM BLOOD Glucose-83 UreaN-19 Creat-0.8 Na-142
K-4.6 Cl-101 HCO3-29 AnGap-12
___ 06:19AM BLOOD proBNP-951*
bcx pending
___:
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
Brief Hospital Course:
Mr. ___ is a ___ yo man with HTN, atrial fibrillation on
warfarin, presented with worsening LLE cellulitis.
#LLE Cellulitis
#bilateral lower extremity edema
Presenting with spreading erythema despite oral antibiotics as
an outpt.
(Keflex). Much improved with IV vancomycin since ___. DC'd IV
vanco ___ and started PO doxycycline with ongoing clinical
improvement. Plan to complete a total of 7 days of antibiotic
therapy. Avoided Bactrim due to use ___ and potential hyperk.
___ negative.
#Atrial Fibrillation -Continued metoprolol. Continued warfarin.
Monitored INR daily. Got 7.5mg ___ and 10mg ___ and ___. INR 3
on ___ and instructed pt to hold his dose ___ and resume ___
___. Instructed to call his PCP for ___ and to have INR
rechecked ___ or ___.
#Hypertension -Losartan and Lasix continued.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Warfarin 10 mg PO DAILY16
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*8 Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
3. Losartan Potassium 50 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. HELD- Warfarin 7.5 mg PO DAILY16 This medication was held.
Do not restart Warfarin until ___
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for a skin infection of the leg called
cellulitis. You were given IV antibiotics for a few days with
improvement. Then, you were transitioned to pill antibiotics
(doxycycline) which you should take for a few more days to
complete a ___ue to your antibiotics, your INR may be higher and more
irregular. Due to this, would not take any warfarin on ___ and
then resume taking 7.5mg a day for ___ and have your INR
checked on ___ or ___ at your PCP's office. Then, Dr ___
adjust your dose further from there.
Thank you for allowing us to participate in your care,
Your ___ team
Followup Instructions:
___
|
19792113-DS-23
| 19,792,113 | 22,914,170 |
DS
| 23 |
2157-09-18 00:00:00
|
2157-09-18 16:17:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
inability to walk
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
The pt is a ___ year-old right-handed man with history of
cervical and lumbar spondylosis who presents today after his
legs
went out on him at home. He and his daughter report that he had
gotten out of bed using his walker, with his home health aid
behind, took about 7 steps, then told his aid that his knees
were
going out, so his aid helped lower him to the floor slowly. As
he
was unable to get up, his aid then called EMS. His daughter
reports that she had seen him yesterday evening and although he
spent most the time sitting in a chair, she did see him ambulate
with his walker for a short distance. His walking appeared
similar to his recent baseline, with slow, short, low steps,
leaning heavily on the walker.
His daughter only came up from ___ a few days ago, when
she was called that the patient had come to the ED ___. Prior
to this, she had last seen her father in ___. This ___,
her father was at home in his independent living, when he fell
on
his right hip. He was unable to get up and staff found him when
he failed to show up for dinner. EMS was called, who helped to
get him up, but then left when he appeared to be ok. However,
EMS
returned a few hours later, when he was unable to ambulate well.
They brought him here to the ED. There were no acute injuries
found. ___ evaluated him and suggested 24 hour supervision, which
is why he now has a home health aid. He returned home ___
with
the supervision. When his daughter saw him, he complained of
pain
in the right buttocks. They talked to his PCP, who sent him for
outpatient MR brain and MR ___ spine and pelvis, which was
done at ___. His daughter reports that overall his
gait appeared the same to her. His thinking and cognitive
processes also appeared to be stable in her opinion. She did
note
that he has been drinking and eating slightly less over the past
few days, which may be related to being off schedule due to the
healthcare visits.
Currently in the ED, the patient's primary complaint currently
is
right shoulder pain. He also complains occasionally of right
hip/buttock pain, particularly with movement of the right leg.
He and his daughter deny any new falls or injuries since his
fall
on ___.
On neuro ROS, the pt reports bladder incontinence (per PMH) and
gait difficulties. He 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 incontinence or retention.
On general review of systems, the pt reports arthritis pain at
right shoulder and mild right hip pain. He denies recent fever
or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies rash.
Past Medical History:
PMH:
-mitral valve prolapse with moderate MR
-___ of bladder and prostate CA
-urinary incontinence - due to lack of inhibition per
cystometogram, trialed on oxybutinin, stopped after 1 dose due
to
dizziness
-arthritis - particularly on right shoulder
- hx of BPPV
- cervical and lumbar spondylosis and stenosis
Social History:
Social Hx:
Lives alone in independent living that provides cleaning and ___
meals per day, up until fall this past ___, since which he
has
had 24 hr home health aid. Per daughter, he does all his
finances
himself. He is able to prepare a small meal himself and do all
ADLs himself. He has been walking with a rolling walker for
about
___ year due to arthritis pain. His wife passed away a few years
ago. He has 2 kids, a daughter (who is HCP/power of attorney)
who
lives in ___ and a son who lives in ___. Prior to
retirement,
he worked in ___. He completed
college. He has a remote history of tobacco over ___ years ago.
He
has not drank alcohol in the past ___ years, never had significant
alcohol use. No drugs.
Family History:
No history of CAD/CVD/DM
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.3 P: 100 BP: 135/69 RR: 20 SaO2: 92% RA
General: Awake, mostly cooperative, c/o pain in right shoulder
HEENT: NC/AT, no scleral icterus, MMM, clear oropharynx
Neck: Supple, no tenderness on palpation of paraspinal cervical
musculature
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, ___ systolic murmur over apex
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Tenderness on palpation of the right shoulder and
hip with limited ROM due to pain.
Skin: no rashes or lesions
Neurologic:
-Mental Status: Alert, oriented x 2 (person and date, not
place).
Inattention, only able to complete 2 serial 7's subtraction,
with
repeated prompting. On verbal Trails B, failed to alternate and
replied ___. Grasp reflex present bilaterally. Visual
frontal release sign. Provides a very vague history. 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 ___ objects with
5 trials, and recall 3 at 5 minutes spontaneously, ___ with
cueing. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Right pupil is 0.5mm larger than left, briskly reactive.
Left pupil is irregular, reactive. VFF to confrontation.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric, mild
bilateral ptosis.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline and has symmetric strengh.
-Motor: Strength exam limited by pain, particularly in the right
shoulder and hip. Increased tone in the bilateral lower
extremities. No adventitious movements.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R - ___ ___ 4 5 5 5 5 5
-Sensory: Distal loss of pin/cold in bilateral LEs to knees, as
well as bilateral hands in stocking/glove distribution.
Proprioception decreased at great toes b/l.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2 ___
R 2+ 2 ___
Plantar response was extensor bilaterally.
-Coordination: No dysmetria on FNF on left, unable to complete
with right arm. Difficulty cooperating with HKS.
-Gait: Delayed initiation. When attempting gait exam, it took 10
minutes to get the patient to move to the side of the bed, due
both to inattention and right shoulder and hip pain. With 2
person assist, we were able to get him to sit at the side of the
bed, but he could not sit unassisted. He attempted to stand with
the 2 person assist, but he was unable to stand completely
upright and continued to fall back towards the bed.
Discharge exam:
General: WDWN in no distress
HEENT: wearing cervical collar, MMM
CV: RRR, no murmurs
Lungs: CTAB, breathing comfortably
Abdomen: soft, NT, ND
Extremities: WWP, 2+ distal pulses, no swelling, erythema,
tenderness
Neuro:
Mental status: alert, oriented x3, speech fluent, no dysarthria,
disinhibited, follows commands
CN: EOMF, face symmetric, tongue midline
Motor: Normal bulk and tone. Can lift both arms antigravity and
against some resistance, right arm limited secondary to right
shoulder pain. Can lift both legs antigravity and against some
resistance, right leg limited secondary to right hip pain.
Gait: Can stand up with assistance. Gait with assistance is
suffling very small steps, unsteady, slightly dragging right
foot.
Coordination: FNF intact bilaterally.
Pertinent Results:
___ 08:50PM GLUCOSE-104* UREA N-28* CREAT-1.0 SODIUM-134
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-20* ANION GAP-17
___ 08:50PM CK(CPK)-462*
___ 08:50PM CALCIUM-9.4 PHOSPHATE-3.1 MAGNESIUM-2.3
___ 08:50PM VIT B12-244 FOLATE-17.4
___ 08:50PM TSH-2.5
___ 08:50PM WBC-11.2* RBC-4.83 HGB-13.8* HCT-42.9 MCV-89
MCH-28.6 MCHC-32.3 RDW-13.7
___ 08:50PM PLT COUNT-229
___ 11:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:40AM URINE RBC-0 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
___ 10:14AM LACTATE-1.9
___ 10:00AM GLUCOSE-114* UREA N-29* CREAT-1.1 SODIUM-135
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
___ 10:00AM ALT(SGPT)-36 AST(SGOT)-64* ALK PHOS-76 TOT
BILI-1.1
___ 10:00AM ALBUMIN-4.4 CALCIUM-10.0 PHOSPHATE-2.4*
MAGNESIUM-2.1
___ 10:00AM WBC-11.6* RBC-4.97 HGB-14.3 HCT-44.0 MCV-88
MCH-28.8 MCHC-32.6 RDW-13.6
___ 10:00AM NEUTS-88.0* LYMPHS-6.4* MONOS-4.8 EOS-0.6
BASOS-0.3
___ 10:00AM PLT COUNT-203
Glenohumeral X-ray Right shoulder (___): No acute fracture
or dislocation. Severe osteoarthritis of the right glenohumeral
joint.
NCHCT (___): Examination is limited by motion artifact.
There is no hemorrhage, mass effect or midline shift, edema, or
infarct. There is global cortical volume loss with dilatation of
the lateral ventricles, similar to the prior study from ___.
The basal cisterns are patent. Mild periventricular white
matter hypodensities are nonspecific but likely due to chronic
small vessel ischemic disease.
Healed nasal bone fracture is noted. The paranasal sinuses,
mastoid air
cells, and middle ear cavities are clear. The orbits are
unremarkable.
Vascular calcifications are noted at the carotid siphons
bilaterally.
MR cervical spine (___): 1. Multilevel degenerative changes
throughout the cervical spine appear relatively stable since the
prior study dated ___, causing moderate to severe
spinal canal stenosis.
2. No focal or diffuse lesions are visualized throughout the
cervical spine to indicate spinal cord edema or cord expansion.
Brief Hospital Course:
___ yo RH man with history of cervical and lumbar spondylosis who
presents today after his legs went out on him at home. His other
prime complaint currently is right shoulder and hip pain. He had
imaging as an outpatient a few days ago that suggested possible
NPH. Labwork shows mildly increased BUN and a WBC that is
slightly higher than baseline, possibly due to
hemoconcentration. Hip and shoulder Xrays show no acute
findings.
Overall, the patient has a multifactorial gait disorder, due to
arthritis, cervical and lumbar stenosis causing myelopathy,
sensory loss, and possibly communicating hydrocephalus. It is
unclear what has acutely exacerbated his arthritis pain, and
also worsened his gait, as his daughter reports that he was able
to ambulate with his walker yesterday and did not report as much
pain. We will hydrate him and re-evaluate to see if this
improves his acute symptoms. This will allow better evaluation
of his gait and allow for consideration of further evaluation
for NPH.
NEURO: Obtained MR ___ which showed multilevel degenerative
changes throughout the cervical spine appear relatively stable
since the prior study dated ___, causing moderate to
severe spinal canal stenosis. Placed on soft cerval collar.
Given acetaminophen and hydration to help with arthritis pain
and
decreased po intake. Physical therapy evaluated patient and felt
he would benefit from discharge to acute rehab for strengthening
and gait training.
FEN/GI: Poor nutritional status and elevated BUN/Cr on admission
so gave fluid bolus and started on IVF at 100mL/hr. With IV
hydration, BUN and creatinine improved.
CARDS: Patient with paroxysmal afib. Continued home doses of
atenolol, clopidogrel, aspirin and atorvastatin. Patient
initially with elevated CK and CKMB but hemolyzed. Troponins
checked which were normal. EKG was unchanged from prior with
RBBB. CK and CKMB likely elevated from mild rhabdomyolisis
status post fall. these trended down nicely during
hospiatlization and were normal on discharge.
Transitional Issues:
-To follow up with PCP, ___ continued care
-Recommend soft cervical collar while he sleeps
-To take Tylenol prn pain and Tramadol prn pain not helped by
Tylenol
-Will need to be evaluated for best assistive device for gait,
previously used Rollator
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Aspirin 325 mg PO DAILY
5. Calcium Carbonate 500 mg PO TID:PRN indigestion
6. Vitamin D 1000 UNIT PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Acetaminophen 650 mg PO Q8H:PRN pain
6. Docusate Sodium 100 mg PO BID
7. Senna 17.2 mg PO HS
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain refractory to tylenol
9. Calcium Carbonate 500 mg PO TID:PRN indigestion
10. Fish Oil (Omega 3) 1000 mg PO BID
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cervical spine stenosis
Ventriculomegaly
Arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted for difficulty walking with your legs giving
out and new right shoulder pain. Xray of your shoulder was
negative for fracture. CT of your head showed enlarged
ventricles which in some cases, can contribute to difficulty
walking. We also performed a cervical spine MRI which showed
degenerative changes of your spine with some stenosis. We placed
you on a soft cervical collar to protect your cervical cord.
Physical therapy evaluated you and recommended rehab to regain
some of your strength.
Please take your medications. Please follow-up with your Primary
care Provider, Dr. ___. He may refer you to Neurologist at
___ as needed.
It was a pleasure taking care of you.
Followup Instructions:
___
|
19792113-DS-25
| 19,792,113 | 29,486,768 |
DS
| 25 |
2159-06-15 00:00:00
|
2159-06-26 22:47:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Facial droop
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ M w PMHx of HTN, HLD, and pAfib on
ASA who presents to ___ ED after ___ noticed left facial
droop.
Mr. ___ states that when his ___ came to visit this
morning
she reported that Mr. ___ left face was drooping. She
also said that his blood pressure was low, he thinks around sBP
~110, and that he was lethargic ("I had just woken up!"). The
___
tried to get in contact with his doctor, but was unable to. They
subsequently called EMS and brought him to the ___ ED. Of
note,
the ___ who called EMS had seen Mr. ___ several times
before.
In the ED, Mr. ___ reports that he "feels fine" and that
his "health is perfect." His nephew is at the bedside and
reports
that his uncle seems at baseline to him. When a mild L facial
droop is pointed out, the nephew cannot recall if it has always
been there. There are no old pictures to look at for reference.
On ROS, he broadly denies any systemic symptoms or recent
illness. He denies HA, CP, abdominal pain. He denies confusion,
difficulty speaking, weakness, numbness, new bowel / bladder
issues. He does complain of persistent OA pain, "from my toes to
my fingers."
Past Medical History:
- h/o prostate Ca
- transitional cell Ca vs papilloma of the bladder
- pAfib
- mitral valve prolapse / MR
- OA
- HLD
Social History:
___
Family History:
NC
Physical Exam:
============================
ADMISSION PHYSICAL EXAM
============================
VS T98.9 HR95 BP113/73 RR18 Sat98%RA
GEN - elderly M, joking and sarcastic, NAD
HEENT - NC/AT, MMM
NECK - age appropriate restricted motion
CV - RRR
RESP - normal WOB
ABD - soft, NT, ND
EXTR - WWP
NEUROLOGICAL EXAMINATION
MS - Brightly awake, alert, oriented x3. Speech is fluent with
normal prosody and no paraphasias. Content demonstrates intact
naming and comprehension. No evidence of apraxia or neglect.
CN - Decreased visual acuity out of left eye (chronic), can
appreciate only light and movement.
MOTOR - Complicated by OA pain. RUE could be mildly weaker,
though he does state that pain is worse on this side.
SENSORY - Intact to LT and PP throughout.
REFLEXES - 1+ throughout, absent at ankles; toes are tonically
up
going bilaterally
COORD - No evidence of appendicular ataxia
GAIT - Deferred
.
==============================
DISCHARGE PHYSICAL EXAM
==============================
.
General - NAD, appears younger than stated age
MS - Alert, Oriented to month, year, date, ___.
CN - Left nasolabial fold flattening, denies any chagne from
baseline. Mild pupil assymetry and decreased visual acuity in
left eye (bsl). L ptosis, likely senile in addition to
compensatory given decreased visual acuity in left eye. Tongue
midline.
Motor - ___ bilaterally in Deltoid, biceps, triceps, ECR, IO,
Quad, TA.
Sensory - LT symmetric in all four extremities
Coordination - No dysmetria.
Pertinent Results:
===========================
PERTINENT LABS
===========================
___ 02:33PM BLOOD WBC-9.9 RBC-4.31* Hgb-12.0* Hct-37.8*
MCV-88 MCH-27.8 MCHC-31.7* RDW-14.6 RDWSD-46.6* Plt ___
___ 02:33PM BLOOD Neuts-68.8 ___ Monos-8.4 Eos-2.7
Baso-0.5 Im ___ AbsNeut-6.79* AbsLymp-1.88 AbsMono-0.83*
AbsEos-0.27 AbsBaso-0.05
___ 08:18AM BLOOD ___ PTT-32.2 ___
___ 08:18AM BLOOD Glucose-89 UreaN-16 Creat-0.9 Na-136
K-4.8 Cl-104 HCO3-25 AnGap-12
___ 08:18AM BLOOD ALT-22 AST-28 LD(LDH)-139 AlkPhos-65
TotBili-0.7
___ 08:18AM BLOOD Albumin-3.5 Calcium-10.0 Phos-2.5* Mg-2.0
Cholest-110
___ 02:38PM BLOOD %HbA1c-5.8 eAG-120
___ 08:18AM BLOOD Triglyc-126 HDL-25 CHOL/HD-4.4 LDLcalc-60
___ 02:33PM BLOOD TSH-2.1
___ 02:38PM BLOOD Lactate-2.2* K-4.6
___ 04:08AM URINE Color-Yellow Appear-Hazy Sp ___
___ 04:08AM URINE Blood-TR Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 04:08AM URINE RBC-5* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
.
========================
STUDIES
========================
CTA HEAD AND NECK ___
1. No flow limiting stenosis within the head and neck vessels.
No evidence
of aneurysm formation.
2. No acute intracranial abnormality.
3. Moderate partially calcified atheromatous plaque involves
the left carotid
artery at its origin resulting in minimal narrowing.
4. Heterogenous thyroid gland with left thyroid nodule which
measures up to 2
cm for which correlation with ultrasound can be pursued on a
non-emergent
basis if clinically warranted.
.
ECG
Sinus rhythm. Right bundle-branch block. Left axis deviation.
Left anterior
fascicular block. Non-specific inferior T wave changes. Compared
to the
previous tracing of ___ no diagnostic interval change.
Intervals Axes
Rate PR QRS QT QTc (___) P QRS T
96 ___ 30 -64 4
.
CHEST PA AND LATERAL ___
Low lung volumes and a mild basilar atelectasis without definite
focal
consolidation.
.
STROKE PROTOCOL BRAIN ___
1. No acute infarct or mass effect.
2. Moderate to marked dilation of the lateral and the third
ventricles more than the sulcal prominence, correlate for
communicating hydrocephalus such as NPH, superimposed on
parenchymal volume loss. No significant change compared to the
prior study of ___ mild progression compared to ___.
Brief Hospital Course:
Mr. ___ is a ___ M w PMHx of HTN, HLD, and pAfib on
ASA who presents to ___ ED after ___ noticed left facial
droop.
Mr ___ left nasolabial fold asymmetry persisted during
this admission and after discussion with the patient it appears
to have be baseline.
.
CTA head and neck was unremarkable without any significant
vessel stenosis or dissection/aneurysm. MRI brain was negative
for stroke.
.
His risk factors were sent and showed HbA1C and TSH within
normal limits. LDL was under good control at 60.
.
Therefore, no changes were made to his medications and
echocardiogram was not performed.
.
However, on UA he was found to have significant pyuria and was
discharged on Ciprofloxacin for treatment of UTI for 7 days.
This urinary tract infection was likely related to his chronic
catheter. The patient had an appointment to see his outpatient
urologist the ___ after discharge.
.
Of note, the patient is at higher risk for stroke given his
atrial fibrillation, however due to the risk of bleeding and
fall given his age and functional status, we did not initiate
any anticoagulation and leave this decision up to the patient
and his cardiologist to be discussed as an outpatient.
.
# TRANSITIONAL ISSUES #
- UTI - treating with 7 days of ciprofloxacin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1000 UNIT PO DAILY
2. Acetaminophen 650 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Calcium Carbonate 200 mg PO TID:PRN upset stomach
7. ___ (cranberry extract) 1 tab oral TID
8. Docusate Sodium 100 mg PO BID:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Senna 8.6 mg PO BID:PRN constipation
6. Vitamin D 1000 UNIT PO DAILY
7. Acetaminophen 650 mg PO QHS
8. Calcium Carbonate 200 mg PO TID:PRN upset stomach
9. ___ (cranberry extract) 1 tab oral TID
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Ciprofloxacin HCl 750 mg PO Q12H
Continue this medication for a total of 6 more days, to be
stopped after ___ dose on ___
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice daily
Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1.) Left facial asymmetry
2.) urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr ___,
You were admitted from your assisted living with concerns for a
left facial droop. You continued to have a facial asymmetry
while you were admitted that you thought was actually your
baseline appearance.
You underwent a Brain MRI that did not show any strokes.
Your risk factors for stroke were checked, your HbA1C showed you
do not have diabetes, your thyroid tests were normal, and your
cholesterol labs are pending. These will need to be followed up
by your primary care provider or cardiologist. Also note that
we found you likely have evidence of a mild urinary tract
infection, (no fever, no elevated white count, but evidence of
bacteria in urine). This may be related to your chronic
catheter but we decided to treat you with an antibiotic for 1
week, or at least until you see your outpatient Urologist on
___
Because you have atrial fibrillation, which increases your risk
for stroke, there may be an indication for anticoagulation to
decrease this risk. However, due to your age and risk of
bleeding/fall, the risk of anticoagulation may also be high so
this can be discussed with your cardiologist as an outpatient.
Followup Instructions:
___
|
19792113-DS-26
| 19,792,113 | 24,549,552 |
DS
| 26 |
2159-09-21 00:00:00
|
2159-09-22 11:08:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Rigors
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with a PMH of pAF on ASA,
transitional cell cancer vs papilloma of the bladder, MVP/MR,
OA, and HLD who presented to the ED from his nursing home after
experiencing rigors. He denied any other symptoms at the time of
ED admission. In the ED, he was noted to have significant
hypotension with an SBP of 88, which responded to fluid
resuscitation.
In the ED, initial vitals were:
99.6 ___ 18 97% RA
12.2>12.8/40.8<195
N89, L7, M1.7
132 100 24
------------___
7.5 20 1.0
**grossly hemolyzed**
Repeat K: 5.3
Troponin 0.02
Initial lactate 4.0, repeat 1.7
UA 73 WBC, mod bacteremia, + nitrite, Lg blood, 0 epis
CXR: Lung volumes are low with bibasilar atelectasis
EKG: NSR, RBBB, LAD
The patient was given:
___ 14:34 IVF 1000 mL NS 1000 mL
___ 15:13 IV CefePIME 2 g
___ 15:14 IVF 1000 mL NS 1000 mL
___ 15:49 IV Vancomycin 1000 mg
___ 17:25 IVF 1000 mL NS 1000 mL
Vitals on transfer:
99.8 110 144/87 24 97% RA
On the floor, the patient states that he has been coughing for
the past ___ weeks, but he denies any fever, chills, CP, SOB,
lymphadenopathy, abdominal pain, N/V, weakness, numbness,
rashes. He does complaint of severe joint pain from his "toes to
his head" on account of his osteoarthritis
Past Medical History:
- h/o prostate and bladder Ca
- radiation cystitis
- pAF on ASA
- mitral valve prolapse / MR
- Severe OA
- HLD
- gait disturbance
Social History:
___
Family History:
Rheumatoid arthritis in mother, colon cancer in father
Physical Exam:
ADMISSION EXAM
==============
Vital Signs: 98.9 149/88 114 20 97% RA
I/O: 400 out in foley since admission
General: Pleasant, NAD, lying in bed comfortably
HEENT: Bilateral cataracts, EOMI, PERRLA, MMM, oropharynx clear,
neck supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur best heard in PMI.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, exam limited by inability of patient to sit forward
completely due to severe arthritis
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: Foley draining clear urine
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3. left eyelid droop. CNII-XII grossly intact,
strength exam limited by severe OA but is moving all extremities
spontaneously. Gait deferred.
DISCHARGE EXAM
==============
Vital Signs: 97.8, 149/79, 84, 18, 98% on RA
General: Pleasant, NAD, lying in bed comfortably
HEENT: Bilateral cataracts, EOMI, PERRLA, MMM, oropharynx clear,
neck supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur best heard in PMI.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, exam limited by inability of patient to sit forward
completely due to severe arthritis
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: Foley draining clear urine
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: left eyelid droop.
Pertinent Results:
ADMISSION LABS
==============
___ 02:00PM BLOOD WBC-12.2* RBC-4.52* Hgb-12.8* Hct-40.8
MCV-90 MCH-28.3 MCHC-31.4* RDW-15.7* RDWSD-51.6* Plt ___
___ 02:00PM BLOOD Neuts-88.7* Lymphs-7.0* Monos-1.7*
Eos-1.4 Baso-0.4 Im ___ AbsNeut-10.77*# AbsLymp-0.85*
AbsMono-0.21 AbsEos-0.17 AbsBaso-0.05
___ 02:00PM BLOOD Glucose-76 UreaN-24* Creat-1.0 Na-132*
K-7.5* Cl-100 HCO3-20* AnGap-20
___ 02:00PM BLOOD ALT-31 AST-80* AlkPhos-61 TotBili-0.4
___ 02:00PM BLOOD cTropnT-0.02*
___ 02:00PM BLOOD Albumin-3.9
___ 02:15PM BLOOD Lactate-4.0* K-5.3*
___ 05:13PM BLOOD Lactate-1.7
DISCHARGE LABS
==============
___ 06:50AM BLOOD WBC-5.1 RBC-3.88* Hgb-10.8* Hct-34.2*
MCV-88 MCH-27.8 MCHC-31.6* RDW-15.8* RDWSD-50.2* Plt ___
___ 06:50AM BLOOD Glucose-83 UreaN-15 Creat-0.9 Na-134
K-4.2 Cl-104 HCO3-22 AnGap-12
IMAGING
=======
CXR PA and LAT ___
IMPRESSION:
Lung volumes are low with bibasilar atelectasis.
MICROBIOLOGY
============
BCx x 2, ___, NGTD
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
Brief Hospital Course:
BRIEF SUMMARY
=============
Mr. ___ is a very pleasant ___ year old male with a PMH of
pAF on ASA, transitional cell cancer vs papilloma of the
bladder, MVP/MR, OA, and HLD who presented to the ED from his
nursing home after experiencing rigors.
He was noted in the emergency department to have hypotension to
SBP of 85, as well as a leukocytosis, tachycardia, and lactic
acidosis. He was given IVF with resolution of his hypotension
and leukocytosis. He was admitted to medicine for antibiotic
treatment, and was treated with vancomycin and ceftriaxone then
transitioned to cefpodixime. His urine culture was contaminated.
He was discharged to complete a 10-day course of antibiotics.
ACUTE ISSUES
============
# Severe sepsis: The patient presented to the ED with a
leukocytosis, tachycardia, hypotension, lactic acidosis, and
urinalysis consistent with a UTI. He has a history of UTI with
E. coli and enterococcus sensitive to vanc and ceftriaxone. The
patient has a chronic foley which is changed q 6 weeks and was
changed on the day of admission prior to his rigors. Pressures
improved and lactic acidosis resolved after IVF administration
in the ED. He was treated with vancomycin and ceftriaxone given
his previous culture data, and his leukocytosis resolved on day
two. The patient was transitioned to cefpodoxime PO given that
his UA was nitrite positive and was less concerning for an
enterococcus infection. His UCx was fecally contaminated. He was
discharged to complete a 10-day course.
# Hypotension: The patient presented to the ED with hypotension
with SBP of 85, potentially secondary to bacteremia in the
setting of a UTI and foley change prior to his rigors. His
pressures normalized after fluid and antibiotic administration
# Rigors: The patient presented to the hospital after
experiencing rigors while eating lunch. The patient's symptom
may represent transient bacteremia. The patient's foley was
changed prior to these symptoms, which may have caused
hematologic seeding of bacteria. He did not have any further
episodes.
# Hyponatremia: Initial sodium of 132, potentially due to
hypovolemic hyponatremia in the setting of poor PO intake. His
sodium normalized during his course.
CHRONIC ISSUES
# severe osteoarthritis: treated with standing and PRN APAP. The
patient required one dose of oxycodone 2.5 mg for further
control.
# pAF on ASA: Not currently anticoagulated
- continued aspirin 81 mg daily
# Hx of prostate and bladder cancer c/b radiation cystitis and
urethral trauma: Continued chronic foley
# mitral valve prolapse / MR: patient has systolic murmur
consistent with MR on exam, no crackles heard on limited lung
exam and no JVP or peripheral edema, however
# HLD: continue home atorvastatin 10 mg daily
TRANSITIONAL ISSUES
===================
#UTI: Patient will need to complete a 10-day course of
cefpodoxime, through ___.
#Follow-Up: Discharged over the weekend. Please be sure his
facility makes a follow-up appointment for him over the next
week.
# CODE: Full (confirmed)
# CONTACT: ___, niece cell: ___, home:
___ ___, daughter home: ___ cell:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Senna 8.6 mg PO QHS
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. clotrimazole-betamethasone ___ % topical BID
6. Aspirin 81 mg PO DAILY
7. Acetaminophen 650 mg PO QHS
8. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Senna 8.6 mg PO QHS
6. Vitamin D 1000 UNIT PO DAILY
7. Cefpodoxime Proxetil 400 mg PO Q12H
Take through ___
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
8. clotrimazole-betamethasone ___ % topical BID
9. Acetaminophen 650 mg PO Q8H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=====================
- Severe sepsis secondary to urinary tract infection
- Hyponatremia
- Osteoarthritis, severe
SECONDARY DIAGNOSES
====================
- History of prostate and bladder cancer
- Radiation cystitis
- Paroxysmal atrial fibrillation on aspirin
- Mitral valve prolapse
- Mitral regurgitation
- Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after you experienced shaking
and low blood pressures while at your nursing home. It is likely
that you had a urinary tract infection which caused these
symptoms. You were treated with strong antibiotics and given
fluids, and your blood pressures returned to normal and you had
no more shaking episodes.
You were discharged on an antibiotic called cefpodoxime to take
for 10 days.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19792113-DS-27
| 19,792,113 | 28,933,749 |
DS
| 27 |
2159-10-10 00:00:00
|
2159-10-12 09:12:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
rigors, hematuria
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ w/hx of CAD, pAFib on ASA, history of prostate cancer s/p
radiation with known radiation cystitis and prior urethral
trauma, who gets routine Foley changes in ___ clinic q6
weeks, p/w hematuria and rigors this AM at nursing home.
Patient states that he had shaking chills and noticed hematuria
with clots. Of note, he was recently admitted to ___ from
___ for UTI with UCx notable for fecal contamination. He was
discharged on a 10-day course of cefpodoxime 400 mg PO Q12H,
which he completed.
Pt denying cough, change in bowel habits, chest pain,
palpitations, sob, abd pain, n/v/d/c, focal weakness,
paresthesias, HAs.
In the ED, initial vitals were: 98.6, HR 120, BP 115/46, RR 16,
94% RA. Exam notable for foley with hematuria and clots.
Labs notable for:
- WBC 18.5
- BUN:Cr ___
- UA: RBC>182, WBC 92. CastHy: 26. Neg Nitrites.
- Lactate:3.0, downtrended to 1.1 after IVF
CXR notable for low lung volumes and bibasilar atelectasis.
Patient developed fever to 101.8 while in the ED, HR to 147.
Patient was given IV CeftriaXONE 1 gm, 1500 mL NS.
Decision was made to admit for management of sepsis.
On transfer, pt's vitals were: 99.5, 90, 110/70, 18, 98% RA
On the floor, pt is feeling well, was w/o complaints
Review of systems:
(+) Per HPI
(-) Denies 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 habits.
Past Medical History:
- h/o prostate and bladder Ca
- radiation cystitis
- pAF on ASA
- mitral valve prolapse / MR
- Severe OA
- HLD
- gait disturbance
Social History:
___
Family History:
Rheumatoid arthritis in mother, colon cancer in father
Physical Exam:
ADMISSION EXAM
==============
VS: T 99.5, BP 154/74, HR 93, RR 18, O2 96% RA
General: Pleasant, NAD, lying in bed comfortably
HEENT: Bilateral cataracts, EOMI, PERRLA, MMM, oropharynx
clear, neck supple
CV: irregularly irregular, III/VI systolic murmur best heard in
PMI.
Lungs: CTABL, no wheezes, rales, rhonchi
Abdomen: +BS, Soft, non-tender, non-distended, no organomegaly,
no rebound or guarding
GU: Foley draining cloudy urine with 1 small blood clot in bag
Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema
Neuro: left eyelid droop, aaox3, ___ backwards.
DISCHARGE EXAM
==============
Vitals: 98.8 ___ 116-130/57-67 17 97% RA
I/O: ___ since midnight, ___ yesterday
General: Pleasant, NAD, lying in bed comfortably
HEENT: Bilateral cataracts, EOMI
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur best heard in PMI.
Lungs: Clear to auscultation bilaterally anteriorly only, no
wheezes, rales, rhonchi, exam limited by inability of patient to
sit forward completely due to severe arthritis
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: Foley draining clear urine
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: left eyelid droop.
Pertinent Results:
ADMISSION LABS
==============
___ 12:45PM BLOOD WBC-18.5*# RBC-4.45* Hgb-12.4* Hct-38.4*
MCV-86 MCH-27.9 MCHC-32.3 RDW-15.9* RDWSD-49.8* Plt ___
___ 12:45PM BLOOD Neuts-85.6* Lymphs-7.4* Monos-6.0
Eos-0.1* Baso-0.2 Im ___ AbsNeut-15.84* AbsLymp-1.37
AbsMono-1.11* AbsEos-0.02* AbsBaso-0.04
___ 12:45PM BLOOD Glucose-101* UreaN-31* Creat-1.4* Na-137
K-4.8 Cl-105 HCO3-22 AnGap-15
___ 05:00AM BLOOD Albumin-3.4* Calcium-9.6 Phos-2.2* Mg-2.0
Iron-38*
___ 05:00AM BLOOD calTIBC-235* Ferritn-170 TRF-181*
___ 12:51PM BLOOD Lactate-3.0*
___ 02:20PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 02:20PM URINE RBC->182* WBC-92* Bacteri-FEW Yeast-NONE
Epi-0
___ 02:20PM URINE Color-Yellow Appear-Hazy Sp ___
PERTINENT LABS
==============
___ 05:00AM BLOOD ___ PTT-29.1 ___
___ 05:00AM BLOOD Albumin-3.4* Calcium-9.6 Phos-2.2* Mg-2.0
Iron-38*
___ 05:00AM BLOOD calTIBC-235* Ferritn-170 TRF-181*
___ 07:40AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 07:40AM URINE Hours-RANDOM Creat-44 Na-193 K-29 Cl-200
DISCHARGE LABS
==============
___ 07:09AM BLOOD WBC-7.9 RBC-3.95* Hgb-11.1* Hct-34.1*
MCV-86 MCH-28.1 MCHC-32.6 RDW-15.7* RDWSD-49.1* Plt ___
___ 07:09AM BLOOD Glucose-86 UreaN-18 Creat-0.9 Na-135
K-4.3 Cl-103 HCO3-24 AnGap-12
___ 07:09AM BLOOD Calcium-9.9 Phos-2.5* Mg-1.8
IMAGING
=======
CXR ___
Low lung volumes and atelectasis
MICROBIOLOGY
============
BCx x ___: NGTD
UCx ___: <10,000 organisms
BCx ___: NGTD
UCx ___:
URINE CULTURE (Preliminary):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- 8 I
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
BRIEF SUMMARY
=============
Mr. ___ is a very pleasant ___ year old male with a PMH of
pAF on ASA, transitional cell cancer vs papilloma of the
bladder, MVP/MR, OA, and HLD who presented to the ED from his
nursing home after experiencing rigors and fever. Of note, he
was recently admitted in early ___ for the same symptoms, and
was treated with a 10-day course of cefpodoxime.
He was noted in the emergency department to have hypotension,
leukocytosis, tachycardia, and lactic acidosis. He was given IVF
with resolution of his hypotension and leukocytosis. He was
admitted to medicine for antibiotic treatment, and was treated
with ceftriaxone. After several days of antibiotics, his urine
culture grew out multi-drug resistant klebsiella sensitive to
ciprofloxacin. He was switched to ciprofloxacin and discharged
to his nursing home with planned follow up with his urologist
Dr. ___ as an outpatient.
ACUTE ISSUES
============
# urinary tract infection:
# Severe sepsis: The patient presented to the ED with a
leukocytosis, tachycardia, hypotension, and urinalysis
consistent with a UTI, with lactate elevated to 3.0. He has a
history of UTI with E. coli and enterococcus sensitive to vanc
and ceftriaxone. He was recently discharged from ___ on ___
for a UTI w/sepsis, but nothing grew from cultures. He was
treated with a 10-day course of cefpodoxime. The patient has a
chronic foley which is changed q6 weeks, the last change was on
___. He received Ceftriaxone and 1.5L NS in the ED with
resolution of hypotension, lactic acidosis, and tachycardia. The
day prior to discharge, his urine culture grew MDR klebsiella
sensitive to ciprofloxacin. He was switched to ___, watched
overnight, then discharged back to his assisted living facility
to complete a 10-day course. He will follow up with his
urologist Dr. ___ as an outpatient in early ___.
# ___: Pt's Cr normally ~1.0, elevated to 1.4 on presentation,
resolved with IVF administration.
CHRONIC ISSUES:
==========================
# severe osteoarthritis:
- c/w APAP PRN
# pAFib on ASA: CHADS2 of ___ (?HTN). Not currently
anticoagulated
- continued home aspirin
# Hx of prostate and bladder cancer c/b radiation cystitis and
urethral trauma:
- Continued chronic foley
# HLD: c/w home atorvastatin 10 mg daily
# mitral valve prolapse / MR: patient has systolic murmur
consistent with MR on exam, no crackles heard on limited lung
exam and no JVP or peripheral edema
TRANSITIONAL ISSUES
===================
#UTI: Patient will need to complete a 10-day course of
ciprofloxacin (through ___
#the patient will follow up with his urologist Dr. ___ as an
outpatient for cystoscopy and further urological evaluation
# CODE: Full (confirmed)
# CONTACT: ___, niece cell: ___, home:
___ ___, daughter home: ___ cell:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Senna 8.6 mg PO QHS
6. Vitamin D 1000 UNIT PO DAILY
7. clotrimazole-betamethasone ___ % topical BID
8. Acetaminophen 650 mg PO Q8H:PRN pain
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
DIAGNOSES
=========
#urinary tract infection
#severe sepsis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital after you experienced shaking
and low blood pressures while at your nursing home. It is likely
that you had a urinary tract infection which caused these
symptoms. You were treated with a strong antibiotic and given
fluids with improvement in your symptoms. The day prior to
discharge, a bacteria grew out of your urine culture which was
somewhat resistant to the antibiotic we originally gave you. We
switched this antibiotic to a drug called ciprofloxacin, and
discharged you back to your nursing home to follow up with Dr.
___ as an outpatient.
We wish you the best,
Your ___ Care Team
You were discharged on an antibiotic called cefpodoxime to take
for 10 days.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19792113-DS-28
| 19,792,113 | 26,771,736 |
DS
| 28 |
2159-10-22 00:00:00
|
2159-10-22 16:00:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/hx of CAD, pAFib on ASA, history of prostate cancer s/p
radiation with known radiation cystitis and prior urethral
trauma, who gets routine Foley changes in ___ clinic q6
weeks, p/w hematuria and rigors this AM at ___ ALF.
Per nurse at ___, yesterday pt developed hematuria,
worsening penile pain and then today had a fever to 100 after
tyenlol. He had just been d/c'ed from ___ ___ and was
still on cipro for klebsiella UTI.
In ED, VS were 98.6 78 101/60 16 98% RA. Labs revealed a
leukocytosis, and mildly elevated lactate. Urine was red. Pt
admitted for further eval.
ROS: Ten point ROS otherwise negative except as per HPI.
Past Medical History:
- h/o prostate and bladder Ca
- radiation cystitis
- pAF on ASA
- mitral valve prolapse / MR
- Severe OA
- HLD
- gait disturbance
Social History:
___
Family History:
Rheumatoid arthritis in mother, colon cancer in father
Physical Exam:
VSS afeb
General: Pleasant, NAD, lying in bed comfortably
HEENT: Bilateral cataracts, EOMI, PERRLA, MMM, oropharynx clear,
neck supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, III/VI systolic
murmur best heard in PMI.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, exam limited by inability of patient to sit forward
completely due to severe arthritis
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: three way urinary catheter in place to CBI, urine red
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: left eyelid droop.
Psych: A+Ox3 pleasant
Pertinent Results:
___ 10:45AM BLOOD WBC-10.9* RBC-4.12* Hgb-11.5* Hct-35.3*
MCV-86 MCH-27.9 MCHC-32.6 RDW-15.4 RDWSD-48.4* Plt ___
___ 10:45AM BLOOD Neuts-78.3* Lymphs-12.9* Monos-6.7
Eos-0.8* Baso-0.4 Im ___ AbsNeut-8.55* AbsLymp-1.41
AbsMono-0.73 AbsEos-0.09 AbsBaso-0.04
___ 10:45AM BLOOD ___ PTT-30.6 ___
___ 10:45AM BLOOD Glucose-90 UreaN-30* Creat-1.1 Na-136
K-4.6 Cl-104 HCO3-21* AnGap-16
___ 10:57AM BLOOD Lactate-2.3*
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ URINE URINE CULTURE-PENDING EMERGENCY WARD
RENAL U.___. Study Date of ___ 6:41 ___
The right kidney measures 11.3 cm. The left kidney measures 11.7
cm. There is no hydronephrosis, stones, or solid masses
bilaterally. Multiple bilateral Bosniak ___ renal cysts are
noted. A right upper pole cyst measures 6.1 cm. Normal
cortical echogenicity and corticomedullary differentiation are
seen bilaterally.
The bladder is decompressed around a Foley catheter and
difficult to evaluate.
IMPRESSION:
The bladder is decompressed around a Foley catheter and cannot
be fully
assessed. Bilateral Bosniak ___ renal cysts.
Brief Hospital Course:
___ with pAF on ASA, transitional cell cancer vs papilloma of
the bladder, MVP/MR, OA, and HLD who presented to the ED from
his nursing home after experiencing hematuria and fever. Of
note, he was admitted twice this month for the same symptoms,
and was treated with a 10-day course of cefpodoxime and then a
course of cipro.
# Recent urinary tract infection, funguria: During the pt's most
recent admit, Urine culture grew MDR klebsiella sensitive to
ciprofloxacin. Discharged with plan for 10-day course of
ciprofloxacin (through ___. Leukocytosis raised concern for
new organism resistant to cipro, but the quick resolution of the
leukocytosis with no change in antibiotic suggested that this
was more likely primarily a case of obstruction. The urine
culture grew yeast, and we elected to treat it with fluconazole
for ___ompleted 2 weeks cipro.
# severe osteoarthritis:
- c/w APAP PRN
# pAFib on ASA: CHADS2 of ___ (?HTN). Not currently
anticoagulated. Given ongoing quality of life issues and
continued hematuria, the patient's aspirin was stopped and his
PCP was emailed and all were in agreement with stopping the ASA
for now given bleeding risk >> stroke risk. This decision can
be re-considered depending on how he does.
# Hx of prostate and bladder cancer c/b radiation cystitis and
urethral trauma:
- f/u with Dr. ___. Will follow up in 1 week
# HLD: c/w home atorvastatin 10 mg daily
# mitral valve prolapse / MR: patient has systolic murmur:
Appears euvolemic on exam.
# fen/gi: normal diet
# ppx: heparin sc
# CODE: Full (confirmed)
# CONTACT: ___, niece cell: ___, home:
___ ___, daughter home: ___ cell:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Atorvastatin 10 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Senna 8.6 mg PO QHS
7. Ciprofloxacin HCl 500 mg PO Q12H
8. clotrimazole-betamethasone ___ % topical BID
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Senna 8.6 mg PO QHS
6. Vitamin D 1000 UNIT PO DAILY
7. clotrimazole-betamethasone ___ % topical BID
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Fluconazole 200 mg PO Q24H Duration: 11 Days
through ___
RX *fluconazole 200 mg 1 tablet(s) by mouth once a day Disp #*11
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hematuria
Funguria/CA-UTI
Prostate cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with blood in your urine. You were treated
with continuous bladder irrigation to remove the blood clots.
The urologists saw you and felt that the bleeding was related to
your radiation and that you need to be very careful to not pull
on your foley catheter (the urinary catheter that you use).
- Your foley leg bag should not be lower than your knee to
prevent pulling/traction on it.
- You should use two catheter fasteners to keep the foley in
place.
Please follow up with Dr. ___ as scheduled next week. Please
complete your course of Fluconazole for yeast UTI
Followup Instructions:
___
|
19792649-DS-21
| 19,792,649 | 26,363,250 |
DS
| 21 |
2126-04-17 00:00:00
|
2126-04-18 09:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ Alzheimer's dementia transferred after a fall w/ SDH and
L radial styloid fracture. Patient is AxOx1 and does not
remember falling. Per report he frequently falls at his long
term care facility. Per the ED report he was found down, and it
is unknown if he had LOC. Pt is unable to provide any history
due to his dementia.
Past Medical History:
Past Medical History:
- Alzheimers Dementia
- depression
- prostate cancer
- macular dengeneration
- HTN
Past Surgical History:
Unknown
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals:98.0 72 156/100 18 98 Ra
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist. No tenderness
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender, no rebound or guarding,
Discharge Physical Exam:
VS: 98.3 PO 139 / 79 68 18 94 Ra
Gen: Awake, interactive. no acute distress.
HEENT: PERRL, EOMI. Neck supple. Trachea midline.
CV: RRR
Pulm: Clear to auscultation bilaterally.
Abd: Soft, non-tender, non-distended. Foley to gravity, yellow
clear urine.
Ext: Warm and dry. No edema.
Neuro: Alert, oriented to self only. Follows commands and moves
all extremities.
Pertinent Results:
___ 10:04AM BLOOD WBC-7.3 RBC-4.07* Hgb-11.4* Hct-37.2*
MCV-91 MCH-28.0 MCHC-30.6* RDW-15.9* RDWSD-53.5* Plt ___
___ 09:27AM BLOOD WBC-9.4 RBC-3.84* Hgb-10.7* Hct-34.2*
MCV-89 MCH-27.9 MCHC-31.3* RDW-15.9* RDWSD-52.0* Plt ___
___ 06:20AM BLOOD Glucose-80 UreaN-15 Creat-1.2 Na-139
K-3.7 Cl-102 HCO3-27 AnGap-14
___ 10:04AM BLOOD Glucose-118* UreaN-13 Creat-1.2 Na-141
K-3.3 Cl-104 HCO3-27 AnGap-13
___ 09:27AM BLOOD Glucose-90 UreaN-18 Creat-1.2 Na-142
K-3.7 Cl-104 HCO3-26 AnGap-16
___ 06:20AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.0
___ 10:04AM BLOOD Calcium-9.3 Phos-2.6* Mg-1.7
___ 09:27AM BLOOD Calcium-9.7 Phos-2.3* Mg-1.8
___ CT head:
1. Mixed density left-sided subdural hematoma with some
high-density blood
products compatible with acute hemorrhage, unchanged from CT
head ___ 06:56. No evidence of new or worsening intracranial
hemorrhage.
2. 6 mm of rightward midline shift, unchanged.
___ CT chest:
1. No evidence of acute intrathoracic or intraabdominal injury
within the
limitation of an unenhanced scan.
2. No acute fracture or hematoma demonstrated.
Brief Hospital Course:
Mr. ___ is a ___ yo M past medical history significant for
alzheimers dementia, depression, prostate cancer, chronic foley,
and hypertension admitted to the Acute Care Surgery service on
___ after sustaining a fall. Imaging showed subdural
hematoma and left radial styloid fracture. Neurosurgery
recommended frequent neurologic monitoring while inpatient and
no further intervention if stable. Hand surgery was consulted
and sugar tong splint was placed. He was hemodynamically stable
and admitted to the floor for neurologic monitoring and further
management.
Neuro: The patient was alert and confused at baseline level.
Pain was managed with oral medication.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint. Good pulmonary toilet, early ambulation and
incentive spirometry were encouraged throughout hospitalization.
GI/GU/FEN: The patient tolerated a regular diet without
difficulty. Chronic foley catheter was changed on ___.
Urine anaylsis was positive for nitites and leukocytes which was
not treated due to likely colonized bacteria and no leukocytosis
or fever. Urine culture pending. Patient's intake and output
were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
The patient was seen and evaluated by physical and occupational
therapy who recommended discharge to ___ rehab; patient
and family agreeable.
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 with understanding
verbalized and agreement with the discharge plan. The patient
was discharged to rehab with outpatient hand surgery and
neurosurgery follow up.
Medications on Admission:
Amlodipine 5 mg daily, Bupropion 100 mg QM, 37.5mg QPM,
Venlafaxine 50 mg QAM, 25mg QPM, Memantine 10mg BID, Flomax 0.4
mg daily, Donepezil 10QHS, Trazadone 25mg QHS prn.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
do not exceed 4 grams/ 24 hours
2. amLODIPine 5 mg PO DAILY
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. BuPROPion 100 mg PO QAM
5. BuPROPion 37.5 mg PO QHS
6. Donepezil 10 mg PO QHS
7. Ferrous Sulfate 325 mg PO DAILY
8. Ipratropium-Albuterol Neb 1 NEB NEB Q6H shortness of breath
9. Memantine 10 mg PO BID
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 17.2 mg PO BID
13. Tamsulosin 0.4 mg PO QHS
14. TraZODone 25 mg PO QHS:PRN insomnia
15. Venlafaxine 25 mg PO QHS
16. Venlafaxine 50 mg PO QAM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left radial styloid nondisplaced fracture
Left subdural hematoma
History of Falls
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the Acute Care Surgery Service on ___
after a fall. You were found to have a left wrist fracture and
bleeding in your head called a subdural hematoma. You had a
splint placed by the hand surgeons to stabilize the bones. You
neurologic status was closely monitored and remained stable. You
were seen and evaluated by physical therapy recommended
discharge back to rehab.
You are now doing better and ready to be discharged from the
hospital to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Followup Instructions:
___
|
19792653-DS-2
| 19,792,653 | 28,300,273 |
DS
| 2 |
2154-08-31 00:00:00
|
2154-09-02 23:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ranitidine / montelukast / aspirin
Attending: ___.
Chief Complaint:
Septic sacroiliitis
Major Surgical or Invasive Procedure:
CT-guided joint aspiration and joint washings of the left SI
joint, core biopsy of the posterior left iliac bone.
History of Present Illness:
The patient is a ___ with recent L sided pain presents for
further work-up of possible septic sacroiliitis. Four weeks ago,
the patient had onset of left back/hip pain with radiation down
back of leg to knee. She was treated conservatively for sciatica
with acetaminophen, ibuprofen, cyclobenzaprine, and a heating
pad but this did not produce any improvement. The patient was
unable to ambulate and she went to an urgent care clinic 2 days
later, where she got IV toradol and her pain was relieved.
However, by the end of the first week, she had worsening of
symptoms, was febrile to 100-101, and went to the ED while in
___ on vacation. She had an XR of the pelvis that was
unremarkable, and morphine did not provide relief. She was
ultimately given more IV toradol, resulting in enough
improvement to get back to ___.
Since that time (3 weeks ago), she had been walking with a
walker (no previous history of walking with a walker) due to an
inability to bear weight on her LLE due to pain. She described
the pain as constant in the left lumbar region with intermittent
spasms down her left leg. She took ibuprofen with some mild
relief and her position of comfort was lying on her right hip.
She was seen by ___ a couple of weeks ago, who prescribed
exercises which helped the pain and also noticed left leg
atrophy; patient was also prescribed walker at this time.
Patient went to spine clinic a week ago, where she received 5
days of prednisone (completed ___, more ___, and ordered an MRI
L spine for suspected herniated disc. The MRI L-spine showed
abnormal muscle enhancement and ? SI joint abnormalities.
Follow-up MRI pelvis on ___ raised concern for septic
sacroiliitis and she was referred to the ED.
In the ED, she was tachycardic to 110. She was given
Oxycodone-Tylenol and Ibuprofen for pain. Antibioitcs were
deferred. She denied fevers, chills, and night sweats. She
denied N/V/D. She denied urinary incontinence, fecal
incontinence, bilateral sciatica, saddle anesthesia, or leg
weakness. She described weight loss that was intentional. Of
note, she had previous sciatica on the right ___ a bulging disc,
which resolved. She also traveled to ___ and ___ in the
past year. The rest of her review of systems was negative.
Past Medical History:
- Hypertension
- R sided Sciatica in past treated conservatively
Social History:
___
Family History:
Mother's side of the family is significant for pancreatic,
colon, and stomach cancer. Father's side of family with heart
disease, father needed bypass surgery before age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals - T:98.5 BP:156/101 HR:92 RR:18 02 sat:99RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
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, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Moderate L sided paraspinal tenderness by sacrum. L
leg ___ hip flexion and extension though somewhat limited by
pain. No numbness appreciated in L leg
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength intact though exam limited by
pain
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
VS: Tc: 98.0, Tm: 98.4, BP: 136-155/89-94, P: 92-102, R: ___,
O2: 97-100% RA
GENERAL: NAD, lying on her right side
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Moderate L sided paraspinal tenderness by sacrum.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
NEURO: Alert and oriented, CN II-XII intact, L leg ___ hip
flexion and extension though somewhat limited by pain. ___
strength present throughout. 3+ reflexes in UE, 2+ in lower
extremities, symmetric. Plantar response is flexor. No gross
numbness appreciated.
Pertinent Results:
ADMISSION LABS
==============
___ 04:30PM BLOOD WBC-16.1*# RBC-4.09* Hgb-11.2* Hct-35.2*
MCV-86 MCH-27.5 MCHC-31.9# RDW-14.3 Plt ___
___ 04:30PM BLOOD Neuts-66.6 ___ Monos-6.4 Eos-0.9
Baso-0.5
___ 04:42PM BLOOD ___ PTT-22.7* ___
___ 04:30PM BLOOD ESR-47*
___ 04:30PM BLOOD Glucose-118* UreaN-18 Creat-0.9 Na-137
K-3.9 Cl-101 HCO3-25 AnGap-15
___ 04:30PM BLOOD AlkPhos-132*
___ 05:30AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
___ 04:30PM BLOOD CRP-8.3*
___ 04:37PM BLOOD Lactate-1.7
___ 05:05PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:05PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
___ 05:05PM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-1
NOTABLE LABS
============
___ 05:15AM BLOOD RheuFac-10
DISCHARGE LABS
==============
___ 06:03AM BLOOD WBC-8.7 RBC-3.47* Hgb-9.8* Hct-29.9*
MCV-86 MCH-28.1 MCHC-32.6 RDW-14.5 Plt ___
___ 06:03AM BLOOD Glucose-95 UreaN-14 Creat-0.7 Na-143
K-4.0 Cl-109* HCO3-26 AnGap-12
___ 05:15AM BLOOD ___
MICRO
=====
Blood cultures, aspirated joint fluid cultures pending.
IMAGING
=======
___: CT-guided joint aspiration and joint washings of the
left SI joint, in addition to core biopsy of the posterior left
iliac bone. Specimens were sent for micro and culture.
Brief Hospital Course:
___ who presents with 4 weeks of worsening L sided back pain
found to have L sided sacroiliitis.
ACUTE ISSUES
============
# Septic Sacroilitis: After initial outpatient and urgent care
workup of the patient's left-sided back pain, the patient
presented to ___ with 2 SIRS criteria (leukocytosis and
tachycardia) and a source of fluid collection on pelvic MRI. In
the ED, antibiotics were deferred and pain control was achieved
with percocet and ibuprofen. As an inpatient, ___ sampled the
fluid collection for gram stain and culture and a bone marrow
biopsy was also obtained. Because it was unclear why she has
developed this fluid collection with no history of IV drug use
or foreign bodies, ID was consulted. Given the suspicion for
infectious sacroiliitis, the decision was made to treat her
empirically with Ceftriaxone for 6 weeks as no other compelling
etiology presented itself and her clinical syndrome certainly
may be consistent with infection. A PICC line was placed and ID
provided instructions for at-home antibiotics administration and
labs below (in transitional issues). She achieved adequate
relief of her pain with percocet. At discharge, blood cultures,
cultures of the aspirated joint fluid, bone marrow biopsy, and
___ labs are pending.
CHRONIC ISSUES
==============
# Hypertension: Lisinopril was continued in-house and at
discharge.
TRANSITIONAL ISSUES
===================
# Pt will be set up for at-home ___ and ___ services for
antibiotic administration and blood draws.
# ID OPAT Program Intake Note - Order Recommendations
OPAT Diagnosis: Sacroiliitis, presumed septic etiology.
OPAT Antimicrobial Regimen and Projected Duration:
Agent & Dose: Ceftriaxone 2g IV q24 hours
Start Date: ___
Projected End Date: ___
LAB MONITORING RECOMMENDATIONS: NOTE: For lab work to be drawn
after discharge, a specific standing order for Outpatient Lab
Work is required to be placed in the Discharge Worksheet -
Post-Discharge Orders. Please place an order for Outpatient Labs
based on the MEDICATION SPECIFIC GUIDELINE listed below:
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
CEFTRIAXONE WEEKLY: CBC with differential, BUN, Cr, AST, ALT,
TB,
ALK PHOS.
ADDITIONAL ORDERS: PLEASE OBTAIN WEEKLY ESR/CRP
FOLLOW UP APPOINTMENTS: With Infectious Disease, on ___ at
9:00AM and ___ at 9AM.
# Code: Full (confirmed)
# Emergency Contact: ___ (Daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. Ibuprofen 800 mg PO Q8H:PRN pain
4. Acetaminophen w/Codeine Elixir ___ mL PO Q4H:PRN pain
Discharge Medications:
1. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone 2 gram 2 g IV daily Disp #*42 Vial Refills:*0
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. Lisinopril 10 mg PO DAILY
4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4-6H PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every ___ hours as needed Disp #*56 Tablet Refills:*0
5. Outpatient Lab Work
Please obtain weekly CBC with differential, BUN, Cr, AST, ALT,
TB, ALK PHOS, ESR, CRP. First day of lab draw ___.
Duration: continue weekly until ___
Fax to ___ CLINIC - FAX: ___
ICD-9: V58.69
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
1. Septic sacroiliitis
SECONDARY DIAGNOSES
===================
1. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during our stay at ___.
You were recently admitted for a likely infection in your hip, a
condition known as septic sacroiliitis. There was a fluid
collection noted in your hip joint. This fluid was drained by
interventional radiology and a bone marrow biopsy was also
obtained. Your pain was treated with percocet
(oxycodone-acetaminophen). The most likely cause of such a fluid
collection is infection. The infectious disease sepcialists were
consulted and recommended that you receive a course of
antibiotics. You had a PICC line placed so that these
antibiotics could be easily administered for an extended period.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19792691-DS-19
| 19,792,691 | 23,106,488 |
DS
| 19 |
2190-06-11 00:00:00
|
2190-06-15 19:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fever, cough, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male w/ hx of HLD p/w 1 week of cough, dyspnea and
dark urine. He states that he has had intermittent
chills/fevers/night sweats with about one week of cough without
production of sputum. His dypsnea is not exacerbated by
exertion. He notes that the had muscle/joint aches leading up to
the cough. He also had n/v with two episodes of emesis as well
as diarrhea over the last two days but denies abd pain. He notes
significant reduction in PO intake associated with some
intermittent lightheadedness. He denies chest pain, leg
swelling. He states that he has travelled, stating that he has
not ever left the ___. He denies any family with recent travel or
illness and denies recent hospitalizations or medical treatment.
He was seen at his PCP's office and found to be hypoxic to 89 so
was sent to the ED.
In the ED initial vitals were: 99.9 96 135/85 18 96% 2L. He was
treated with CTX and doxycycline in the ED with vitals prior to
transfer were: 98.5 96 128/81 18 93% RA.
On the floor, patient notes mild shortness of breath improved
with 2L O2 by nasal cannula.
Past Medical History:
Colon adenoma
R thigh lipoma
HLD
Hx gastric ulcer
Rotator cuff repair x2
Right elbow bone chip removal
Social History:
___
Family History:
Father died elderly of pneumonia, mother died at ___ of unknown
cancer, sister died of unknown cancer, brother died lung ca. 1
brother with copd. 8 sons, 1 daughter are well.
Physical Exam:
Admission Physical Exam:
Vitals - T: 99 BP: 152/73 HR: 94 RR: 24 02 sat: 92%RA
GENERAL: Well appearing man lying in bed in NAD
HEENT: EOMI, PERRL, anicteric sclera, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Crackles on L from base to mid-lung field, breathing
comfortably without use of accessory muscles, no dullness to
percussion
ABDOMEN: Soft but mildly distended, +BS, nontender in all
quadrants, no rebound/guarding
EXTREMITIES: Warm and well perfused, no cyanosis, clubbing or
edema
PULSES: 2+ DP pulses bilaterally
NEURO: AAOx3, motor and sensory exam grossly intact
LYMPH NODES: No cervical, axillary, or inguinal LAD
Discharge Physical Exam:
PE 98.6 98.5 134/85 81 20 93RA(90-94)
General- Alert, oriented, NAD
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- L side crackles from base up to mid lung and R upper lung
decreased breath sounds, dullness,
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- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 08:10AM BLOOD WBC-11.1* RBC-4.90 Hgb-12.4* Hct-40.4
MCV-82 MCH-25.4* MCHC-30.8* RDW-14.9 Plt ___
___ 07:55AM BLOOD WBC-11.2* RBC-4.65 Hgb-12.3* Hct-39.3*
MCV-85 MCH-26.6* MCHC-31.4 RDW-15.1 Plt ___
___ 08:30AM BLOOD WBC-12.8* RBC-4.76 Hgb-12.2* Hct-39.3*
MCV-83 MCH-25.7* MCHC-31.1 RDW-14.9 Plt ___
___ 04:49PM BLOOD WBC-13.9*# RBC-4.94 Hgb-13.3* Hct-41.0
MCV-83 MCH-26.9* MCHC-32.4 RDW-15.0 Plt ___
___ 04:49PM BLOOD Neuts-79.3* Lymphs-15.1* Monos-4.9
Eos-0.1 Baso-0.5
___ 08:10AM BLOOD Glucose-110* UreaN-11 Creat-0.8 Na-141
K-3.9 Cl-102 HCO3-31 AnGap-12
___ 07:55AM BLOOD Glucose-111* UreaN-13 Creat-0.9 Na-141
K-3.9 Cl-103 HCO3-31 AnGap-11
___ 08:30AM BLOOD Glucose-100 UreaN-16 Creat-1.1 Na-139
K-4.4 Cl-103 HCO3-28 AnGap-12
___ 04:49PM BLOOD Glucose-125* UreaN-17 Creat-1.4* Na-139
K-4.1 Cl-100 HCO3-27 AnGap-16
___ 08:10AM BLOOD ALT-59* AST-73* LD(___)-277*
___ 07:55AM BLOOD ALT-58* AST-74* CK(CPK)-177 AlkPhos-111
___ 08:30AM BLOOD ALT-65* AST-106* LD(___)-361* AlkPhos-110
TotBili-0.4
___ 04:49PM BLOOD CK(CPK)-721*
___ 04:49PM BLOOD cTropnT-<0.01
___ 04:49PM BLOOD CK-MB-3
___ 08:10AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.2
___ 08:30AM BLOOD TotProt-5.2* Albumin-2.9* Globuln-2.3
Calcium-8.6 Phos-2.7 Mg-2.3
___ 08:30AM BLOOD Hapto-438*
___ 02:50AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:03PM URINE Color-Yellow Appear-Hazy Sp ___
___ 02:50AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:03PM URINE Blood-LG Nitrite-NEG Protein->600
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-6.5 Leuks-NEG
___ 02:50AM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 12:03PM URINE RBC-4* WBC-6* Bacteri-FEW Yeast-NONE
Epi-0
___ 10:48AM URINE Hours-RANDOM Creat-147 TotProt-85
Prot/Cr-0.6*
___ 2:50 am SPUTUM Source: Expectorated.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
___ 4:10 pm SPUTUM Source: Expectorated.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
___ 9:38 am SPUTUM Source: Expectorated.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR
Brief Hospital Course:
#CAP/?TB: Patient presented with two weeks of
fevers/chills/joint pains, a week of cough with progressive
dyspnea, left sided crackles on exam, and was found to have
leukocytosis, and multifocal opacities on CXR without recent
health-care contact consistent with community acquired
pneumonia. Urine legionella was negative. He was started on
ceftraixone and azithro. Patient improved quickly and was
dicharged on cepodoxime and azithro. Given the hx of two weeks
of fever/chills/night sweats and hx of incarceration, there was
initial concern for TB. Patient subsequently ruled out with
three AFP negative smears.
___: Patient with Cr 1.4 (from baseline 1.2) with dark urine
and UA with SG 1.039 likely evidence of hypovolemia in the
setting of poor PO intake and fevers. 1L LR on admission.
resolved.
# Nephropathy: ___ w/ large blood & protein, small bili on
initial UA. Spot protein/Cr 0.6, non nephrotic range
proteinuira, most likely NSAID induced acute interstitial
nephritis given hx of significant NSAID use(6 naproxen every
other day for 4 months). Repeat UA unremarkable. ___ resolved.
=================================
Transitional issues
=================================
- continue Azithromycin 500mg through ___
- continue Cefpodoxime through ___
- PPD needs to be read ___ afternoon at ___ (form
provided)
- Follow up final blood and sputum cultures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Naproxen 1250 mg PO EVERY OTHER DAY
2. Aspirin 81 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Azithromycin 500 mg PO Q24H
RX *azithromycin 500 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
4. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp
#*16 Tablet Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia, community-acquired
Acute renal failure/ AIN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a pleasure taking care of you at ___
___. You were admitted with pneumonia. You were given
antibiotics and seemed to improve. Because of concern for
tuberculosis, you were tested for this in the sputum and this
was negative. You had a skin test placed, which needs to be read
at ___ between ___ tomorrow. Please make sure to
go there with the letter provided to have this read.
Please continue your antibiotics as prescribed and follow up
with Dr ___ as scheduled.
We wish you the best,
your ___ team
Followup Instructions:
___
|
19792705-DS-13
| 19,792,705 | 23,758,183 |
DS
| 13 |
2159-06-08 00:00:00
|
2159-06-24 19:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Nsaids / Brilinta
Attending: ___.
Chief Complaint:
left sided paresthesias
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old right-handed woman with HTN, HLD
fibromyalgia, prior seizure disorder who presents with new onset
left sided numbness and tingling.
The patient complains of new onset left-sided tingling with
acute onset starting at approximately 10am. A "numbness with
pins and needles sensation" started in the left hand and
fingertips and spread proximally to involve the entire arm over
the course of ___ minutes. By 45 minutes the sensation
involved the left face and leg. There was no associated
headache, vision change, weakness or dizziness. She got up to
take a shower and noticed no sensory change to temperature while
in the shower. After about an hour, she began to note "pins an
needles" in the anterior right leg from the knee distally and in
the foot, also in the right V2-V3 distribution and right hand
fingertips. The right side symptoms are not a senory loss, but
more of a positive paresthesia. She came to the ED for
evaluation of possible TIA. En route to ___ she developed a 4
out of 10 left-sided non-throbbing HA associated with mild
photophobia. She has no prior history of migraines and no
family history. She sometimes gets mild headaches that are like
this but never associated with paresthesia. She does endorse a
prior history of seizure in ___ (possible frontal seizure
noted as brief episode of confused speech) and has been
seizure-free on trileptal since that time.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness. No bowel or
bladder incontinence or retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. +weight loss since gastric bypass ___. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
HTN
HLD
Fibromyalgia since ___
anxiety
CAD, aortic stenosis
CHF
GERD
Osteoarthritis
s/p gastric bypass in ___. Poor diet with 1500cal/day diet
Seizure disorder- episodes of nonsensical speech in ___, has
been stable on trileptal
Past Surgical History:
Plantar Fasciitis surgery
R knee arthroscopy
Carpal tunnel syndrome (left)
2 lumbar back surgeries
Social History:
___
Family History:
Mother: Died at ___ of Leukemia
Father: Died at ___ of bone cancer
Siblings: 3 sisters: 1 with leomyosarcoma, 1 with fibromyalgia,
1
with thyroid cancer and scleroderma
Children: Son with cancer and PE/DVT
Physical Exam:
Vitals: T:97.4 76 97/63 16 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, +III/VI holosystolic murmur
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. 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. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. No RAPD. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades. ? slight
L lid droop.
V: Facial sensation reduced to PP, coldtemp and light touch on
the left. Right V2-V3 has subjective pins and needles
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 5 5- ___ 4+ 5 5 5 5 5 5 5
R 5 5 5- ___ 4+ 5 5 5 5 5 5 5
Leg adbuction/adduction ___
-Sensory: Reduced sensation on the left hemibody to light touch
(80%), pinprick (50%), cold sensation, and vibratory sense.
Proprioception appears intact bilaterally. No overt extinction
to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor bilaterally.
-Coordination: Slight bilateral intention tremor, no
dysdiadochokinesia noted. No dysmetria on FNF or HKS
bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Exam was unchanged at the time of discharge.
Pertinent Results:
LABS:
___ 03:35PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
___ 03:35PM URINE RBC-1 WBC-4 BACTERIA-NONE YEAST-NONE
EPI-1
___ 03:35PM URINE AMORPH-RARE
___ 03:35PM URINE MUCOUS-RARE
___ 01:40PM GLUCOSE-79 UREA N-11 CREAT-0.7 SODIUM-130*
POTASSIUM-4.9 CHLORIDE-92* TOTAL CO2-34* ANION GAP-9
___ 01:40PM LIPASE-14
___ 01:40PM cTropnT-<0.01
___ 01:40PM ALBUMIN-3.8 CALCIUM-9.4 PHOSPHATE-2.7
MAGNESIUM-2.0
___ 01:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:40PM WBC-3.5* RBC-4.02* HGB-11.6* HCT-35.8* MCV-89
MCH-28.9 MCHC-32.4 RDW-14.9
___ 01:40PM NEUTS-48.7* LYMPHS-42.7* MONOS-6.1 EOS-1.2
BASOS-1.2
___ 01:40PM PLT COUNT-262
___ 01:40PM ___ PTT-33.9 ___
IMAGING:
CT HEAD ___:
1. No acute intracranial process. MR is more sensitive for
detection of acute infarct.
2. 5 mm colloid cyst.
CXR ___:
New small bilateral pleural effusions. Otherwise, no acute
cardiopulmonary process.
MRI/MRA HEAD/NECK ___:
1. No acute intracranial process. White matter changes, which
are nonspecific, but compatible with small-vessel ischemic
disease as described above.
2. Likely 2 mm infundibulum of the basilar artery at the AICA
origin.
Otherwise, no evidence of intracranial aneurysm larger than 3
mm.
ECHO ___:
The left atrium is mildly dilated. With maneuvers, there is
early appearance of agitated saline/microbubbles in the left
atrium/left ventricle most consistent with a patent foramen
ovale. 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 are moderately thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Patent foramen ovale. Normal global and regional
biventricular systolic function. Minimal aortic stenosis.
Brief Hospital Course:
___ is a ___ year-old right-handed woman with HTN, HLD
fibromyalgia, and prior seizure disorder who presented with new
onset left sided numbness and tingling and headache.
# Numbness: Her presentation with numbness and headache was
initially consistent with a complex migraine. However, her
numbness did not resolve during her hospitalization. This was
thought to be more consistent with a small ischemic stroke, for
which she has numerous risk factors. Her MRI however showed no
stroke. She underwent a stroke workup which was largely
unremarkable, although was significant for a patent foramen
ovale and small (2mm) infundibulum of the basilar artery. Her
HBA1c was 5.1%. B12 was above assay; she continued her home B12.
She continued aspirin and high potency statin.
# Chronic diastolic CHF: EF in ___ was preserved. Her cardiac
enzymes were negative. Her home antihypertensives were held and
beta blocker halved in the setting of possible stroke. ___
stockings were placed for mild BLE edema. She had mild
hyponatremia, likely from her heart failure. Despite having her
blood pressure medications, her blood pressure was notably low
(around 100 systolic). Her amlodipine was held at the time of
discharge.
# History of Seizures: continued home Trileptal
# GERD: continued PPI
TRANSITIONAL ISSUES:
- full code
- consider restarting amlodipine outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN SOB
4. Losartan Potassium 100 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Oxcarbazepine 150 mg PO BID
8. OxycoDONE (Immediate Release) 15 mg PO Q8H:PRN pain
9. Pregabalin 200 mg PO TID
10. QUEtiapine Fumarate 75 mg PO QHS
11. Aspirin 81 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Cyanocobalamin 1000 mcg PO DAILY
14. Vitamin D ___ UNIT PO DAILY
15. Calcium Carbonate 500 mg PO TID
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Calcium Carbonate 500 mg PO TID
3. Cyanocobalamin 1000 mcg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Oxcarbazepine 150 mg PO BID
7. OxycoDONE (Immediate Release) 15 mg PO Q8H:PRN pain
8. Pregabalin 200 mg PO TID
9. QUEtiapine Fumarate 75 mg PO QHS
10. Vitamin D ___ UNIT PO DAILY
11. Aspirin 81 mg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN SOB
13. Losartan Potassium 100 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
Take as needed for headache; do NOT take daily or around the
clock
RX *butalbital-acetaminophen-caff [Fioricet] 50 mg-300 mg-40 mg
1 capsule(s) by mouth every eight (8) hours Disp #*12 Capsule
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
possible ischemic stroke
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 meeting your during your recent
hospitalization. You came to the hospital with numbness on the
left side of your body and a headache. It is possible that you
had a very small stroke that was too small to be seen on your
MRI. You are on medications to help prevent strokes in the
future. For your headache, we have prescribed fiorocet. You
can take it occasionally, but, as we discussed, do not take it
daily as it could then worsen your headache.
During the admission, we noticed that your blood pressure was a
little bit low. After discussing with Dr. ___, we
felt that it would be best for you to NOT take amlodipine for
now.
MEDICATION CHANGES:
STOP
Amlodipine
START
Fiorocet
On discharge, please follow up with Drs. ___ as
scheduled below.
Please call Dr. ___ to schedule an appointment.
Followup Instructions:
___
|
19792705-DS-16
| 19,792,705 | 28,693,926 |
DS
| 16 |
2163-05-13 00:00:00
|
2163-05-13 18:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Nsaids / Brilinta / Plavix
Attending: ___.
Chief Complaint:
Fever, altered mental status
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
This is a ___ F with multiple medical comorbidities who was
brought in to the emergency department yesterday morning by her
husband, due to concerns of fevers of ___ at home, and altered
mental status. The AMS was so acute and notable, that initial
diagnostic efforts pursued ruling out CVA, or encephalitis. Abx
were started empirically. Eventually it was noted that she had
LFT abnormalities, and so a CT scan was ordered, which showed
possible cholecystitis. RUQ u/s was also obtained. ACS was
consulted for possible cholecystitis.
Past Medical History:
HTN
HLD
Fibromyalgia since ___
anxiety
CAD, aortic stenosis
CHF
GERD
Osteoarthritis
s/p gastric bypass in ___. Poor diet with 1500cal/day diet
Seizure disorder- episodes of nonsensical speech in ___, has
been stable on trileptal
Past Surgical History:
Plantar Fasciitis surgery
R knee arthroscopy
Carpal tunnel syndrome (left)
2 lumbar back surgeries
Social History:
___
Family History:
Mother: Died at ___ of Leukemia
Father: Died at ___ of bone cancer
Siblings: 3 sisters: 1 with leomyosarcoma, 1 with fibromyalgia,
1
with thyroid cancer and scleroderma
Children: Son with cancer and PE/DVT
Physical Exam:
Admission Physical Examination
Physical Exam: Vitals: 98.3 PO112 / 70
R ___
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: unlabored on RA
ABD: Soft, nondistended, TTP epigastrium and RUQ, positive
___, no palpable masses
Ext: 1+ ___ edema, ___ warm and well perfused
Discharge Physical Examination:
Pertinent Results:
___ 04:57AM BLOOD WBC-5.1 RBC-3.34* Hgb-8.5* Hct-27.0*
MCV-81* MCH-25.4* MCHC-31.5* RDW-16.8* RDWSD-48.9* Plt ___
___ 05:22AM BLOOD WBC-5.0 RBC-3.46* Hgb-9.1* Hct-27.7*
MCV-80* MCH-26.3 MCHC-32.9 RDW-16.8* RDWSD-48.5* Plt ___
___ 12:57PM BLOOD WBC-4.5 RBC-3.31* Hgb-8.5* Hct-26.1*
MCV-79* MCH-25.7* MCHC-32.6 RDW-16.5* RDWSD-47.6* Plt ___
___ 05:24AM BLOOD WBC-4.1 RBC-3.56* Hgb-9.1* Hct-28.5*
MCV-80* MCH-25.6* MCHC-31.9* RDW-16.6* RDWSD-48.8* Plt ___
___ 11:18AM BLOOD WBC-4.3 RBC-3.99 Hgb-10.4* Hct-32.0*
MCV-80* MCH-26.1 MCHC-32.5 RDW-17.1* RDWSD-50.0* Plt ___
___ 06:55AM BLOOD WBC-4.5 RBC-3.77* Hgb-9.8* Hct-30.2*
MCV-80* MCH-26.0 MCHC-32.5 RDW-17.7* RDWSD-52.0* Plt ___
___ 06:42AM BLOOD WBC-4.2 RBC-3.41* Hgb-8.9* Hct-28.2*
MCV-83 MCH-26.1 MCHC-31.6* RDW-18.2* RDWSD-55.0* Plt ___
___ 08:35PM BLOOD WBC-9.8 RBC-4.20 Hgb-10.8* Hct-33.6*
MCV-80* MCH-25.7* MCHC-32.1 RDW-17.5* RDWSD-50.9* Plt ___
___ 04:57AM BLOOD Glucose-87 UreaN-13 Creat-0.7 K-4.5
Cl-100 HCO3-32 AnGap-9*
___ 05:22AM BLOOD Glucose-86 UreaN-9 Creat-0.5 Na-145 K-4.3
Cl-104 HCO3-30 AnGap-11
___ 12:57PM BLOOD Glucose-160* UreaN-11 Creat-0.7 Na-138
K-4.0 Cl-100 HCO3-27 AnGap-11
___ 05:24AM BLOOD Glucose-90 UreaN-8 Creat-0.6 Na-144
Cl-103 HCO3-33* AnGap-8*
___ 11:18AM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-141 K-3.5
Cl-99 HCO3-27 AnGap-15
___ 06:55AM BLOOD Glucose-83 UreaN-9 Creat-0.7 Na-147
K-3.4* Cl-103 HCO3-29 AnGap-15
___ 06:40PM BLOOD K-3.7
___ 06:42AM BLOOD Glucose-121* UreaN-10 Creat-0.5 Na-144
K-4.3 Cl-110* HCO3-26 AnGap-8*
___ 08:35PM BLOOD Glucose-121* UreaN-23* Creat-1.0 Na-141
K-4.4 Cl-97 HCO3-29 AnGap-15
___ 05:24AM BLOOD ALT-66* AST-29 AlkPhos-129* TotBili-0.2
___ 11:18AM BLOOD ALT-89* AST-40 AlkPhos-144* TotBili-0.3
___ 06:55AM BLOOD ALT-116* AST-66* AlkPhos-109* TotBili-0.2
___ 06:42AM BLOOD ALT-171* AST-110* AlkPhos-106*
TotBili-0.3
___ 05:19AM BLOOD ALT-297* AST-371* AlkPhos-129*
TotBili-0.3
___ 08:35PM BLOOD ALT-378* AST-608* AlkPhos-146*
TotBili-0.4
___ 04:57AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.8
___ 05:22AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0
___ 12:57PM BLOOD Calcium-8.8 Phos-3.9 Mg-1.6
___ 11:18AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.5*
___ 06:40PM BLOOD Mg-1.3*
___ 06:42AM BLOOD Calcium-8.6 Phos-2.1* Mg-1.8
___ 05:19AM BLOOD Albumin-3.1*
___ 08:35PM BLOOD Albumin-3.8
Imaging:
cT abd/pelvis:
IMPRESSION:
1. Distended gallbladder with mild gallbladder wall edema, which
given the
presence of ascites, periportal edema, and anasarca is likely
due
to fluid
overload state. However if there is continued concern for acute
cholecystitis, a gallbladder ultrasound may be considered.
2. Trace right pleural effusion with small amount fluid overload
in the lungs.
3. Patient is status post Roux-en-Y gastric bypass with no
evidence of bowel
obstruction or other complication.
RUQ U/S:
Distended gallbladder containing marked amount of sludge and
mild
gallbladder
wall edema. Findings may reflect acute cholecystitis in the
correct clinical
setting however gallbladder wall thickening may also be
secondary
to third
spacing. Clinical correlation is needed and if there is high
clinical concern
for acute cholecystitis, consider HIDA scan or MRI with
hepatobiliary agent
for further assessment.
Brief Hospital Course:
Ms ___ is a ___ year old woman with a history of fibromyalgia,
hypertension, hyperlipidemia, CAD, seizure disorder, who
presented to the ED with 1 day of fever, chills and altered
mental status. Labs drawn in the ED were notable for elevated
transminases and alk phos, and a UTI. Neurology and medicine
were initially consulted. Surgery was consulted for evaluation
of cholangitis. She had an US which showed... and HIDA scan. She
was therefore consented and taken to the OR for a laparoscopic
cholecystectomy. A large patulous gallbladder was surgically
resected. She tolerated the procedure without any intraoperative
complication. Post-op, after a brief and uneventful stay in the
PACU, she was admitted to the surgical service floor for further
management.
Her post-op course on the floor were complicated pain management
and later orthostatic hypotension. Her diet was advanced as
appropriate. She is on chronic opioid pain management at home.
CPS was consulted for management of pain medications. She was
able to get on a regimen she was comfortable with and eventually
weaned down back to her home dose.
She was triggered on POD#4 for low BP. Physical therapy had
noted that her systolic blood pressure dipped into ___ when she
stood up to work. Her SBP picked up to the ___ once back lying.
Medicine was consulted. Septic work-up was negative. She had no
fevers, no chills and unelevated WBC. Her chest radiograph and
EKG were unremarkable and she looked clinically euvolemic. She
was given gentle IV resuscitation and responded appropriately.
She was initially evaluated by physical therapy on POD#3 who
recommended discharge to short term rehab, which patient was not
amenable to. She was discharged to home with physical therapy
after evaluation by ___ on subsequent days.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. At the time of discharge, the patient was
doing well, afebrile with stable vital signs. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. The patient was
discharged home with physical therapy. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
1. Docusate Sodium 100 mg PO BID
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Omeprazole 40 mg PO BID
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
8. Sucralfate 2 gm PO BID
9. Torsemide 30 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 40 mg PO QPM
12. BusPIRone 15 mg PO BID
13. Magnesium Oxide 400 mg PO DAILY
14. OXcarbazepine 300 mg PO BID
15. Pregabalin 200 mg PO TID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Metoprolol Succinate XL 12.5 mg PO DAILY
4. Omeprazole 40 mg PO BID
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
7. Senna 8.6 mg PO BID:PRN Constipation - First Line
Reason for PRN duplicate override: Alternating agents for
similar severity
8. Sucralfate 2 gm PO BID
9. Torsemide 30 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 40 mg PO QPM
12. BusPIRone 15 mg PO BID
13. Magnesium Oxide 400 mg PO DAILY
14. OXcarbazepine 300 mg PO BID
15. Pregabalin 200 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
acute cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
- we decreased the dose of the metoprolol you were on from 25mg
daily to 12.5mg daily. Please keep your follow-up appointment
with your PCP or cardiologist so they can adjust the dosage as
necessary
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.
Thank you for allowing us to participate in your care
Followup Instructions:
___
|
19792715-DS-7
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| 7 |
2178-08-04 00:00:00
|
2178-08-05 06:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
?Stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo right handed woman, ___ speaking
only, with a past medical history of hypertension who presents
as a transfer for left sided weakness and symptomatic
bradycardia.
Essentially, Ms. ___ awoke feeling well the morning of
presentation. She went about her morning feeling well and at
around noon, took a nap. When she awoke, she was noticed by her
daughter to be weak on her left side- arm and leg. She
attempted to stand, but almost fell to her left. There was also
concern for right facial droop per her daughter.
Her daughter then massaged her arm and leg attempting to improve
her symptoms. This did not work. Subseuqently, due to concern
for stroke, decision was made to present to ___. En
route, it appears her weakness ___ have improved, though exact
details are unclear.
At ___, she was called as a Code Stroke. She underwent
NCHCT. She was undergoing evaluation, but upon return from CT
had bradycardia to the ___. EKG revealed "rare p-waves and
junctional escape". She was given 1mg atropine with resolution
of her bradycardia, IV fluid and aspirin. She was transferred
to ___ for Cardiology and Neurology evaluation.
Of note, she has recently been evaluated by her PCP for
intermittent dyspnea and chest tightness (per her daughter's
report). Though diagnosis is unclear, she was started on an
aspirin at that time.
Of note, she has never had any symptoms like this before. No
prior transient neurologic symptoms such as numbness, weakness,
aphasia, etc.
RoS unable to be gathered from the patient.
Past Medical History:
- Hypertension
- GERD
Social History:
___
Family History:
No neurologic family hx. No particular diseases run in the
family
Physical Exam:
Admission Exam:
General: NAD.
HEENT: NC/AT,MMM
Neck: Supple. No nuchal rigidity. no nuchal rigidity.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND,
Extremities: WWP.
Skin: no rashes or lesions noted.
.
Neurologic:
-Mental Status: Eyes closed. Rouses with examiner persistence
(voice or noxious), but then drift off. Extremely inattentive.
Requires multiple repetitions of commands to follow. Oriented
to person, "hospital" and date. Unable to ___ forward or
back. Language is fluent per report. Able to name hand,
finger, and nail. Speech was slightly slurred. Able to follow
both midline and appendicular commands with examiner
persistance. Unable to test recall. There is evidence of a left
hemineglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Can cross to left, but favors right gaze. Normal
saccades. Decreased BTT on Right.
V: Facial sensation intact to light touch.
VII: Clear left NLF flattening, with decreased activation.
Right ptosis.
VIII: Hearing intact to room voice .
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline.
-Motor: Exam difficult due to inattention and left neglect.
Normal bulk, tone throughout. Left arm quickly drifts down. No
adventitious movements, such as tremor, noted. No asterixis
noted. Motor exam difficult due to inattention and left
neglect. Her right side is grossly full at all major muscle
groups including Delt, Bic Tri, FFl, IP, Quad, Ham, TA, Gastroc.
Her left side is
difficult to assess. She is easily antigravity in the LUE and
LLE. There is a question of mild weakness at her left deltoid
and left tricep, perhaps 4+ or 5-.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 2 2 3 1
R 2 2 2 2 2
Plantar response was up on left, down on right.
-Coordination: Assessment limited, but she appears to have LUE
ataxia with FNF out of proportion to her weakness (however as
she often closed eyes during assessment, there are alternative
explanations for ataxia). Additionally, she has significant
difficult with left heel on right shin. More complete
evaluation unable to be done.
-Gait: Unable to assess.
.
==========================================
.
Discharge Exam:
VS 98.6F, 153/89 (SBP 120-150), HR 86, RR 19, 98% on RA
Gen: Comfortable, NAD
Pulm: Clear to auscultation anteriorly
CV: Regular rate and rhythm, no murmurs, rubs or gallops
Abd: Bowel sounds present, soft
NEUROLOGIC EXAM
- Mental status: Awake. Alert. Promptly follows commands. At
first states that she is at home but then corrects to hospital
when prompted by her daughter.
- Cranial nerves: L pupil 4 -> 3, R pupil 3 -> 2. Pronounced L
facial weakness. R ptosis. Rightward gaze preference but crosses
midline to the left without fully burying sclera.
- Motor exam: L arm spasticity. Stereotypes movement in L leg
with pain. Left leg is fixed in abduction and flexion.
Delt Bic Tri FEx FFI IP TA Gas
L 0 0 0 0 0 0 0 0
R 4 ___ ___ 5
Sensory: ___ sign present on LUE. Plantar reflex extensor
on L, flexor on R. No deficits to light touch throughout.
Pertinent Results:
ADMISSION LABS
===============
___ 10:40PM BLOOD WBC-10.2*# RBC-3.66* Hgb-10.9* Hct-33.4*
MCV-91 MCH-29.8 MCHC-32.6 RDW-13.4 RDWSD-44.7 Plt ___
___ 10:40PM BLOOD Neuts-59.4 ___ Monos-9.7 Eos-1.1
Baso-0.7 Im ___ AbsNeut-6.06 AbsLymp-2.94 AbsMono-0.99*
AbsEos-0.11 AbsBaso-0.07
___ 10:45PM BLOOD ___ PTT-32.6 ___
___ 10:40PM BLOOD Plt ___
___ 10:40PM BLOOD Glucose-106* UreaN-18 Creat-0.8 Na-137
K-4.4 Cl-105 HCO3-21* AnGap-15
___ 10:40PM BLOOD ALT-44* AST-27 AlkPhos-88 TotBili-0.4
___ 10:40PM BLOOD cTropnT-<0.01
___ 10:40PM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.6 Mg-1.8
___ 10:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:51PM BLOOD Lactate-1.8
.
DISCHARGE LABS
================
___ 06:35AM BLOOD WBC-7.1 RBC-4.04 Hgb-12.0 Hct-36.9 MCV-91
MCH-29.7 MCHC-32.5 RDW-13.3 RDWSD-44.1 Plt ___
___ 06:45AM BLOOD Neuts-69.1 ___ Monos-7.0 Eos-0.3*
Baso-0.4 Im ___ AbsNeut-5.31 AbsLymp-1.74 AbsMono-0.54
AbsEos-0.02* AbsBaso-0.03
___ 06:35AM BLOOD Glucose-130* UreaN-13 Creat-0.6 Na-141
K-4.2 Cl-103 HCO3-28 AnGap-14
___ 06:35AM BLOOD Calcium-9.9 Phos-4.8* Mg-2.5
.
IMAGING
=============
___ CHEST (PORTABLE AP)
Cardiomegaly with possible mild pulmonary vascular congestion.
No focal
consolidation to suggest pneumonia.
.
___ CTA HEAD & CTA NECK
1. Abrupt vascular cutoff at the right internal carotid artery
terminus with absent filling of the proximal intracranial
internal carotid artery and diminished filling of the cervical
internal carotid artery suspicious for thrombus. There is
reconstitution of the anterior circulation via the circle of
___.
2. No CT evidence of acute infarct or hemorrhage.
3. Sub 4 mm pulmonary nodules at the lung apices which do not
require imaging follow up in low risk patients per the
___ criteria guidelines.
.
___ CT HEAD W/O CONTRAST
1. Right thalamic hypodensity is unchanged from outside hospital
examination of ___. This ___ represent prior
lacunar infarct however acuity is uncertain.
2. No evidence of large territorial infarction. Recommend
correlation with MRI for further evaluation of acute infarct
given findings of CTA.
.
___ MR HEAD W/O CONTRAST
1. Right basal ganglia and deep watershed infarction with no
evidence of mass effect or hemorrhage.
2. Re- demonstration of the thrombus in the right petrous,
cavernous and
communicating ICA, reconstituting at the level of the MCA,
better visualized on prior CTA.
.
___ Cardiovascular ECHO
+PFO, normal EF, mild aortic regurg
.
___ CT HEAD W/O CONTRAST
1. Evolving appearance of previously seen right MCA territorial
infarct. No significant mass effect. No evidence of hemorrhage
or new infarction.
.
___ CTA HEAD & CTA NECK
1. Continued evolution of deep watershed infarction in the right
basal
ganglia, thalamus and insula.
2. New complete occlusion of the distal M1 segment of the right
MCA to the
level of the bifurcation, with distal collateralization but
overall attenuated vascular supply in the right MCA
distribution. These findings are likely due to arterio-arterial
embolism, with interval distal migration of the previously
described thrombus at the right internal carotid artery
terminus.
3. Distal cervical and proximal intracranial portions of the
right internal carotid artery are now patent.
.
___ MRV PELVIS W&W/O CONTRA
1. Mild narrowing of the left common iliac vein as it courses
posterior to the left common iliac artery, but no significant
compression or imaging evidence of ___ syndrome. No
thrombus is identified.
2. The IVC appears slit-like and collapsed, possibly secondary
to dehydration.
.
___ BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
.
___ CT HEAD W/O CONTRAST
1. Unchanged appearance of evolving right MCA territorial
infarct. No
significant mass effect or midline shift.
.
___ Video Swallow Study #1
Silent aspiration of thin liquids with delayed throat clearing
and subsequent aspiration of nectar thick liquids with slight
cough.
.
___ CHEST (PORTABLE AP)
In comparison with the study of ___, the previous
Dobhoff tube has
been removed and replaced with a new tube with its tip in the
distal stomach. Little overall change in the appearance of the
heart and lungs.
.
___ PICC LINE PLACMENT SCH
1. The accessed vein was patent and compressible.
2. Basilicvein approach single lumen right PICC with tip in the
distal SVC.
.
___ CHEST PORT LINE/TUBE PL
New feeding tube placement. The course of the tube is
unremarkable, the tip projects over the middle parts of the
stomach right-sided PICC line with unremarkable course. The tip
projects over the right atrium and the line should be pulled
back by approximately 2-3 cm for correct placement at the
cavoatrial junction. No pleural effusions. No pneumonia. No
pneumothorax.
.
___ CHEST (PORTABLE AP)
Comparison to ___ 17:11. The position of the
feeding catheter and the right PICC line are constant. No
evidence of kinking in the feeding catheter. Moderate
cardiomegaly and low lung volumes persist. Minimal left and
right basal areas of atelectasis. No pleural effusions. No
pulmonary edema.
.
___ CHEST PORT LINE/TUBE PL
1. Dobhoff tube terminates in the stomach.
2. Stable or improving right lower lobe pneumonia.
.
___ DX CHEST PORT LINE/TUBE
1) Ductal tube tip is in the stomach. Heart size mediastinum
are stable. Mild vascular congestion is re- demonstrated.
2) Bibasal atelectasis is noted, right more than left on the
right more
conspicuous than on the previous study in and potentially
represent developing infectious process.
3) Right PICC line is mild positioned currently, coiled within
the right internal jugular vein and then continuing toward the
___, reposition/ flushing is recommended.
.
___ DX CHEST PORTABLE PICC
1) New right PIC line now passes into the ipsilateral jugular
vein and out of view.
2) Leftward mediastinal shift suggests new atelectasis in the
left lower lobe although the left hemidiaphragm is not elevated.
Moderate atelectasis at the right base has increased. Pleural
effusions are small if any. No pneumothorax. Moderate
cardiomegaly stable.
.
___ VENOUS LINE CHECK
Successful repositioning of the right basilic PICC line, with
final position of the distal tip projecting over the lower SVC,
in appropriate location. The line is ready to use.
.
___ Imaging VIDEO OROPHARYNGEAL SWA (pending)
Brief Hospital Course:
TRANSITIONAL ISSUES
- Anticoagulation started with Apixaban
- Started Atorvastatin 40mg daily
- Follow up with Neurology at scheduled appointment time in DC
instructions
- Follow up with cardiology after discharge from rehab
- Recently DC'ed ___
- Diet: puree solids and nectar thick liquids. Aspiration
precautions needed.
- PICC placed on ___ and adjusted on ___ during this
admission. Kept it in as patient had poor peripheral access.
Should be DC'ed when no longer needed.
.
.
HOSPITAL COURSE
===============
Mrs. ___ is a ___ year old right handed ___ woman with a
past history of hypertension presented with left sided weakness
and dysarthria in the context of severe bradycardia the day
previously w/ HR in the ___ requiring atropine at the outside
hospital. At the time of ED evaluation on ___, the patient's
left sided weakness briefly resolved but left facial droop
continued. Her NIHSS stroke score was 1 for mild loss of L
nasolabial fold. An EKG showed increased sinus beats. Cardiology
was consulted and recommended discontinuing the patient's
verapamil. The a patient was admitted to neurology for further
CVA workup.
.
Neuro: At 1:27am on ___, a CTA showed abrupt vascular cutoff at
the right internal carotid artery terminus with absent filling
of the proximal intracranial internal carotid artery and
diminished filling of the cervical internal carotid artery
suspicious for thrombus, but with no evidence of acute infarct.
.
On the neurology floor later that day ___ @ ~2:00pm, she
redeveloped worsening left hemiparesis, going to ___ in LUE and
LLE, to total hemiplegia, which ___ showed evolving R MCA
infarct. On the subsequent day, repeat CTA showed partial
recannulization of the R ICA but with clot progression into the
distal R M1 resulting in a new cutoff, at which point she was
beyond the window for IA therapy and continued maximal medical
therapy.
.
The R Horner's and dense R MCA syndrome thought to be secondary
cardioembolic embolus initially placed in R ICA causing
sympathetic nerve disruption, and subsequent clot migration to
distal M1. Upon review of outside records patient with
suspected history of paroxysmal atrial fibrillation per
cardiologist Dr. ___, which is most likely source. PFO was
found on Echo, but no lower extremity DVT or ___ anatomy
on ultrasound or pelvic MRV respectively. Patient was initially
kept flat with IV fluids and BP allowed to autoregulate before
slowly liberalizing head of bed requirements and narrowing BP
goals.
.
Subsequent hospital course was complicated by failed swallow
evaluation. The family was offered to take part in a DBS swallow
study but declined. An NG tube was placed after the patient was
found to be silently aspirating liquids on ___. S&S was not
able to reassess patient for clinical improvement until ___.
At this time it was determined that the patient had improved and
could safely drink nectar thickened liquids. She developed no
signs or symptoms of aspiration pneumonia during admission.
.
CV: Cardiology consulted regarding sinus bradycardia on
presentation, requiring atropine at outside facility. Possibly
due to verapamil causing low heart rate, perhaps with some
additional low rate atrial fibrillation, but no afib seen on
tele while admitted. On review of records, patient was noted to
have paroxysmal atrial fibrillation per outpatient cardiologist
Dr. ___. Her verapamil was stopped and her losartan was also
held during this admission as her blood pressures were within
normal without it. She will need to follow up with cardiology
for Holter x2 weeks.
.
Started the patient on Atorvastatin 40mg daily and aspirin 81mg
initially. Aspirin was stopped and Apixiban was started prior to
discharge after she passed her MBS/speech and swallow eval.
.
FEN: Patient required nasogastric tube placement with tube
feeds while failing bedside swallow and with silent aspiration
of thin and nectar thick liquids on video swallow ___.
Repeat MBS on ___ showed that she had a small degree of silent
aspiration with thins and had some trouble mobilizing soft food.
She did well with puree solids and nectar thick liquids which
was started. Her Dobhoff tube was kept in to continue tube
feeds, decreased as she increased PO intake. Her Dobhoff was
DC'ed on ___ and she will continue on her PO diet. She will
need 1:1 supervision with aspiration precautions with feeding -
small bites alternating with sips of liquids.
.
#Persistent RLL consolidation
Ongoing aspiration risk before Mrs. ___ passed her repeat video
swallow. Portable chest X rays taken to assess PICC line
placement showed development and the persistence of
consolidation in RLL. At first this was thought to represent
aspiration pneumonitis. However the patient never developed a
significant white count, fever, hypoxia, or shortness of breath
and so she was not treated with antibiotics. At the time of
discharge she showed no signs or symptoms of infection.
.
#IV ACCESS
She had difficult vascular access and PICC was placed ___.
This PICC required repositioning on ___. On the ___ the ___
line was confirmed to be in the correct location. ___ was DC'ed
prior to DC.
.
# Diarrhea
Intially on stool softeners but this was stopped due to some
diarrhea prior to discharge. Cdif was negative during the
hospital admission. This self resolved.
.
CORE MEASURES
=============
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 - ASA () No
4. LDL documented? (x) Yes (LDL = 121) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - Atorva 40mg
() No [if LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - rehab () No
9. Discharged on statin therapy? (x) Yes - Atorva 40 () No [if
LDL >100, reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fish Oil (Omega 3) 1000 mg PO TID
2. Daily-Vite (multivitamin) oral DAILY
3. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
1X/WEEK
4. Omeprazole 20 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Verapamil 180 mg PO Q12H
7. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right middle cerebral artery infarct
Discharge Condition:
Awake, alert, makes eye contact, follows commands consistently
in ___. No movement on left arm, leg. Left facial droop.
Right Horner's syndrome.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of left sided weakness and
slow heart rate resulting from an acute ischemic stroke, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
You have high LDL, which is a type of fatty acid. You also have
atrial fibrillation. Both of these can cause strokes, so to
prevent future strokes, we plan to modify your risk factors as
follows:
- Start Atorvastatin 40 mg by mouth every evening
- Start oral anticoagulation with apixaban 5mg twice daily
- ___ need Holter monitor for 2 weeks per cardiology - However
you were monitored for 12 days as an inpatient with no atrial
fibrillation seen.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
It was a pleasure to take part in your care,
Your ___ Neurology Team
Followup Instructions:
___
|
19792715-DS-8
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2178-08-12 17:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___.
Chief Complaint:
chest pain, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with history of paroxysmal AFib,
HTN, GERD, recent discharge for Right MCA infarct, presenting
with chest pain.
Patient describes sudden onset substernal chest pain at 4PM on
day of presentation. The pain was sharp, substernal,
non-radiating, non-pleuritic and non-positional. Pain was
associated with dyspnea. Patient also appeared flushed during
this episode. Symptoms lasted 10 minutes and resolved with NTG
x2 and ASA 324. She has not had chest pain since that time.
Patient has not had leg pain or swelling and has been on
apixaban since her stroke. She was sent to ___
with workup there notable for negative troponin, CXR with small
opactity at base of R lung most likely due to atelectasis.
Of note patient was recently admitted ___ with
symptomatic bradycardia requiring atropine, R MCA stroke,
embolic secondary to paroxysmal atrial fibrillation and PFO. She
was started on apixaban prior to discharge. Patient's course
complicated by silent aspiration, poor IV access. Her
symptomatic bradycardia thought to be secondary to verapamil.
Verapamil and losartan discontinued during admission with plan
for holter monitor and outpatient cardiology follow up. For her
aspiration she had a dobhoff placed that was removed ___ with
resumption of normal diet.
In the ED, initial vitals:
98.2 78 137/72 14 96% Nasal Cannula
EKG: NSR, HR77, NA, NI with QTc 487, TWI V2 and V3, no STE
Labs were significant for WBC 10.6 without left shift, normal
H/H, thromboctyosis 490k, lytes notable for baseline creatinine
0.7, elevated Phos 4.8, Calcium 10.5, elevated PTT 40.8, INR
1.3; negative UA, ddimer 515, trop <0.01.
CTA showed: No evidence of pulmonary embolism or aortic
abnormality.
Vitals prior to transfer: 70 126/74 18 96% RA
Past Medical History:
- Hypertension
- GERD
- R CVA in ___ w/ residual left-sided weakness
- Atrial fibrillation on apixiban
Social History:
___
Family History:
No neurologic family hx. No particular diseases run in the
family
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.7 131/74 82 18 98%RA
Wt 56.6 kg
GEN: Vietamese-speaking female laying in bed, NAD
HEENT: L sided facial droop, MMM, anicteric sclerae
NECK: Supple
PULM: CTAB, no wheezes, rales or rhonchi heard anteriorly
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema. ___ strength LUE and LLE,
___nd RLE
NEURO: L facial droop, weakness as above. AAOx3
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 97.4 120-130/70 60-70 16 98% RA
GEN: ___ female seated in bed, NAD
HEENT: L sided facial droop, MMM, anicteric sclerae
NECK: Supple
PULM: CTAB, no wheezes, rales or rhonchi heard anteriorly
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-tender, non-distended
EXTREM: Warm, well-perfused, no edema. ___ strength LUE and LLE,
___nd RLE
NEURO: L facial droop, weakness as above.
Skin: No rashes, areas of erythema.
Pertinent Results:
ADMISSION LABS:
===============
___ 06:49AM PLT COUNT-482*
___ 06:49AM WBC-10.1* RBC-4.01 HGB-12.0 HCT-36.8 MCV-92
MCH-29.9 MCHC-32.6 RDW-13.3 RDWSD-45.0
___ 06:49AM CALCIUM-10.5* PHOSPHATE-4.9* MAGNESIUM-2.1
___ 06:49AM estGFR-Using this
___ 06:49AM GLUCOSE-118* UREA N-25* CREAT-0.8 SODIUM-142
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-32 ANION GAP-13
___ 01:30AM ___ PTT-40.8* ___
___ 01:30AM PLT COUNT-490*
___ 01:30AM NEUTS-54.4 ___ MONOS-8.4 EOS-2.5
BASOS-0.8 IM ___ AbsNeut-5.77 AbsLymp-3.55 AbsMono-0.89*
AbsEos-0.27 AbsBaso-0.08
___ 01:30AM WBC-10.6* RBC-4.11 HGB-12.1 HCT-37.6 MCV-92
MCH-29.4 MCHC-32.2 RDW-13.4 RDWSD-44.7
___ 01:30AM D-DIMER-515*
___ 01:30AM ALBUMIN-4.1 CALCIUM-10.5* PHOSPHATE-4.8*
MAGNESIUM-2.1
___ 01:30AM cTropnT-<0.01
___ 01:30AM LIPASE-48
___ 01:30AM ALT(SGPT)-32 AST(SGOT)-26 ALK PHOS-92 TOT
BILI-0.7
___ 01:30AM GLUCOSE-95 UREA N-28* CREAT-0.7 SODIUM-139
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-26 ANION GAP-16
___ 02:01AM URINE MUCOUS-FEW
___ 02:01AM URINE HYALINE-1*
___ 02:01AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 02:01AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 02:01AM URINE COLOR-Yellow APPEAR-SlHazy SP ___
___ 02:01AM URINE GR HOLD-HOLD
___ 02:01AM URINE UHOLD-HOLD
___ 02:01AM URINE HOURS-RANDOM
___ 08:50AM cTropnT-<0.01
___ 02:01AM URINE HOURS-RANDOM
___ 02:50PM URINE RBC-3* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 02:50PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:06PM 25OH VitD-27*
___ 05:06PM PTH-41
___ 05:06PM cTropnT-<0.01
___ 06:13PM freeCa-1.02*
___ 06:13PM ___ PH-7.64*
IMAGING/STUDIES:
+ EKG: NSR, HR77, NA, NI with QTc 487, TWI V2 and V3, no STE
+ ___ Imaging CTA CHEST W&W/O C&RECON
IMPRESSION:
No evidence of pulmonary embolism or aortic abnormality.
+ ___ Imaging CHEST (PA & LAT)
IMPRESSION:
Comparison to ___. No relevant change. Mild
elevation of the right hemidiaphragm with mild atelectasis at
the right lung basis. No
evidence of pneumonia. No pleural effusions. No pulmonary
edema. Normal
size of the heart, normal hilar and mediastinal contours.
MICRO:
blood cultures: Finalized negative x2
urine culture:
___ 2:50 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| ENTEROCOCCUS SP.
| |
AMIKACIN-------------- <=2 S
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM------------- 1 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- =>16 R
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S
DISCHARGE LABS:
___ 07:14AM BLOOD WBC-8.0 RBC-3.91 Hgb-11.6 Hct-36.0 MCV-92
MCH-29.7 MCHC-32.2 RDW-13.2 RDWSD-43.8 Plt ___
___ 07:14AM BLOOD Glucose-102* UreaN-20 Creat-0.6 Na-140
K-4.2 Cl-105 HCO3-23 AnGap-16
___ 07:14AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of paroxysmal
atrial fibrillation on apixaban, HTN, GERD, recent discharge
___ for Right MCA infarct, presenting with chest pain. Patient
was found to have TWI in V2, V3, cardiac biomarkers negative x1.
Patient was admitted to medicine for chest pain rule out.
ACTIVE ISSUES:
==============
# Chest Pain: Patient without significant cardiac risk factors-
no smoking history, no diabetes, no family history of MI, no
hyperlipidemia, ___ Risk Score <10%. Troponins were
trended and were negative x3. The TWI in V2, V3 were found to be
stable from prior to this admission and serial EKGs showed no
further changes. Patient was maintained on telemetry and had no
further episodes of chest pain.
# Proteus & Enterococcus UTI: Patient was found to have an
uptrending leukocytosis (7-->13). Urinalysis was negative but
urine culture intially showed Proteus species and patient was
therefore started on ceftriaxone with improvement in
leukocytosis. Urine culture subsequently grew enterococcus, so
she was treated with PO Augmentin for 3 days.
CHRONIC ISSUES:
===============
# Recent MCA Stroke: Patient had been discharged ___ after an
MCA stroke secondary to pAF. She was maintained on atorvastatin
and apixaban. ___ and OT followed the patient in house. She
remained on aspiration precautions with a pureed dysphagia diet
and nectar prethickened liquids.
# Paroxysmal atrial fibrillation: Patient on apixaban. Was not
on rate control agents during this hospitalization because
during previous hospitalization developed symptomatic
bradycardia requiring atropine, and therefore home verapamil was
discontinued. Patient's heart rates were well-controlled without
any agents.
# ESSENTIAL HYPERTENSION: Losartan and verapamil were stopped
during last hospital stay. Blood pressures remained under good
control despite not being on these medications during this
hospital stay.
TRANSITIONAL ISSUES:
====================
- Patient to take one more dose of Augmentin 875 mg (finishing
on ___
- On previous hospitalization patient was noted to have
symptomatic bradycardia - will need follow-up to be scheduled
with Dr. ___ in ___, to be seen within ___ weeks
of hospital discharge.
- Patient should not receive any nodal agents (beta blockers or
calcium channel blockers) until evaluated by cardiology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
1X/WEEK
2. Omeprazole 20 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO TID
4. Atorvastatin 40 mg PO QPM
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Multivitamins 1 TAB PO DAILY
7. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
8. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
9. Apixaban 5 mg PO BID
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Atorvastatin 40 mg PO QPM
3. Fish Oil (Omega 3) 1000 mg PO TID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Multivitamins 1 TAB PO DAILY
6. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
7. Docusate Sodium 100 mg PO BID
8. Senna 17.2 mg PO HS
9. Omeprazole 20 mg PO DAILY
10. Vitamin D2 (ergocalciferol (vitamin D2)) 50,000 unit oral
1X/WEEK
11. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 3 Days
Take 1 more dose in the evening on ___, then stop
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Chest Pain
Urinary Tract Infection
Secondary diagnoses:
s/p R MCA Stroke
Paroxysmal Atrial fibrillation
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure caring for you at ___
___. You were admitted to hospital because you were
having chest pain at your rehab. You had blood tests and EKGs
that were reassuring that you were not having a heart attack.
During your hospital stay, we found that you had a urinary tract
infection, which we treated with antibiotics. You stayed in the
hospital for a few days while we arranged a new rehab facility
for you, and you were discharged.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19792891-DS-16
| 19,792,891 | 28,919,837 |
DS
| 16 |
2169-06-21 00:00:00
|
2169-06-26 22:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Transesophageal echo, ___:
The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque to35 cm
from the incisors. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are severely thickened/deformed. The mitral valve
leaflets are myxomatous. There is moderate/severe bi-leaflet
mitral valve prolapse. There is partial A2 mitral leaflet flail.
The mitral valve leaflets do not fully coapt. No mass or
vegetation is seen on the mitral valve. Severe (4+) mitral
regurgitation is seen with reversal of flow in the pulmonary
veins without reversal of flow in the descending aorta.
IMPRESSION: Severe bileaflet mitral valve prolapse with partial
flail. Severe eccentric mitral regurgitation.Mild aortic
regurgitation.
Cardiac catheterization, ___:
Dominance: right, normal right dominant coronary system
LMCA is patent
LAD is patent
Circumflex is patent
RCA is patent
History of Present Illness:
Mr. ___ is a ___ with a past medical history of murmur who
presented to the ER ___ for evaluation of dyspnea. He is an
ophthalmologist and states that the dyspnea has been
intermittent for the past ___ weeks at a maximum, but became
significantly worse ___. He describes dyspnea on moderate
exertion that was not limiting him from normal activities
(climbing trees, hiking, and doing moderately intense exercise).
He thinks he's been stopping to catch his breath slightly more
frequently for a few weeks, but wasn't at all concerned and
thought he was out of shape. He spent 10 days abroad in the
___ and when he got back over the weekend noted that he
had to stop to catch his breath ___ times while taking out the
trash, which was significantly worse than ever before.
Additionally, on ___ and ___ he says he heard "rales" when he
was laying down at night, but assumed he had a respiratory
infection. He has not had any exertional chest pressure/pain,
cough, wheeze, PND, or fever.
He denies any fever, leg pain, leg swelling, history of PE,
history of cancer, abdominal swelling, abdominal pain,
confusion. He did say he had indigestion the a day or two ago
and took an antacid.
Past Medical History:
Murmur
Social History:
___
Family History:
Mother - MI at ___, DM
Brother - MI and CABG in ___
Physical Exam:
PHYSICAL EXAM UPON ADMISSION:
VS: T= 98.1 BP=136/84 HR=80 RR=18 O2 sat=99% ___
GENERAL: Well-appearing, well-groomed middle-aged man in NAD
HEENT: Sclera anicteric. No oral lesions. No xanthelasma
NECK: JVP 7cm
CARDIAC: RR, normal S2, inaudible s1. ___ blowing holosystolic
murmur loudest at apex. No s3/s4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bibasilar crackles. No
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
PHYSICAL EXAM UPON DISCHARGE:
BP 113/68 (110/60s) HR ___ T 97.9 RR 18 99% on room air
Weight 78.3 kg (78.2 on ___
General: well appearing, no acute distress
Neck: supple, no JVD
Heart: RRR, s1 and s2 are heard, holystolic blowing murmur heard
best at apex
Lungs: CTABL, no wheezes or rhonci
Abdomen: NABS, soft, non tender to palpation, no rebound or
guarding
Extremities: No ___ edema
Pertinent Results:
___ 07:00PM CREAT-1.1 SODIUM-139 POTASSIUM-3.6
CHLORIDE-101
___ 07:00PM MAGNESIUM-2.3
___ 10:22AM cTropnT-0.02*
___ 04:34AM ___ PTT-27.8 ___
___ 04:20AM GLUCOSE-107* UREA N-25* CREAT-0.9 SODIUM-142
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-22 ANION GAP-17
___ 04:20AM estGFR-Using this
___ 04:20AM cTropnT-<0.01
___ 04:20AM proBNP-539*
___ 04:20AM WBC-5.8 RBC-4.27* HGB-13.2* HCT-39.5* MCV-93
MCH-30.9 MCHC-33.4 RDW-13.1 RDWSD-43.8
___ 04:20AM NEUTS-72.2* LYMPHS-16.3* MONOS-5.5 EOS-4.6
BASOS-0.7 IM ___ AbsNeut-4.22 AbsLymp-0.95* AbsMono-0.32
AbsEos-0.27 AbsBaso-0.04
___ 04:20AM PLT COUNT-163
___ 04:55AM BLOOD WBC-6.6 RBC-4.37* Hgb-13.4* Hct-40.8
MCV-93 MCH-30.7 MCHC-32.8 RDW-13.1 RDWSD-44.4 Plt ___
___ 04:55AM BLOOD Glucose-94 UreaN-32* Creat-1.0 Na-136
K-4.1 Cl-100 HCO3-25 AnGap-15
___
Suface echo:
IMPRESSION: Severe mitral regurgitation with suggestion of flail
posterior mitral leaflet. Preserved biventricular systolic
function.
___
Surface echo:
IMPRESSION: Posterior mitral leaflet flail with moderate-severe
eccentric mitral regurgitation. Mild symmetric left ventricular
hypertrophy with normal cavity size and hyperdynamic left
ventricular systolic function with mild resting outflow tract
obstruction. Mild aortic regurgitation. Mild aortic root
dilatation
___:
Surface echo:
Focused study. Overall left ventricular systolic function is
normal (LVEF>55%). RV with normal free wall contractility.
Significant aortic regurgitation is present, but cannot be
quantified. The mitral valve leaflets are mildly thickened.
There is moderate mitral valve prolapse. An eccentric, jet of
moderate to severe (3+) mitral regurgitation is seen. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
change.
Brief Hospital Course:
___ with no significant PMHx presents with acute-subacute
dyspnea over several days and found to have acute decompensated
CHF secondary to severe MR.
# Severe mitral regurgitation:
In our ED, echo revealed severe bileaflet mitral valve prolapse
with partial flair with evidence of myxomatous change along the
mitral valve. It was unlikely to be papillary muscle rupture
from AMI given negative troponins, which excluded significant
infarct several days prior to his admission. The patient was
admitted to the cardiology service for diuresis and work up for
cardiac surgery. The patient was diuresed with IV lasix but echo
after diuresis continued to show severe mitral valve
regurgitation and prolapse. A cardiac cath was performed and did
not reveal any stenosis or evidence of coronary artery disease.
The patient was seen and evaluated by cardiac surgery and
surgery was scheduled for ___. Anesthesia also evaluated the
patient for surgery, and a dental workup revealed no issues. The
patient was discharged on aspirin and given seven doses of 20 mg
PO lasix in case symptoms return.
Transitional issues:
Please contact Dr. ___ if ___ have any questions
regarding your cardiac surgery (___).
Please set up an appointment with Dr. ___. (___)
___ were started on 81 mg PO aspirin daily. ___ can take this on
the morning of your surgery.
___ were also given seven pills of lasix (20 mg each)- please
take one of these if ___ feel like ___ are accumulating fluid
and contact Dr. ___ need to take it.
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. Furosemide 20 mg PO DAILY:PRN volume overload Duration: 7
Doses
Please take this medication if ___ feel like ___ are
accumulating fluid
Discharge Disposition:
Home
Discharge Diagnosis:
Severe mitral regurgitation
Severe mitral valve prolapse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ were ___ to ___ on ___ with shortness of breath
with exertion. ___ were found to have severe mitral
regurgitation with mitral valve prolapse. A cardiac cath
revealed no evidence of coronary artery disease. ___ were seen
by cardiac surgery and evaluated for mitral valve
repair/replacement. Your surgery was scheduled for ___.
It was nice to meet ___.
Best,
Your ___ care
Followup Instructions:
___
|
19792891-DS-18
| 19,792,891 | 24,107,464 |
DS
| 18 |
2170-10-03 00:00:00
|
2170-10-03 15:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / shrimp
Attending: ___
Chief Complaint:
Sensory change, Gait difficulty
Major Surgical or Invasive Procedure:
- Transesophageal echocardiogram (___)
History of Present Illness:
___ is a ___ year-old R-handed man, pmh of MR ___ MVR
and prior L parietal-occipital stroke, who presents with changes
in sensation to left upper extremity and changes in gait.
He was in his usual state of health. He was at a gym of her
stay
shower, when he took off his shirt, he felt that "someone else's
hand was touching" him. He felt lightheaded, but he took a
shower annually. He felt lightheaded while in the shower. He
felt like his left hand was behaving oddly "as if he did not
have
control over it" the sensation also felt different but he was
unable to describe further. He denies numbness tingling or
weakness. He will use this strange sensation "as if it was
someone else's hand" and he thought "it was in the evening" but
he was still able to move his hand as he needed. This these
changes in the left upper extremity lasted for about 5 minutes.
He walked upstairs to his apartment. He noticed while he was
walking that he was dragging his left foot behind him. He
denied
weakness numbness tingling or any similar changes in sensation
Has had on the left upper extremity. He mostly notes that it
was
not moving as well as the right, but he was still able to stand
and walk on his left foot. Duration was about less than 5
minutes. He denies any falls at this time. He is very anxious
about falling so he remained leaning against a wall. He was
worried that he possibly would not wake up in the morning or
that
if he fell no one would find him, so he called ___ to get
evaluated. He initially attributed his symptoms to a heavy meal
and red wine, but then was later concern for stroke. WHen EMS
arrived, he noticed his speech was slurred for about 30 seconds,
but he had no difficulties understanding.
Per chart review, he had a stroke in L parieto-occipital region
with Right upper quadrantsnopia. He was seen by Dr. ___ see notes for details.), but was notable for "a strand
or
Lambl's excressance in the left atrium. He was placed on heparin
and then Lovenox, which he still is on
and then transitioned to Coumadin". Dr. ___ was concerned a
clot can form on clot and could result in further strokes.
Patient was recommended for TEE.
On neuro ROS, the pt endorses headache lasting a few mins of
daily, but none today. Denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, lightheadedness, vertigo,
tinnitus or hearing difficulty. Denies difficulties
comprehending
speech. Denies focal weakness, numbness, parasthesiae. No bowel
or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
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:
Mitral regurgitation ___ MVR
CVA in ___ -- Right upper qradrantopsia
Social History:
___
Family History:
Mother - MI at ___, DM
Father - ___ in ___
Brother - MI and CABG in ___
Physical Exam:
==============
ADMISSION EXAM
==============
Vitals: T: 98.5 P: 63 r: 16 BP: 143/57 SaO2: NM percent on room
air
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits.
Pulmonary: CTABL. No R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, +BS, no masses or organomegaly noted.
Extremities: No C/C/E bilaterally
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 ___ -> ___ MC 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 finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 3 2 3 1
Plantar response was flexor bilaterally.
R suprapatellar reflex, Crossed adductor
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
==============
DISCHARGE EXAM
==============
Essentially unchanged -- normal.
Pertinent Results:
====
LABS
====
___ 02:25AM BLOOD WBC-6.2 RBC-4.54*# Hgb-13.7 Hct-41.9
MCV-92 MCH-30.2 MCHC-32.7 RDW-13.5 RDWSD-46.1 Plt ___
___ 06:20AM BLOOD WBC-5.0 RBC-4.46* Hgb-13.4* Hct-41.1
MCV-92 MCH-30.0 MCHC-32.6 RDW-13.6 RDWSD-46.4* Plt ___
___ 06:10AM BLOOD WBC-5.6 RBC-4.35* Hgb-13.0* Hct-40.6
MCV-93 MCH-29.9 MCHC-32.0 RDW-13.5 RDWSD-46.4* Plt ___
___ 02:25AM BLOOD Neuts-58.1 ___ Monos-6.8 Eos-4.1
Baso-0.5 Im ___ AbsNeut-3.52 AbsLymp-1.83 AbsMono-0.41
AbsEos-0.25 AbsBaso-0.03
___ 02:25AM BLOOD ___ PTT-42.4* ___
___ 06:20AM BLOOD ___ PTT-42.2* ___
___ 06:10AM BLOOD ___
___ 02:25AM BLOOD Glucose-120* UreaN-26* Creat-1.3* Na-140
K-4.4 Cl-108 HCO3-23 AnGap-13
___ 06:20AM BLOOD Glucose-103* UreaN-24* Creat-0.9 Na-143
K-3.8 Cl-106 HCO3-21* AnGap-20
___ 06:10AM BLOOD Glucose-94 UreaN-26* Creat-1.0 Na-140
K-3.9 Cl-102 HCO3-24 AnGap-18
___ 02:25AM BLOOD ALT-29 AST-39 AlkPhos-108 TotBili-0.8
___ 06:20AM BLOOD ALT-30 AST-50* LD(LDH)-247 AlkPhos-96
TotBili-0.9
___ 06:10AM BLOOD ALT-29 AST-45* AlkPhos-96 TotBili-1.0
___ 02:25AM BLOOD Albumin-4.4 Calcium-9.3 Phos-2.6* Mg-2.1
___ 06:20AM BLOOD Albumin-3.8 Calcium-8.9 Phos-3.4 Mg-2.3
Cholest-132
___ 06:10AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.2
___ 06:20AM BLOOD %HbA1c-5.9 eAG-123
___ 06:20AM BLOOD Triglyc-71 HDL-48 CHOL/HD-2.8 LDLcalc-70
___ 02:37AM BLOOD Glucose-116* Lactate-2.1* Na-143 K-4.1
Cl-104 calHCO3-24
=======
IMAGING
=======
- ___ CT head
No evidence of hemorrhage or recent infarction.
- ___ CTA head & neck
1. Dental amalgam streak artifact limits study.
2. Subtle hypodensities are seen within the right parietal lobe,
left centrum semiovale and posterior margin of the right insular
cortex, which may be secondary to an acute infarction. An MRI
may be helpful for further evaluation.
3. No acute intracranial hemorrhage.
4. Hypodensity within the left occipital ___ be secondary
to a chronic infarction.
5. Unremarkable CTA of the head without evidence of stenosis or
aneurysm.
6. Unremarkable CTA of the neck without significant internal
carotid artery stenosis by NASCET criteria.
7. Nonspecific enlarged right supraclavicular lymph node with
short axis measurement up to approximately 1.4 cm, with
additional subcentimeter nonspecific lymph nodes described.
While finding may be reactive in nature, infectious or
neoplastic etiologies are not excluded on the basis examination.
- ___ MRI head
1. Late acute/early subacute infarcts involving the right
insula, frontal operculum, and inferior parietal lobe,
corresponding to the right MCA distribution.
2. Single punctate focus of slow diffusion in the left occipital
cortex, in proximity to a chronic infarct in this region.
3. Multiple scattered chronic supra and infratentorial micro
hemorrhages are grossly unchanged. There is no new hemorrhage.
- ___ TEE
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers. Overall left ventricular systolic function is
normal (LVEF>55%). There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. No masses or vegetations are seen on the aortic
valve. Trace aortic regurgitation is seen. A bioprosthetic
mitral valve prosthesis is present. A bioprosthetic mitral valve
prosthesis is present. The mitral prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. There are two very small mobile echodensities
measuring 3mm by 2mm on the left atrial side of the mitral valve
that appear to originate from the mitral valve support ring
(clip 10, 85) consistent with suture tips versus thrombus.
Vegetation cannot be excluded and should be considered in the
appropriate clinical context. No mitral regurgitation is seen.
IMPRESSION: Well seated biologic mitral valve replacement with
normal gradient and no regurgitation. Two small echodensities
that appear to originate from the mitral valve support ring are
most consistent with suture tips versus thrombus. Vegetation
cannot be excluded and should be considered in the appropriate
clinical context.
PRELIMINARY REPORT developed by a Cardiology Fellow. Not
reviewed/approved by the Attending Echo Physician.
Brief Hospital Course:
Dr. ___ is a ___ year-old man with a history of MR ___ MVR
and left occipital stroke now on Coumadin, who presented due to
gait difficulty and left extremity sensation changes which had
resolved by the time of initial examination. MRI found
acute/subacute infarcts in the right insula, frontal operculum,
and inferior parietal lobe, corresponding to the right MCA
distribution; and a punctate acute infarct in the left occipital
cortex. A1c and LDL were normal. ___ revealed "Two small
echodensities that appear to originate from the mitral valve
support ring are most consistent with suture tips versus
thrombus. Vegetation cannot be excluded and should be considered
in the appropriate clinical context." There was concern that
these are serving as a nidus for thrombi leading to his
bilaterally distributed infarcts -- especially given his
therapeutic INR of 3.1 and minimal atherosclerotic burden. Labs
for arterial hypercoagulability were drawn prior to discharge.
He was started in aspirin 81mg DAILY in the interim, and will
follow-up with stroke neurology (Dr. ___ and cardiac
surgery (Dr. ___, with whom updated appointments were
made.
- Started aspirin 81mg DAILY in addition to previous medication
regimen.
- Follow-up with Drs. ___.
- Follow-up anti-cardiolipin, beta-2 glycoprotein, and D-dimer
labs.
=======================================
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 = 70) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
() Yes - (x) 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 - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
========================================
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Warfarin 5 mg PO 4X/WEEK (___)
3. Warfarin 7.5 mg PO 3X/WEEK (___)
4. Metoprolol Tartrate 12.5 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Metoprolol Tartrate 12.5 mg PO BID
4. Warfarin 5 mg PO 4X/WEEK (___)
5. Warfarin 7.5 mg PO 3X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of decreased sensation on
the left side and changes in gait resulting from an ACUTE
ISCHEMIC STROKE, a condition where a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Prosthetic mitral valve
We are changing your medications as follows:
- START aspirin 81mg DAILY.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19792891-DS-19
| 19,792,891 | 21,790,699 |
DS
| 19 |
2170-12-15 00:00:00
|
2170-12-15 16:41:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Penicillins / shrimp
Attending: ___.
Chief Complaint:
aphasia, and RT arm numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr. ___ is a pleasant ___ y/o man with medical history of RT
MCA distribution punctate strokes, and previous ischemic stroke
with residual quadrantanopsia, MVR on Coumadin with possible MV
thrombi on latest TEE. He presents to the ED for evaluation
after
developing acute onset RT arm numbness and severe aphasia, on
his way to a cardiology appointment. LKW unclear but reports was
well this morning when he woke up. NIHSS 4 for inability to
state
age, severe aphasia, and RT arm extinction.
History limited by aphasia. He attempts to report he woke up
today in his usual state of health. He had a cardiology
appointment for a TEE. Around 7:30 AM on the way to his
appointment he developed acute onset right arm numbness and
associated difficulty speaking so presented to the emergency
department. During our interview he speaks in stereotyped
phrases
such as "I cannot speak well", "I cannot read that". He knows
what he is trying to say but the words do not come out right,
which he is visibly frustrated with. He is also able to gesture
about what he is trying to say, however spontaneous speech is
limited by many paraphasic errors.
In the ED code stroke was called he was initially scored as a
___
stroke scale of 2 for aphasia and right arm numbness. He was
taken emergently to non-contrast head CT which did not show any
evidence of large territory hemorrhage. CTA head and neck was
performed without acute findings. TPA was held as INR was 3.0.
On review of systems he denies headache, fall, trauma, chest
pain, shortness of breath.
Past Medical History:
Mitral regurgitation s/p MVR on Coumadin
Previous ischemic stroke p/w Right upper qradrantopsia
TIA corresponding with RT MCA territory ___, found to have
punctate occipital ischemic stroke
Social History:
___
Family History:
Mother - MI at ___, DM
Father - ___ in ___
Brother - MI and CABG in ___
Physical Exam:
PHYSICAL EXAMINATION
Vitals:
89
173/78
16
100% RA
General: Visibly frustrated gentleman
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR
Pulmonary: Nonlabored breathing on room air
Abdomen: Soft
Extremities: Warm, no edema
Neurologic Examination:
Mental status: Awake, alert, oriented to self and month but not
age. Unable to relate history without difficulty. Speech is
fluent, but with many paraphasic errors. Verbal comprehension is
intact, naming is impaired but he is able to circumvent around
the objects on the stroke card. For example when pointing to
the
key will say "it is used to open doors", when pointing to the
glove he motions as if to put the glove on his hand, when
pointing to the hammock he says "it is used to sleep and dream".
There is also some degree of perseveration in his speech. He is
able to describe the cookie jar scene with many paraphasic
errors. No dysarthria. No left-right confusion. Able to follow
both midline and appendicular commands.
Cranial Nerves: PERRL 3->2mm brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Palate elevation
symmetric. SCM/Trapezius strength ___ bilaterally. Tongue
midline.
- Motor: Normal bulk and tone. RT pronation but no drift. No
tremor or asterixis.
[___]
L 5 5 5 5 ___ 5 5 5 5 5
R 5 4 4 5 ___ 5 4 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor bilaterally
- Sensory: Light touch diminished over right arm, however
pinprick intact bilaterally. RT extinction to DSS.
- Coordination: No dysmetria with finger to nose testing
bilaterally.
- Gait: Deferred in the setting of CT
Discharge Exam
A&O x4, complex commands, normal prosody, no aphasia, no
weakness, no pronation, no drift, no sensory deficits.
Pertinent Results:
___ 06:20AM BLOOD WBC-5.7 RBC-4.38* Hgb-13.1* Hct-40.9
MCV-93 MCH-29.9 MCHC-32.0 RDW-13.4 RDWSD-46.2 Plt ___
___ 08:50AM BLOOD WBC-5.9 RBC-4.57* Hgb-14.2 Hct-43.2
MCV-95 MCH-31.1 MCHC-32.9 RDW-13.7 RDWSD-46.9* Plt ___
___ 06:20AM BLOOD ___ PTT-43.8* ___
___ 10:55AM BLOOD ___
___ 06:20AM BLOOD Glucose-103* UreaN-22* Creat-1.0 Na-140
K-4.6 Cl-105 HCO3-26 AnGap-14
___ 06:20AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.0 Cholest-134
___ 06:20AM BLOOD %HbA1c-5.9 eAG-123
___ 06:20AM BLOOD Triglyc-43 HDL-53 CHOL/HD-2.5 LDLcalc-72
___ 08:58AM BLOOD Glucose-117* Na-146* K-3.6 Cl-102
calHCO3-24
ECHO ___
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. The left ventricle is not
well seen. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. No discrette
vegetations are seen. Trace aortic regurgitation is seen. A
bioprosthetic mitral valve prosthesis is present. Motion of the
prosthetic mitral valve leaflet adjacent to the aorta appears
abnormal. The gradients are normal for this type of prosthesis.
There is a very small echodensity in the atrial aspect of the
posterior portion of the mitral bioprosthesis (clips 31, 55) c/w
suture, thrombus, or vegetation . Trivial mitral regurgitation
is seen. There is no pericardial effusion.
IMPRESSION: Small echodensity in the posterior aspect of the
mitral bioprosthesis with abnormal leaflet motion, but normal
gradient.
Compared with the prior study (images reviewed) of ___,
the prior small echodensities are no longer present but a new
small echodensity in present in a different location of the
mitral bioprosthesis. The anterior leaflet motion abnormality is
more prominent.
CTA Head/Neck ___. Subtle areas of encephalomalacia/hypodensity in the right
operculum and
right posterior parietal subcortical white matter corresponding
to evolution
of known prior infarct. Unchanged left frontal centrum semiovale
lacunar
infarct.
2. No hemorrhage or acute large territorial infarct.
3. Patent intracranial arterial vasculature without significant
stenosis,
occlusion, or aneurysm formation.
4. Patent cervical arterial vasculature without significant
stenosis,
occlusion, or dissection.
CXR ___
The patient is status post prior median sternotomy. The size of
the cardiac
silhouette is enlarged. There are bibasilar opacities which may
reflect
atelectasis and/or consolidation. No pleural effusion or
pneumothorax is
identified.
MRI Head ___. New small foci of late acute infarction at the gray-white
junction of the right posterior frontal and left parietotemporal
operculum, likely embolic in etiology.
2. Evolving subacute infarcts as described. Chronic left
occipital infarct.
3. Scattered punctate micro hemorrhages are unchanged. There is
no recent
hemorrhage.
Brief Hospital Course:
Dr. ___ is a pleasant ___ y/o man with medical history of RT
MCA distribution punctate strokes, and previous ischemic stroke
with quadrantanopsia, MVR on Coumadin with possible MV thrombi
on latest TEE. He presented to the ED for evaluation after
developing acute onset RT arm numbness and severe aphasia on
his way to a cardiology appointment. Admission neurologic exam
was notable for RT arm pronation, RT bi, tri, and ham weakness
___. LT touch subjectively diminished on RT but intact
to PP. NCHCT with likely chronic RT hypodensity, CTA h/n w/o
acute abnormality. INR was 3.0. MRI showed new small foci of
late acute infarction at the gray-white junction of the right
posterior frontal and left parietotemporal operculum, likely
embolic in etiology. TEE showed a small vegetation on the MV. We
recommended increasing his INR goal to ___ but he refused this
because he was concerned that the increase in INR wouldn't
decrease his risk for emboli and would greatly increase his
bleeding risk. We also suggested changing the aspirin to
cilostazol per Dr ___ but he refused this as well. We
did send another set of blood cultures on his request because he
had read a report that perhaps the equipment used during the
valve replacement may have been contaminated with mycobacterium.
We also considered starting a NOAC but there is no strong
evidence for this so we deferred it for now. We discharged him
home in stable condition with instructions to call his
outpatient providers on the next business day to schedule
outpatient follow up appointments.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Warfarin 5mg/7.5mg mg PO DAILY16
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Warfarin 5mg/7.5mg mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
cerebral infarction due to left MCA embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr ___,
___ were admitted with new symptoms of right arm numbness and
aphasia and were found to have new strokes on MRI. It is thought
that these strokes are embolic from known vegetations on your
mitral valve. We recommended increasing your INR goal to ___
but ___ refused this secondary to your concern that the increase
in INR won't decrease your risk for emboli but will increase
your bleeding risk. We also suggested changing the aspirin to
cilostazol per your neurologist, Dr ___
recommendations but ___ refused this as well. We did send
another set of blood cultures to help rule out an infectious
etiology to of the masses on your MV including mycobacterium.
___ have subsequently retuned to your baseline functioning. We
will discharge ___ home with no changes in your medications and
instructions to follow up with your outpatient providers in ___
timely manner.
Followup Instructions:
___
|
19792924-DS-5
| 19,792,924 | 26,235,016 |
DS
| 5 |
2110-08-30 00:00:00
|
2110-08-31 17:03:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p assault, back pain and EtOH withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ current alcohol abuse, cirrhosis and history of falls
requiring recent neurosurgical intervention now here with back
pain and tremors. She was hospitalized within the last week at
___ for a UTI and then discharged. She reports sometime in the
evening yesterday that a man kicked her in the back. She can not
elaborate on any more details, however shortly there after
developed severed back pack, non-radiating. She does reports
numbness on her feet and thinks this ___ be new. She denies any
chest pain, fevers/chills, SOB.
Past Medical History:
- cirrhosis
- h/o of cranial bleed requiring neurosurgical drainage at
___
- ETOH dependence
Social History:
___
Family History:
nc
Physical Exam:
ON ADMISSION:
98.0 88 129/68 18 96% RA
Slightly tearful, tremulous, half of head is shaved, A&Ox3
Knows name, month, and hospital
RRR
Unlabored respirations
Slight distended abdomen, nontender, no rebound or guarding
___ strength in UE, there is an ecchymosis on the LUE
___ strength in RLE, ___ in LLE, does report some pain in back
with hip flexion, mild numbness on b/l ___ tenderness at level of T9, no other spinal tenderness
Moves ext to command
+asterixis, no pronator drift
___ edema L>R
ON DISCHARGE:
Vitals: 98.6, 67, 95/45, 18, 100RA
General: disheveled, sleeping comfortably in bed in NAD, easily
arousable.
Mental status: Appears more clear this morning. Responds
appropriately to questions.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, though decreased
breath sounds
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: firm, tender, enlarged left hepatic lobe, otherwise abd
benign; normoactive bowel sounds
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert and oriented to person, being in hospital, month
and year, no focal deficits
Pertinent Results:
==========ADMISSIONS LABS==========
___ 11:30PM BLOOD WBC-11.0* RBC-3.16* Hgb-9.5* Hct-28.1*
MCV-89 MCH-30.1 MCHC-33.8 RDW-14.8 RDWSD-48.1* Plt Ct-93*
___ 11:30PM BLOOD Neuts-57.9 ___ Monos-7.8 Eos-3.3
Baso-0.5 Im ___ AbsNeut-6.35* AbsLymp-3.32 AbsMono-0.86*
AbsEos-0.36 AbsBaso-0.06
___ 11:30PM BLOOD Glucose-138* UreaN-10 Creat-0.6 Na-141
K-3.5 Cl-101 HCO3-26 AnGap-18
___ 11:30PM BLOOD ALT-49* AST-101* AlkPhos-191* TotBili-1.5
___ 11:30PM BLOOD Lipase-45
___ 11:30PM BLOOD Albumin-4.0
___ 09:08AM BLOOD Ammonia-70*
___ 11:30PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 05:34AM BLOOD Lactate-1.4
==========DISCHARGE LABS==========
___ 08:16AM BLOOD WBC-4.0 RBC-3.05* Hgb-9.2* Hct-28.1*
MCV-92 MCH-30.2 MCHC-32.7 RDW-16.6* RDWSD-54.7* Plt ___
___ 08:16AM BLOOD Glucose-96 UreaN-7 Creat-0.5 Na-136 K-3.9
Cl-103 HCO3-27 AnGap-10
___ 08:16AM BLOOD ALT-35 AST-69* AlkPhos-141* TotBili-1.2
___ 08:16AM BLOOD Calcium-9.4 Phos-4.5 Mg-1.5*
==========OTHER PERTINENT LABS==========
___ 06:47AM BLOOD 25VitD-29*
___ 06:47AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE HAV Ab-POSITIVE
___ 06:47AM BLOOD HCV Ab-NEGATIVE
MICROBIOLOGY:
URINE CULTURE ___: NO GROWTH.
URINE CULTURE ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
Blood cx x2: No Growth
Imaging:
___ CT abd/pelv with contrast
1. Diffuse hepatic disease as described in detail above with
hepatomegaly, mass effect on the hepatic veins; IVC and early
stigmata of portal hypertension. Considering the age and female
predilection; primary biliary cirrhosis is the most favored
differential. Other differentials include cirrhosis secondary
to viral or alcohol as underlying etiology. Diffuse hepatic
metastases is less likely. Further evaluation with
gastroenterology consult, MRI liver and a liver biopsy are
recommended. This recommendation was communicated to Dr. ___
by Dr. ___ on ___ at 10:05 am.
2. Sequelae of probable prior right renal infection, possibly
due to reflux.
No acute pyelonephritis.
3. T9 comminuted fracture with 4-mm posterior angulation of the
superior
aspect posteriorly into the spinal canal is age-indeterminate
but given the
patient's focal symptoms in this region, acute traumatic injury
cannot be
excluded. No associated prevertebral soft tissue swelling. MRI
could be
performed to further evaluate.
4. Left L2 and L3 transverse process fractures, minimally
displaced.
5. Mild anterior wedging of the L3 vertebral body ___ be only
from
degenerative change, but in the setting of trauma and known
adjacent
transverse process fractures, acute injury cannot be excluded.
6. Multilevel degenerative changes in the thoracolumbar spine.
7. Small right non-hemorrhagic pleural effusion.
___ Skull plain films
Large metallic plate overlying the left temporal bone
superficial to a
craniectomy site.
___ T/L SPINE MRI
IMPRESSION:
1. Markedly motion degraded study, especially in the
postcontrast images
limiting the evaluation.
2. Multiple benign-appearing vertebral body fractures,
especially at T9 with loss of height by approximately 50%. Also
seen is compression deformity along the superior endplates of
T4, T5 and L3 vertebrae E as described above.
3. Mild multilevel degenerative disease of the thoracic spine
without neural foramina or spinal canal stenosis at any level.
4. Multilevel multifactorial degenerative disease of the lumbar
spine,
especially at L4-L5 and L5-S1 with severe spinal canal stenosis
secondary to epidural lipomatosis with ligamentum flavum
thickening and disc bulge. Also seen is moderate bilateral
neural foramen narrowing at L5-S1.
___ AP/LATERAL T-SPINE XRAYS STANDING AND SITTING
IMPRESSION:
Burst fracture of T9 and fracture deformities of T11 and T12 as
described
above.
___ - MRI T-Spine
1. Markedly motion degraded study, especially in the
postcontrast images
limiting the evaluation.
2. Multiple benign-appearing vertebral body fractures,
especially at T9 with loss of height by approximately 50%. Also
seen is compression deformity along the superior endplates of
T4, T5 and L3 vertebrae as described above.
3. Mild multilevel degenerative disease of the thoracic spine
without neural foramina or spinal canal stenosis at any level.
4. Multilevel multifactorial degenerative disease of the lumbar
spine,
especially at L4-L5 and L5-S1 with severe spinal canal stenosis
secondary to epidural lipomatosis with ligamentum flavum
thickening and disc bulge. Also seen is moderate bilateral
neural foramen narrowing at L5-S1.
___ - MRI Liver
1. Cirrhotic liver with fibrosis and patchy hepatic steatosis,
which explains the liver's heterogeneous appearance on the
recent CT.
2. No worrisome liver lesions.
3. Patent hepatic vasculature.
4. Evidence of portal hypertension with splenomegaly, a
recanalized
paraumbilical vein, and a small amount of ascites, including a
loculated focus of ascites along the right lobe of the liver.
5. Pancreatic divisum.
___ - CT head noncontrast
1. Streak artifact from left frontoparietal craniectomy metallic
mesh limits
examination.
2. Nonspecific, approximately 4 mm hyperdense region adjacent to
left frontal
and left temporal lobe, which ___ be postsurgical change,
however small
subdural is not excluded on the basis of this examination.
Recommend
correlation with neurological exam and prior outside studies as
available.
3. Punctate hypodense focus adjacent to metallic mesh ___ be a
focus of gas
versus metallic artifact. Recommend correlation with history of
recent
neuro-instrumentation, such as lumbar puncture.
4. Left frontal encephalomalacia.
___ - CXR PA+LATERAL
IMPRESSION:
1. No findings to suggest pulmonary TB.
2. Moderate right pleural effusion, likely on the basis of
cirrhosis.
3. T9 compression fracture, better evaluated on prior exams.
Brief Hospital Course:
___ year old female with history of EtOH cirrhosis, active EtOH
use, and possible ___ who was brought in by EMS
for intoxication and tremulousness, found to have T9 burst
fracture and evidence of cirrhosis on imaging now with EtOH
withdrawal.
#Encephalopathy: Noted to be encephalopathic this admission with
rapid mood shifts and alterations in mental status. Suspect
multifactorial etiology given extensive history of EtOH use,
possible underlying ___, recent intracranial
hemorrhage and infection, known psychiatric illness, and known
cirrhosis. On presentation with UTI s/p CTX x 4 days, otherwise
no e/o infection. No electrolyte abnormalities, no known recent
head trauma, no e/o medication/substance withdrawal. Given
concerns about capacity and ability to care for herself,
obtained noncontrast CT head with no acute changes. Mental
status improved and was alert and oriented to person, being in a
hospital as well as month and year.
#ETOH withdrawal: Patient tremulous on presentation and per
neurosurgery reports has been scoring on CIWA, requiring
diazepam. Patient reports no history of withdrawal seizures or
DT's. Patient homeless, so will likely require significant
support post-hospitalization if she hopes to maintain sobriety.
On the floor, she was managed with lorazepam IV but developed
hallucinations and was transferred to the MICU. She was started
on phenobarbital protocol. Required Haldol for agitation once
and improved. Detox programs were considered, but did not
qualify for inpatient program. Ultimately was discharged home
with information on partial programs which pt seems amenable to
and will try PAATHS program. Originally was going to stay with
friend, but per social work on talking to sister unable to stay
with said friend. Per SW, pt is estranged from family unable to
stay with them. Unclear if pt with a place to stay on discharge.
Offered to have her stay another night to help find shelter bed
prior to D/C, but pt not amenable and with capacity, so
ultimately discharged to friend's home.
#UTI: Positive UA on presentation, urine culture with >100K E
coli sensitive to CTX. Treated with CTX 1gram q24 x 4 days.
#EtOH Cirrhosis: C/b synthetic dysfunction, possible
___. CT A/P revealed diffuse heterogeneous
enhancement of the liver with slightly nodular contour and mass
effect on IVC and hepatic veins, consistent with cirrhosis. Had
been started on Lasix and aldactone as outpatient in ___, on
discharge per volume status and poor medication compliance these
were not started. Pt amenable to establish care at the liver
center, awaiting apt scheduling.
# T9 burst fracture, L2/L3 tranverse process fractures: per
neurosurgery, no need for surgical intervention or brace.
Patient to have repeat ct thoracic/lumbar w/o contrast in ___
weeks and follow up with neurosurgery.
#Depression/Anxiety: continued on home Citalopram. On
mirtazapine at home, restarted on discharge.
#History of subdural hematoma: s/p craniectomy at ___ with
some residual neurological defects. Continued Keppra BID.
Transitional issues:
- Pt. with EtOH cirrhosis and no gastroenterologist. Would
recommend outpatient Hepatology follow-up for screening EGD and
___ surveillance. Pt amenable to f/u at ___,
awaiting apt to be scheduled
- Pt. should have repeat CT T/L spine w/o contrast in ___ weeks
(end of ___ and f/u with neurosurgery (Dr. ___
scheduled for ___
- Previously started on Lasix and spironolactone, but per pt not
currently taking. Given euvolemia and poor medication
compliance, deferred starting new medication. Should be
considered as an outpatient.
- while inpatient, pt and social worker filled out fill out
intake packet for ___, the program run by ___
___, which serves as clearinghouse for all levels
of substance abuse care throughout the ___. Pt. understands
that she will need to present herself at ___ every day until
she is placed. The address is ___.
- FULL code
- Contact: ___ ___
Medications on Admission:
The Preadmission Medication list ___ be inaccurate and requires
futher investigation.
1. TraZODone 150 mg PO QHS
2. HydrOXYzine 50 mg PO BID:PRN anxiety
3. Ferrous Sulfate 325 mg PO DAILY
4. Cyclobenzaprine 5 mg PO BID:PRN spasm
5. Citalopram 30 mg PO DAILY
6. Spironolactone 50 mg PO 3X/WEEK (___)
7. Furosemide 20 mg PO 3X/WEEK (___)
Discharge Medications:
1. Citalopram 10 mg PO DAILY
2. LeVETiracetam 750 mg PO BID
RX *levetiracetam [Keppra] 750 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
3. Furosemide 20 mg PO 3X/WEEK (___)
4. Spironolactone 50 mg PO 3X/WEEK (___)
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing, SOB
6. Hydrocortisone (Rectal) 2.5% Cream ___AILY PRN
hemorrhoids
7. Mirtazapine 15 mg PO QHS
8. Omeprazole 20 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. Ferrous Sulfate 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol abuse disorder
Alcohol withdrawal
Thoracic spine fractures
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 ___ with back pain after a traumatic
injury. You were found to have some fractures in your back.
The surgeons saw you and did not think you needed surgical
treatment, but the spine doctors recommend that ___ get another
CT scan of your back after you leave the hospital and see them
again in clinic. You then had very serious alcohol withdrawal
symptoms and were admitted to the ICU were your symptoms were
managed with medication, and your symptoms improved.
We strongly recommend that you stop drinking alcohol completely.
You are at high risk for having serious withdrawal again in the
future. You also already have scarring of the liver from
alcohol use and this could get worse if you continue to drink
alcohol. We have provided you with some resources to help stop
drinking.
It was a pleasure caring for you and we wish you all the best.
Kind regards,
Your ___ Team
Followup Instructions:
___
|
19792938-DS-19
| 19,792,938 | 27,535,944 |
DS
| 19 |
2165-11-10 00:00:00
|
2165-11-13 07:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right-sided pelvic pain
Major Surgical or Invasive Procedure:
exploratory laparotomy, right ovarian cystectomy
History of Present Illness:
The patient is a ___, G0, who developed right-sided
pelvic pain approximately 2 days prior to presentation. The
pain worsened over the ensuing 2 days. She was seen at the
office and found to have rebound tenderness on the right side.
The patient has a history of ovarian cyst formation and a
history of 2 prior laparoscopies. In the emergency room an
ultrasound was obtained, which revealed a 6 cm complex right
ovarian cyst and no blood flow noted to the ovary on the right
side. There was concern for probable torsion of the adnexa. The
findings were discussed with the patient and the necessity of
operative intervention was discussed. The risks, benefits, and
alternatives to laparoscopic exploration followed by addressing
the adnexal findings were discussed with the patient. The
patient was aware that a possible laparotomy might be needed.
Past Medical History:
OBHx: G0
GynHx: history of infertility currently being followed by HMVA
REI, h/o chlamydia infection ___ years ago, denies history of
other
STDs or PID, h/o R ovarian cyst s/p cystectomy in ___ at ___
PMH: GERD, hypothyroidism
PSH: LSC right ovarian cystectomy, done at ___, per pt path was
"complex cyst"
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, appropriately tender, no rebound/guarding, incision
c/d/i
Ext: no TTP
Pertinent Results:
___ 07:30PM GLUCOSE-89 UREA N-13 CREAT-0.7 SODIUM-136
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16
___ 07:30PM URINE UCG-NEG
___ 07:30PM WBC-5.7 RBC-4.46 HGB-12.7 HCT-37.9 MCV-85
MCH-28.5 MCHC-33.5 RDW-13.8 RDWSD-42.8
___ 07:30PM NEUTS-38.9 ___ MONOS-11.5 EOS-0.5*
BASOS-0.4 IM ___ AbsNeut-2.21 AbsLymp-2.75 AbsMono-0.65
AbsEos-0.03* AbsBaso-0.02
___ 07:30PM PLT COUNT-253
___ 07:30PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 07:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
___ 07:30PM URINE RBC-0 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-9
___ 07:30PM URINE MUCOUS-RARE
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
after undergoing laparoscopy converted to exploratory laparotomy
with right ovarian cystectomy. Please see the operative report
for full details. Estimated blood loss during surgery was 750mL.
Immediately post-op, patient's blood pressures decreased to
70/50s, but normalized after 1 liter fluid bolus. Vital signs
otherwise remained stable throughout hospital course. Hematocrit
decreased from 37.9 pre-op to 26.2 post-op, but urine output,
heart rate, and pressures remained normal. Her pain was
controlled immediately post-operatively on dilaudid/toradol. On
post-operative day 2, her urine output was adequate and she was
able to ambulate so her foley was removed and she voided
spontaneously. Her diet was advanced without difficulty and she
was transitioned to PO
oxycodone/ibuprofen/acetaminophen/gabapentin. By post-operative
day 2, she was tolerating a regular diet, voiding spontaneously,
ambulating independently, and pain was controlled with oral
medications. She was then discharged home in stable condition
with outpatient follow-up scheduled.
Medications on Admission:
tizanidine 2mg TID prn spasm, pantoprazole 40mg, levothyroxine
50mcg qd, cetirizine 10mg qd, fluticasone 2sprays qnostril qday
albuterol 2 pufs prn wheeze, tramadol, gabapentin
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY hypothyroid
2. NexIUM (esomeprazole magnesium) 40 mg oral BID gerd
Discharge Disposition:
Home
Discharge Diagnosis:
Hemorrhagic right ovarian cyst
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service after your
procedure. You have recovered well and the team believes you are
ready to be discharged home. Please call Dr. ___ office
with any questions or concerns. Please follow the instructions
below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* You may walk up and down stairs.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No tub baths for 6 weeks.
* If you have steri-strips, leave them on. They will fall off on
their own or be removed during your followup visit.
* If you have staples, they will be removed at your follow-up
visit.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19793096-DS-8
| 19,793,096 | 26,867,717 |
DS
| 8 |
2155-05-29 00:00:00
|
2155-05-29 20:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tetracyclines / Cephalosporins
/ phenobarbital / Bactrim
Attending: ___.
Chief Complaint:
Sudden onset dizziness, nausea, vomiting, falling to the right.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ man with a history of hypertension and chronic back
pain presents with acute onset nausea and vomiting and found to
have a left cerebellar ICH.
Patient states he was at a ___ meeting at 8pm
sitting down and meditating when he acutely became nauseated.
Felt as if he was falling to the right. He was diaphoretic and
nauseated. Attempted to stand up, but fell to the right. ___
down
and felt progressively more nauseated. He threw up multiple
times. Called his wife and EMS. Wife felt his voice sounded
softer than usual. Felt as if he could not stand up due to poor
balance. Never had a headache.
He was taken by EMS to ___, where he was found
to have a BP of 162/83. The patient was taken to MRI, which
revealed a left cerebellar ICH. NCHCT was then done and also
showed left cerebellar ICH.
ROS:
On neurological review of systems, the patient denies headache,
confusion, difficulties producing or comprehending speech, loss
of vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus or hearing difficulty. Denies
focal weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the patient denies recent fever,
chills, night sweats, or recent weight changes. Denies cough,
shortness of breath, chest pain or tightness, palpitations.
Denies nausea, vomiting, diarrhea, constipation or abdominal
pain. Denies dysuria, or recent change in bowel or bladder
habits. Denies arthralgias, myalgias, or rash.
Past Medical History:
- Hypertension (recently about 130/80, per pt)
- Chronic back pain (s/p lumbar and cervical spine surgery)
- GERD
- OSA (CPAP at night)
- Anxiety
- Migraines
- Hyperlipedemia
Social History:
___
Family History:
- Father had many strokes (carotid dz)
- Maternal grandmother had strokes
- Cardiac issues on maternal side (MIs)
Physical Exam:
Physical Exam on Admission:
Temp: 97.6; Pulse 59; RR 18; BP 176/100; O2 sat% 97 on 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. Able to relate history
without difficulty. Attentive, to conversation. Language is
fluent with intact repetition and comprehension. Normal prosody.
There were no paraphasic errors. Able to name both high and low
frequency objects. Able to read without difficulty. No
dysarthria. Able to register 3 objects and recall ___ at 5
minutes. There was no evidence of neglect.
-Cranial Nerves:
II, III, IV, VI: **Anisocoria** (OS 5mm, OD 4mm), both briskly
reactive. EOMI with L beating nystagmus. Normal saccades w/o
dysmetria.
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 and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick. No extinction to
DSS. Romberg absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was neutral on right and **extensor** on left.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally.
-Gait: Deferred by patient request (feeling nauseated).
=========================
Physical Exam at Discharge:
24 HR Data (last updated ___ @ ___
Temp: 98.1 (Tm 98.1), BP: 120/68 (120-162/68-82), HR: 53
(50-53), RR: 18, O2 sat: 94% (94-98), O2 delivery: Ra
General: Awake, cooperative, NAD.
Neurologic:
-Mental Status: AOx3, converses linearly and logically. Relates
o/n history appropriately. No apraxia.
-Cranial Nerves:
II, III, IV, VI: VFF. Very slight Anisocoria, both briskly
reactive 4-> 2. EOMI, no nystagmus. Some saccadic intrusion.
Normal saccades w/o dysmetria. 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 and tone throughout.
___ antigravity. No drift. Slower finger taps on the left
-Sensory: No deficits to light touch.
-Reflexes: differed.
-Coordination: No intention tremor. No dysmetria noted.
- Romberg Negative.
- No clear trunckal instability.
- When performing ___ test falls back to right.
-Gait: still wide based with minor drift to the right, most
evident when eyes closed and marching in place.
Pertinent Results:
___ 02:40AM BLOOD WBC-18.5* RBC-5.11 Hgb-14.2 Hct-43.5
MCV-85 MCH-27.8 MCHC-32.6 RDW-12.9 RDWSD-40.1 Plt ___
___ 02:40AM BLOOD Neuts-94.8* Lymphs-2.8* Monos-1.5*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-17.59* AbsLymp-0.51*
AbsMono-0.28 AbsEos-0.01* AbsBaso-0.03
___ 02:40AM BLOOD ___ PTT-30.9 ___
___ 09:10AM BLOOD Glucose-140* UreaN-10 Creat-0.8 Na-134*
K-3.8 Cl-95* HCO3-24 AnGap-15
___ 02:40AM BLOOD Glucose-148* UreaN-10 Creat-0.9 Na-135
K-3.9 Cl-96 HCO3-26 AnGap-13
___ 04:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-8.0
Leuks-NEG
___ 04:45AM URINE Color-Straw Appear-CLEAR Sp ___
___ 4:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
=================
DC Labs:
___ 09:09AM BLOOD Glucose-124* UreaN-15 Creat-0.9 Na-138
K-4.1 Cl-101 HCO3-25 AnGap-12
___ 09:09AM BLOOD WBC-9.9 RBC-5.27 Hgb-14.9 Hct-44.6 MCV-85
MCH-28.3 MCHC-33.4 RDW-13.0 RDWSD-39.8 Plt ___
___ 06:10AM BLOOD ALT-22 AST-43* LD(LDH)-205 AlkPhos-52
TotBili-0.5
___ 06:10AM BLOOD %HbA1c-5.7 eAG-117
___ 06:10AM BLOOD Triglyc-72 HDL-52 CHOL/HD-2.5 LDLcalc-64
___ 06:10AM BLOOD TSH-1.5
=======
Imaging:
CT HEAD WITHOUT CONTRAST:
There is redemonstration of a left cerebellar hemispheric
intraparenchymal
hemorrhage with the hyperdense component measuring approximately
2.2 cm in AP
dimension. The hematoma is unchanged in size and appearance in
comparison to
the study from 5 hours prior. There is mild interval worsening
of the edema
surrounding the hemorrhage. No evidence of mass effect. There
is no evidence
of new infarction, or additional new hemorrhage. There is
minimal effacement
of the fourth ventricle. The ventricles and sulci are otherwise
normal in
size and configuration.
There is no evidence of acute calvarial fracture. The
visualized portion of
the paranasal sinuses demonstrate mild mucosal thickening in the
ethmoidal air
cells bilaterally, no air-fluid levels are seen, mastoid air
cells, and middle
ear cavities are clear.
The visualized portion of the orbits demonstrate prior lens
surgery on the
right but are otherwise unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches
appear normal without stenosis, occlusion, or aneurysm. The
dural venous
sinuses are patent. No definite vascular malformation. Left
dominant
vertebral artery.
CTA NECK:
Bilateral carotid and vertebral artery origins are patent.
There is no evidence of internal carotid stenosis by NASCET
criteria.
The carotidandvertebral arteries and their major branches appear
normal with
no evidence of stenosis or occlusion.
OTHER:
The visualized portion of the lungs are clear without focal
consolidation..
The visualized portion of the thyroid gland is normal. There is
no
lymphadenopathy by CT size criteria. Mild degenerative change
of the cervical
spine, please note that the patient is status post bilateral
laminectomies and
spinous process resection at C5 level.
IMPRESSION:
1. Redemonstration of left cerebellar hemisphere
intraparenchymal hemorrhage measuring approximately 2.2 cm with
mild progression of surrounding edema without evidence of mass
effect.
2. Patent circle of ___ without evidence of high-grade
stenosis,occlusion,or aneurysm.
3. Patent bilateral cervical carotid and vertebral arteries
without evidence of high-grade stenosis, occlusion,or
dissection.
=================
CT HEAD W/O CONTRASTStudy Date of ___ 10:28 AM
COMPARISON: CT head from ___, MRI brain from ___
and CT from ___.
FINDINGS:
There is redemonstration of a left cerebellar hemispheric
intraparenchymal
hemorrhage measuring 2.3 cm in the AP dimension, not
significantly changed in comparison to the study from ___. There is mild surrounding edema. There is
minimal effacement of the fourth ventricle.
There is no evidence of infarction, new or additional
hemorrhage, or
suspicious mass. The ventricles and sulci are otherwise normal
in size and
configuration.
There is no evidence of acute calvarial fracture. The
visualized portion of the paranasal sinuses demonstrate mild
mucosal thickening in the ethmoid air cells bilaterally, no
air-fluid levels are seen. The, mastoid air cells, and middle
ear cavities are clear.
The visualized portion of the orbits demonstrate prior lens
surgery on the
right and are otherwise unremarkable
IMPRESSION:
1. Redemonstration of left cerebellar hemispheric
intraparenchymal hemorrhage measuring approximately 2.3 cm with
mild surrounding edema. No evidence of mass effect. No
significant interval change in comparison to the study from 1
day prior.
Brief Hospital Course:
Mr. ___ is a ___ year old man with past medical history of
long-standing hypertension, hyperlipidemia, migraines, and
obstructive sleep apnea on cpap who was admitted to the
neurology stroke service with symptoms of acute onset dizziness,
nausea, and vomiting secondary to a hemorrhage in the left
cerebellum. Mr. ___ hemorrhage was most likely secondary to
transient hypertensive event given the location of the bleed.
Mr. ___ had MRI of the brain and there was no evidence of
microbleeds in other areas of the brain and had vessel imaging
which did not reveal a vascular malformation in the area of the
bleed. MRI with contrast was not performed, but will need to be
performed in the future to rule out underlying mass. Mr. ___
initially was not able to walk on his own on admission, but six
days later on day of discharge could walk without assistance.
Mr. ___ remained unsteady on his feet, particularly with
turning and quick movements, and therefore was discharged to
rehabilitation. Mr. ___ was found to be hypertensive on
admission and throughout hospitalizion. He will continue to take
his home atenolol at 37.5 mg daily and we have added amlodipine
10 mg daily. He has been asked to follow up with his primary
physician ___ weeks post discharge and will obtain a referral to
be seen by a neurologist at ___.
Her stroke risk factors include the following:
1) Hypertension
2) A1c 5.7%
3) Hyperlipidemia: well controlled on atorvastatin with LDL 64
4) Obesity
5) Sleep apnea on cpap
Transitional Issues:
1) Hypertension
I would consider ambulatory monitoring as suspect might have
transient episodes of hypertension.
2) Neurology referral
Mr. ___ needs an MRI brain with and without contrast in ___
months to reassess bleed and to evaluate for underlying mass
(though unlikely).
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No. If
no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(bleeding risk, hemorrhage, etc.)
3. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form?
(x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status)
====================================================
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO TID anxiety
2. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
3. Atorvastatin 20 mg PO QPM
4. Aspirin 81 mg PO DAILY
5. Atenolol 35 mg PO DAILY
6. Ranitidine 300 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
3. Atenolol 37.5 mg PO DAILY
4. ClonazePAM 0.5 mg PO Q8H:PRN Anxiety
RX *clonazepam 0.5 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
5. Ranitidine 300 mg PO TID
6. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
RX *hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every six (6) hours Disp #*90 Tablet Refills:*0
7. HELD- Atorvastatin 20 mg PO QPM This medication was held. Do
not restart Atorvastatin until you discuss with your stroke
neurologist when to restart it.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Left Cerebellar Hemorrhagic Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of acute onset dizziness,
nausea and vomiting, resulting from an ACUTE Hemorrhagic STROKE,
a condition where a blood vessel providing oxygen and nutrients
to the brain bleed, preventing blood from getting to its desired
location, and often causing cell death to areas where the blood
cannot reach. The brain is the part of your body that controls
and directs all the other parts of your body, so damage to the
brain from being deprived of its blood supply can result in a
variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Hypertension
- Hyperlipedemia
- Obstructive Sleep Apnea
- Migraines
- Age
- Being on daily aspirin
- Smoking history
We are changing your medications as follows:
- Stop taking aspirin.
- Don't take other blood thinners like NSAIDs such as
Ibuprofen/Aspirin/OTC/Herbals before discussing with your
doctor.
- Temporarily stop taking Atorvastatin until directed by your
provider.
- We started amLODIPine 10 mg DAILY, PCP to add second agent if
needed.
- Talk to your PCP about decreasing dose of atenolol as commonly
bradycardic during admission.
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:
___
|
19793552-DS-11
| 19,793,552 | 24,605,756 |
DS
| 11 |
2185-12-02 00:00:00
|
2185-12-02 17:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic Ileal Colectomy.
History of Present Illness:
___ yo M w/Crohn's disease on Remicade presents with abdominal
pain. The pain is constant, nonradiating, worse with food.
Associated with BRBPR, nausea, NBNB emesis x2 and subjective
fevers. Sx similar to Crohn's flares in the past. Patient was
seen by his GI doctor today who referred him in for evaluation.
Patient is also complaining of atraumatic left knee pain x 1.5
weeks. There is warmth associated with it and some limited range
of motion. He is able to ambulate on it.
In ED knee tapped with improvement in pain. Pt given morphine,
Zofran, Ativan and 500ccLR. GI consulted.
ROS: +as above, otherwise 10-point ROS reviewed and negative
Past Medical History:
Crohn's disease -- terminal ileum, on infliximab, doing well
with this. Had pancreatitis from ___. Occasionally
self-medicates with prednisone when he has symptoms. Stopped
Asacol on ___.
HTN
HL
Hyperparathyroidism
Vitamin D deficiency
Systolic CHF (EF 40%), last TTE ___
PSHx:
none ever
Social History:
___
Family History:
Mother w/DM2
No IBD
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:99 BP:162/112 P:79 R:16 O2:97%ra
PAIN: 6
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, tender lower quadrants
Ext: L knee w/edema, small effusion, full ROM
Skin: no rash
Neuro: alert, follows commands
Discharge PE
General: patient doing well, tolerating a regular diet, pain
controlled, intermittent heart burn however
VSS
Neuro: A&OX3
Cardiac/Pulm: RRR, no shortness of breath
abd: unbilical sites intact without signs of infection, abdomen
not distended and soft, minimally tender
___: no lower extremity edema
Pertinent Results:
ADMISSION LABS:
___ 03:40PM BLOOD WBC-9.0 RBC-5.06 Hgb-14.8 Hct-41.9 MCV-83
MCH-29.3 MCHC-35.4* RDW-14.0 Plt ___
___ 03:40PM BLOOD Glucose-107* UreaN-12 Creat-1.2 Na-137
K-3.7 Cl-103 HCO3-25 AnGap-13
___ 03:40PM BLOOD Albumin-4.1 Calcium-9.0 Phos-3.3 Mg-1.9
___ 03:40PM BLOOD ALT-12 AST-15 AlkPhos-77 TotBili-0.5
___ 03:40PM BLOOD CRP-54.8*
___ 07:14PM BLOOD SED RATE-19
___ 07:24PM BLOOD Lactate-1.1
.
___ 07:45PM JOINT FLUID ___ RBC-6350* Polys-47*
___ Monos-24 Other-13*
___ 07:45PM JOINT FLUID Crystal-NONE
.
MICRBIOLOGY:
___ Blood cultures x 2 sets: No growth, final pending
___ Joint aspirate: Negative Gram stain, 1+ PMN's, culture
pending
___ CMV viral load: pending
.
IMAGING:
___ KUB
IMPRESSION:
Prominent gas-filled loops of small bowel containing fluid
levels, could
reflect early SBO.
.
___ CT A/P
IMPRESSION:
1. Approximately 15 cm of the terminal ileum and another segment
of more
proximal small bowel demonstrate inflammation with normal bowel
in between, consistent with history of Crohn disease.
2. No abscess or fistula identified.
3. No evidence of bowel obstruction.
Brief Hospital Course:
___ yo M w/Crohn's disease on Remicade presents with Crohn's
flare and knee effusion
.
# Crohn's Disease. Though patients symptoms (nausea, abdominal
pain,bloody stool) could represent a GI infection (viral,
bacterial) per patient symtoms are identical to previous Crohn's
flare and patient missed last dose of Remicade. However despite
missing last dose on review patient has had incomplete remission
from Remicade over the last ___. Therefore decision made to
proceed with surgical resection. While awaiting surgery was
treated with Solumedrol, bowel rest and pain control .
# Knee Effusion. Differential diagnosis includes type I
arthopathy secondary to Crohns flare vs septic arthritis vs
reactive arthritis. Patient is vunerable to infection on
Remicade however joint fluid and physical exam is reassuring for
lack of infection. Mindful that patient did take amoxicillin
however this
was roughly ___ prior so less likely to alter joint fluid
results. In house remained afebrile off antibiotics and joint
fluid culture no growth.
# Systolic heart hailure. Etiology unclear per cardiology:
hypertension-induced vs Remicade-induced CMP. No signs of acute
heart failture. Continued BB, ACEI
# HTN: Normotensive in house on home medications
# HL: Continued on home meds
The patient was taken to the operating room with Dr. ___
a ___ ileal colectomy with Dr. ___. He tolerated
surgery well. On post-operative day one, the patient tolerated
clears. CMV viral load was negative. All post-operative labs
were stable. Into post-opertive day two he reported passing
flatus and his diet was advanced to regular, however, he became
nauseated and his diet was backed down and he was given
intravenous fluids while we waited for bowel function to return.
Overnight into post-operative day three he was again passing gas
and had a bowel movements. He tolerated two regular meals and
would like to be discharged home. He did report some baseline
heart burn, however, this improved with TUMS. He was seen by dr.
___ was discharged home in the afternoon of ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. DiCYCLOmine 20 mg PO QID:PRN abdominal pain
4. Metoprolol Succinate XL 50 mg PO DAILY
5. TraMADOL (Ultram) 50-100 mg PO Q4H:PRN pain
6. Cyanocobalamin 1000 mcg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Simvastatin 20 mg PO DAILY
3. Acetaminophen 1000 mg PO Q8H:PRN pain
do not take more than 3000mg of tylenol in 24 hours or drink
alcohol while taking
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*50 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
do not drink alcohol while taking or drive a car
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*50 Tablet Refills:*0
5. Cyanocobalamin 1000 mcg PO DAILY
6. Lisinopril 40 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Crohn disease with a terminal ileal stricture.
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 Laparoscopic Colectomy
for surgical management of your Laparoscopic ileal colectomy.
You have recovered from this procedure well and you are now
ready to return home. Samples from your colon were taken and
this tissue has been sent to the pathology department for
analysis. You will receive these pathology results at your
follow-up appointment. 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, are
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 ___ laparoscopic surgical incisions on your abdomen
which are closed with internal sutures and a skin glue called
Dermabond. These are healing well however it is important that
you monitor these areas for signs and symptoms of infection
including: increasing redness of the incision lines,
white/green/yellow/malodorous drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area. Please call the office if you develop any
of these symptoms or a fever. You may go to the emergency room
if your symptoms are severe.
You may shower; pat the incisions dry with a towel, do not rub.
The small incisions may be left open to the air. If closed with
steri-strips (little white adhesive strips) instead of
Dermabond, these will fall off over time, please do not remove
them. Please no baths or swimming for 6 weeks after surgery
unless told otherwise by your surgical team.
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
3000mg 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.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. ___ Dr.
___.
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:
___
|
19793552-DS-13
| 19,793,552 | 22,756,466 |
DS
| 13 |
2188-04-11 00:00:00
|
2188-04-11 16:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
dicyclomine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ M with history of Crohn's and SBO s/p
ileocecectomy in ___ who was recently discharged on ___
from ___ after treatment for an SBO and Crohn's flare who
presents for worsening abdominal pain. Pain was initially
moderately well controlled at home, however in the last few days
has worsened. He is now unable to eat without vomiting and is
worried that he has a new bowel obstruction. He is still passing
gas. He reports worsening lower abdominal pain. No
fevers/chills, black or bloody stools, no bloody or
coffee-ground material in vomit.
In the ED, initial VS were: 98.0 78 182/100 22 100% RA
-Exam notable for: tenderness to palpation periumbilically
-Labs showed: normal CBC & BMP, Lactate 2.8->1.7, UA +few
bacteria
-Imaging showed: SBO with transition point in RLQ due to bowel
wall thickening in segment of ileum
-He did not want NGT unless he vomits
-Colorectal surgery was consulted - will follow in case surgical
intervention needed, recommend NPO/IVF
On arrival to the floor, patient reports continue nausea, no
vomiting since early this AM, did not notice color and felt like
more dry heaving. He denies fevers, always has mild chills, no
sick contacts, no travel. He has his usual diarrhea without
changes, no active bloody BMs recently. He reports mid abdominal
and L>RLQ crampy diffuse pain, not relieved by most medications.
He is passing gas. Denies CP, SOB. He says he would prefer
surgery than recurrent flare up like this.
ROS as above otherwise 10point ROS negative
Past Medical History:
-Crohn's disease: terminal ileum, was on infliximab, doing well
with this. Had pancreatitis from ___. Occasionally
self-medicates with prednisone when he has symptoms. Stopped
Asacol on ___.
-Systolic CHF (EF 40%), last TTE ___
-Inflammatory Arthritis of b/l knees
-HTN, HLD. Hyperparathyroidism, Vitamin D deficiency
-Laparoscopic ileal colectomy
Social History:
___
Family History:
Mother with diabetes, no family hx of IBD, no hx of early CAD/MI
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98.2 178/104 66 22 99 Ra
GENERAL: fatigued appearing middle aged man
HEENT: PERRL, anicteric sclera, +pale conjunctiva, dry mucous
membranes with white coating over tongue (noted on prior
admission, improves with hydration)
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs
LUNGS: CTA b/l
ABDOMEN: +bowel sounds, mildly distended, mild tenderness in mid
abdominal and LLQ regions, no rebound/guarding,
RECTAL: 2 skin tags, no active bleeding, no skin breakdown,
notable left buttock from fold and extending outward-scaly
silver rash, with xerosis, scattered non erythematous lesions
EXTREMITIES: no edema, left knee with slight swelling and mild
effusion, no pain on knees b/l
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused
DISCHARGE PHYSICAL EXAM:
========================
VITALS: T 98.3, HR 53, BP 152/87, RR 18, O2 96% RA
GENERAL: Lying in bed, no acute distress
CV: RRR, S1/S2, no murmurs
RESP: Breathing unlabored, lungs CTAB
GI: +BS, mildly tender to palpation in mid lower abdomen, no
rebound, guarding
SKIN: Hyperpigmented patch with overlying scale covering left
buttock, gluteal fold. and posterior upper leg. Appears slightly
smaller today. No vesicles, no warmth or tenderness
NEURO: A&Ox3, moving all 4 extremities with purpose
Pertinent Results:
ADMISSION LABS:
===============
___ 01:08PM BLOOD WBC-7.6 RBC-5.76 Hgb-16.1 Hct-47.9 MCV-83
MCH-28.0 MCHC-33.6 RDW-16.1* RDWSD-48.0* Plt ___
___ 01:08PM BLOOD Glucose-87 UreaN-10 Creat-1.1 Na-144
K-3.3 Cl-101 HCO3-25 AnGap-18
___ 01:08PM BLOOD Calcium-9.7 Phos-2.4* Mg-1.8
___ 01:08PM BLOOD ___ PTT-28.5 ___
___ 01:08PM BLOOD CRP-0.6
___ 07:15PM BLOOD Lactate-1.7
DISCHARGE LABS:
===============
___ 07:05AM BLOOD WBC-8.9 RBC-4.94 Hgb-14.1 Hct-41.5 MCV-84
MCH-28.5 MCHC-34.0 RDW-16.0* RDWSD-48.7* Plt ___
___ 07:05AM BLOOD Glucose-106* UreaN-13 Creat-0.9 Na-145
K-3.6 Cl-101 HCO3-26 AnGap-18
IMAGING/STUDIES:
================
CT ABDOMEN/PELVIS ___:
Small bowel obstruction with a transition point in the right
lower quadrant due to bowel wall thickening in a segment of
ileum just prior to the anastomosis. This appearance is very
similar to that seen on ___, and is concerning for an
obstruction related to active inflammation of the terminal ileum
in the setting of Crohn's disease/flare. There is adjacent
mesenteric free fluid and reactive lymphadenopathy. No free air
or pneumatosis. No drainable fluid collection.
Brief Hospital Course:
___ h/o Crohn's disease (dx ___ s/p ileocecetomy in ___,
recent admission for likely partial SBO resolved with medical
management/bowel rest, presented with worsening abdominal pain
and recurrent SBO.
#CROHN'S DISEASE w/ RECURRENT PARTIAL SBO: CT scan showed
repeating obstruction proximal to anastomosis in ileum with
findings consistent with inflammation. GI was consulted: he was
kept NPO and started on IV methylprednisolone. Diet advanced to
full diet, which he was tolerating without issue for >24 hours
prior to discharge. Switched to PO prednisone 40mg daily day
prior to discharge to continue until outpatient GI follow-up. GI
team will coordinate with rheumatology and cardiology whether he
can be started on another biologic for Crohn's management.
Colorectal surgery also followed throughout course, but he did
not require surgical intervention.
#HTN/Chronic Systolic Cardiomyopathy ___ infliximab: No evidence
of decompensated heart failure. Last TTE ___ with EF 42%. As
above, GI team will be in contact with outpatient rheumatologist
and cardiologist regarding potential options for biologic
therapy. Continued on home metoprolol and lisinopril
#RASH: Improving; Has history of tinea which he reports is
similar to current rash. Possibly also psoriatic or related to
underlying crohn's. Failed topical hydrocortisone per patient.
Treated with clotrimazole cream BID while inpatient with
improvement noted, though unclear whether due to cream vs.
steroid therapy. Discharged to continue clotrimazole for up to
two weeks and follow-up with PCP.
TRANSITIONAL ISSUES:
====================
*New Medications*
[] Prednisone 40mg daily until GI follow-up
[] Clotrimazole cream BID x 2 weeks for R buttock, leg rash
[] Please determine appropriate biologic therapy for Crohn's
disease in conjunction with rheumatology and cardiology
[] Please evaluate R buttock and posterior thigh rash for
resolution. Consider derm referral if not improving with
clotrimazole.
>30 minutes spent on discharge planning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cholestyramine 4 gm PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Lisinopril 40 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Vitamin D ___ UNIT PO 1X/WEEK (FR)
6. Ferrous Sulfate 325 mg PO DAILY
7. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
8. FoLIC Acid ___ mcg PO DAILY
9. tocilizumab 162 mg/0.9 mL subcutaneous qMonthly
Discharge Medications:
1. Clotrimazole Cream 1 Appl TP BID apply over buttock rash
RX *clotrimazole 1 % Apply to rash on buttock and leg Twice
daily Refills:*0
2. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Cholestyramine 4 gm PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid ___ mcg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
10. tocilizumab 162 mg/0.9 mL subcutaneous qMonthly
11. Vitamin D ___ UNIT PO 1X/WEEK (FR)
Discharge Disposition:
Home
Discharge Diagnosis:
Crohn's flare
Partial small bowel obstruction
Tinea corporis
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 at ___
___!
WHY YOU WERE ADMITTED:
-You were having abdominal pain
-Imaging showed obstruction and inflammation in your intestines
WHAT HAPPENED IN THE HOSPITAL:
-You were treated with steroids to help decrease the
inflammation
-You were able to tolerate a regular diet without further pain
or issues
-GI saw you and you will follow-up with them in the clinic to
determine which long term treatment will be best for you.
WHAT YOU SHOULD AT HOME:
-Continue taking your prednisone every day until you see your GI
doctor
-___ you develop pain, nausea, vomiting, or bloody stools, call
your primary doctor or GI doctor.
-___ continue using clotrimazole cream twice a day until the
rash on your leg is gone.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Team
Followup Instructions:
___
|
19793569-DS-12
| 19,793,569 | 22,641,558 |
DS
| 12 |
2147-05-13 00:00:00
|
2147-05-13 18:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
House Dust / Feathers / ragweed / pine trees / plantain / lamb
quarter / cocklebur / dogs / cats / nickel / marsh ___
Attending: ___.
Chief Complaint:
Fever, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with PMH cognitive
delay ___ cerebral palsy, autoimmune encephalitis, hypertension,
NAFL, obesity, depression, asthma, recurrent aspiration
pneumonitis, presenting with fever and productive cough,
reported
over 24H. Patient's temperature was 100.2 prior to presenting.
He
was given ibuprofen. Cough associated with mild shortness of
breath, which is relieved by inhaler (using inhaler ___ times
per
day). Patient has gotten his flu shot. He denies headache, chest
pain, abdominal pain, nausea/vomiting/diarrhea,
dysuria/hematuria/frequency, lower extremity or rash.
Notably, patient was admitted ___ for pneumonia vs
bronchitis and asthma exacerbation in ___, completed a 5 day
course of CTX/azithro for community acquired pneumonia as well
as
pred burst of 60 mg daily for 5 days. He was evaluated by SLP
and
underwent modified barium swallow which showed evidence of
aspiration. He was ordered for a nectar thickened liquids and
soft solid diet to prevent further aspiration. He then presented
again in ___ after an episode of aspiration and was empirically
treated at that time with a 7 day course of augmentin for
aspiration PNA. He also has a history of poorly controlled
asthma
and his inhalers were adjusted at his last PCP visit in ___.
In the ED, Initial vitals: 99.5 124 167/83 22 94% 4L NC
General- NAD
HEENT- PERRL, EOMI, normal oropharynx
Lungs- Non-labored breathing, diffuse rhonchi/wheezing, crackles
at the bilateral lower lobes
CV- RRR, no murmurs
Abd- Soft, nontender, nondistended, no guarding, rebound or
masses
Neuro-A&O x3, CN ___ intact, normal strength and sensation in
all extremities, normal speech
Ext- No edema, cyanosis, or clubbing
Peak flow at 10 a.m. 125
Labs notable for:
WBC 17.1, 83.9* PMNs, HB 16.3 HCT 53.3 Plt 242
Lactate: 3.2
Flu swab negative
UA with positive nitrites, 10 RBC, few bacteria, no epis
Grossly hemolyzed: K 5.9, Cr 1.3, HCO3 21
Whole blood K: 8.5 hemolyzed, Lactate:5.7
Repeated again:
K: 3.6, Lactate: 5.7
Labs repeated later in the day after further IVF:
Cr 1.0, K 4.2, Phos 1.4, LFTs WNL
VBG: pH 7.39, pCO2 37, Lactate: 5.5, O2Sat:93
CXR ___: Increased opacity over the lung bases on the lateral
view, with some component of atelectasis in the setting of low
lung volumes though infection would certainly be possible.
EKG with sinus tachycardia
Patient was given:
___ 09:36 PO Acetaminophen 1000 mg
___ 09:36 PO PredniSONE 60 mg
___ 09:50 IH Ipratropium-Albuterol Neb 1 NEB
___ 12:39 IVF NS 1000 mL
___ 13:07 IV CefTRIAXone 1 gm
___ 14:21 IV Azithromycin 500 mg
___ 15:30 IVF NS 1000 mL ___ (2h ___
___ 19:31 IVF LR 1000 mL
Upon interview in the ED, patient reports he has had a severe
cough for two weeks, not 24 hours as reported above. He says his
sputum has been clear with red color. His cough did not get
worse
but was associated with feeling "cold inside and out" today so
was sent to the ED. Cough was somewhat relieved by PRN
benzonatate. He denies hematemesis. He feels a bit short of
breath and can feel his heart beating fast. He says his asthma
bothers him sometimes but does not feel particularly bothered by
it now.
ROS: Pertinent positives and negatives as noted in the HPI. 10
point ROS otherwise negative.
Past Medical History:
Obesity
Hypertension
Asthma
Depression
ADHD
___
Recurrent aspiration pneumonia - ___ video swallow
suggested aspiration
Insomnia
Seasonal allergies
Laugh attacks
Autoimmune encephalitis - ___ brainstem encephalitis
off of immunosuppression
Cerebral Palsy
superficial abdominal wall abscess
Social History:
___
Family History:
Some documentation noting no known family history as patient was
removed from home at age ___. An alternate report says both
parents with substance abuse issues.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: 98 118 115/65 23 96% 2L NC
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular rhythm, tacycardic, no murmur, no S3, no S4.
RESP: Lungs with coarse ronchi at that bases that mostly clear
with cough, no wheezing. Mildly tachypneic but able to speak in
full sentences
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted, WWP
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 PHYSICAL EXAM
VITALS:97.4 PO 138/86 R Lying 78 20 96 RA
GENERAL: Alert and in no apparent distress, sitting up in chair
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 rhythm, tachycardic, no murmur, no S3, no S4.
RESP: Loud upper airway transmitted sounds, lungs distally clear
to auscultation. No wheezes appreciated. No respiratory
distress, speaks in full sentences
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted, WWP
NEURO: Alert, oriented, face symmetric, speech fluent though
sometimes difficult to understand, moves all limbs, sensation to
light touch grossly intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
LABS ON ADMISSION
___ 09:00AM WBC-17.1* RBC-6.43* HGB-16.3 HCT-53.3* MCV-83
MCH-25.3* MCHC-30.6* RDW-13.9 RDWSD-39.8
___ 09:00AM NEUTS-83.9* LYMPHS-8.6* MONOS-6.3 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-14.32* AbsLymp-1.47 AbsMono-1.08*
AbsEos-0.02* AbsBaso-0.05
___ 09:00AM GLUCOSE-89 UREA N-23* CREAT-1.3* SODIUM-140
POTASSIUM-5.9* CHLORIDE-100 TOTAL CO2-21* ANION GAP-19*
___ 09:15AM LACTATE-3.2*
___ 11:34AM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
___ 03:46PM LACTATE-5.7* K+-8.5*
___ 01:43PM URINE BLOOD-NEG NITRITE-POS* PROTEIN-30*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
___ 01:43PM URINE RBC-10* WBC-1 BACTERIA-FEW* YEAST-NONE
EPI-0
MICRO:
BCx- NGTD, PENDING AT DISCHARGE
UCx- NO UTI
SPUTUM - SPARSE RESPIRATORY FLORA
IMAGING:
CXR IMPRESSION:
Increased opacity over the lung bases on the lateral view, with
some component of atelectasis in the setting of low lung volumes
though infection would certainly be possible.
LABS ON DISCHARGE:
___ 07:45AM BLOOD WBC-7.6 RBC-6.34* Hgb-15.6 Hct-51.2*
MCV-81* MCH-24.6* MCHC-30.5* RDW-13.2 RDWSD-37.6 Plt ___
___ 07:45AM BLOOD Glucose-103* UreaN-16 Creat-0.7 Na-140
K-4.0 Cl-100 HCO3-25 AnGap-15
___ 07:45AM BLOOD ALT-52* AST-21 AlkPhos-55 TotBili-0.3
___ 07:45AM BLOOD Calcium-8.8 Phos-4.3 Mg-2.1
___ 07:53AM BLOOD ___ pO2-195* pCO2-45 pH-7.42
calTCO2-30 Base XS-4 Comment-GREEN TOP
___ 07:53AM BLOOD Lactate-2.2*
Brief Hospital Course:
Mr. ___ is a ___ male h/o cognitive delay ___
cerebral palsy, autoimmune encephalitis, hypertension, NAFLD,
obesity, depression, asthma, recurrent aspiration pneumonitis,
presenting with fever and productive cough over the past 24
hours, found to have aspiration pneumonia and lactic acidosis.
ACUTE/ACTIVE PROBLEMS:
# Aspiration vs Community Acquired Pneumonia
# Acute hypoxic respiratory failure
# Acute asthma exacerbation
# Hx recurrent aspiration
# Hemoptysis
Patient has had multiple admissions and courses of treatment for
recurrent aspiration events and is on a modified diet with
thickened liquids and solids cut into small pieces, which he
says
he has been following (in the past there was some
noncompliance). Video swallow done in ___ showed an aspiration
event, so he has continued on a modified diet. He has had
multiple visits and
admissions for coughing, bronchitis, pneumonia, and per OMR has
a history of syncope from coughing fit. He is at high risk for
aspiration and current presentation fitting with previous
episodes. He had low peak flow in the ED at 125 as well thus
asthma exacerbation component also possible. Treated for
CAP/aspiration with ceftriaxone/azithromycin, switched to
levofloxacin at discharge. Treated with 5d course of prednisone
40mg for asthma. Nebs and home inhalers continued. Evaluated
here by speech and swallow who felt he has not had any evolution
of his dysphagia and recommended strict aspiration monitoring
and supervision with meals and strict oral hygiene. Continued
home modified diet of soft solids/nectar thick liquids, meds
whole in apple sauce. Of note, patient had several episodes of
small volume hemoptysis early in hospitalization likely in the
setting of straining to cough. No hemodynamic instability or CBC
drop noted. Issue resolved as he improved clinically. This was
attributed to trauma/abrasion from coughing.
# Diarrhea
New issue during hospitalization. Could be in setting of dietary
indiscretion. cdiff checked and negative. Started on Imodium to
manage symptoms.
# ___
# Dehydration
Cr 1.3 on admission from baseline ~0.7-0.8 likely in setting of
ongoing dehydration. Improved to baseline after 6L IVF. Concern
for possible chronic dehydration in addition to acute
dehydration related to illness.
# Lactic Acidosis, type B
Labs on admission with ___, elevated lactate, tachycardia above
his baseline (which seems to be ___ to 110s), all consistent
with dehydration. Received 6L IVF before lactate improved from
5.5 to
2.9. VBG with normal pH and CO2 even when lactate >5 thus
unlikely to be driving severe metabolic acidosis. Albuterol neb
use possible though has not received back-to-back nebs to
explain rise. Chronic dehydration most likely contributory. Once
medically stable, lactate was repeated and remained elevated at
2.2 without signs of infection or hypoperfusion. Patient was
started on thiamine supplementation for possible contribution of
thiamine deficiency.
# Hypophosphatemia: Repleted IV and PO
CHRONIC/STABLE PROBLEMS:
# Sinus Tachycardia: Patient has a history of sinus tachycardia
during multiple prior
admissions. Possibly related to albuterol. ECG appears stable.
TSH WNL on last admission. HR back to ___ at time of discharge.
# Asthma: Mild persistent per Dr. ___. Continued home
Montelukast, Loratidine, Flovent
# Hypertension: Held home HCTZ initially iso ___. Restarted on
day of discharge
# Depression/ADHD/PTSD: Continued home bupropion and divalproex
# NAFLD: outpatient management. ALT mildly increased on day of
discharge
TRANSITIONAL ISSUES:
[] Complete one more day of prednisone and levofloxacin for a
total of 5 days
[] ALT mildly elevated at discharge, please recheck at follow-up
appointment
[] started on thiamine for possible contribution to type B
lactic acidosis.
[] if possible, maximize supervision during meals to help
prevent aspirations. provide good oral hygiene; brush teeth
before and after meals
[] blood culture pending at discharge
# Contacts: Guardian ___ ___
# Code Status: FC, presumed
[X] I spent 40 min in discharge planning and coordination of
care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (EXTended Release) 1000 mg PO Q1700
2. BuPROPion XL (Once Daily) 150 mg PO DAILY
3. Benzonatate 200 mg PO Q8H:PRN cough
4. Fluticasone Propionate NASAL 2 SPRY NU 2 SPRAYS IN EACH
NOSTRIL AT BEDTIME
5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP APPLY
QUATER-SIZE CREAM ON RASH OF RIGHT ARM TWICE DAILY FOR ONE WEEK
6. Montelukast 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. melatonin 5 mg oral QHS
10. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild
11. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral TID
12. Loratadine 10 mg PO DAILY
13. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
shortness of breath or 20 minutes before vigorous exercise
14. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. LevoFLOXacin 500 mg PO Q24H Duration: 1 Day
take on ___
RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*1
Tablet Refills:*0
2. LOPERamide 2 mg PO QID:PRN diarrhea
RX *loperamide 2 mg 1 tab by mouth four times a day as needed
Disp #*60 Tablet Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 1 Day
take on ___
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*1
Tablet Refills:*0
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
5. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
shortness of breath or 20 minutes before vigorous exercise
6. Benzonatate 200 mg PO Q8H:PRN cough
7. BuPROPion XL (Once Daily) 150 mg PO DAILY
8. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral TID
9. Divalproex (EXTended Release) 1000 mg PO Q1700
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Fluticasone Propionate NASAL 2 SPRY NU 2 SPRAYS IN EACH
NOSTRIL AT BEDTIME
12. Hydrochlorothiazide 12.5 mg PO DAILY
13. Ibuprofen 400 mg PO Q6H:PRN Pain - Mild
14. Loratadine 10 mg PO DAILY
15. melatonin 5 mg oral QHS
16. Montelukast 10 mg PO DAILY
17. Multivitamins 1 TAB PO DAILY
18. Triamcinolone Acetonide 0.1% Cream 1 Appl TP APPLY
QUATER-SIZE CREAM ON RASH OF RIGHT ARM TWICE DAILY FOR ONE WEEK
Discharge Disposition:
Home
Discharge Diagnosis:
Aspiration pneumonia
Asthma exacerbation
Noninfectious diarrhea
Type B lactic acidosis
Hypophosphatemia
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___!
Why did you come to the hospital?
-Because you had fever and were coughing
What happened while you were in the hospital?
-You were found to have an aspiration pneumonia, which is a lung
infection from having food make its way into your lungs, and
possibly worsening of your asthma.
-You received antibiotics and breathing treatments and improved
-You were very dehydrated so you were given a lot of fluids
-You developed diarrhea, which was not infectious, so we gave
you Imodium to help stop it
What should you do after you leave the hospital?
-Have someone help you during your meals to stay focused and
prevent any more food going down the wrong way.
-See your primary care doctor as scheduled
-If you develop any more fevers, trouble breathing, worsening
diarrhea or other concerning symptoms, please call your doctor
or go to the nearest emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19793569-DS-7
| 19,793,569 | 24,483,458 |
DS
| 7 |
2143-08-24 00:00:00
|
2143-08-26 17:54:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
House Dust / Feathers / ragweed
Attending: ___
Chief Complaint:
Fever, productive cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year-old man with NASH, autoimmune encephalitis, cerebral
palsy, OSA not on CPAP, PTSD w/ prior SI and SA, and h/o
aspiration pneumonia who was recently admitted for aspiration
PNA and who now p/w recurrent episode of fevers and productive
cough.
Patient was hospitalized from ___ for aspiration
pneumonia. He was initially in the MICU for hypotension to the
80's and initially required pressors. Patient was initially on
vanc/cefepime/azithro and was narrowed to levofloxacin on
___ to complete an 8 day course. On ___, he spiked a temp
to 101 and was thus referred back to the ED. In the ED, had Tmax
100.9 with HR 108. Labs notable for normal CBC, lactate 2.5, and
normal UA. CXR no change from previous. Patient was started on
vanc/cefepime.
Currently, patient reports feeling well with only a cough. Has
good appetite and denies headache, neck stiffness, abdominal
pain, diarrhea, or rash.
Past Medical History:
Cerebral Palsy
Autoimmune encephalitis
Nonalcoholic Steatohepatitis with suspected fibrosis
Asthma
Hypertension
Insomnia
Polycythemia
Pulmonary Hypertension
OSA
Social History:
___
Family History:
Family history reveals both parents with substance abuse issues.
His siblings, 2 brothers and 1 sister, are described as healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 99.7 98.6 152/86 96 18 98%RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse rhonchi, no wheezes or rales
CV: RRR, 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: AOx3, some difficulty with articulation but answers
questions appropriately
DISCHARGE EXAM:
Vitals: Tm 98.5, Tc 97.8, (Tm since admission 99.7 on ___,
128/87, 100, 18, 95% RA, 1 large BM yest
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Moderate rhonchi, transmitted upper airway sounds, no
wheezes or rales
CV: RRR, 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: AOx3, some difficulty with articulation but answers
questions appropriately
Pertinent Results:
ADMISSION LABS:
___ 06:19AM BLOOD WBC-4.7 RBC-5.95 Hgb-15.2 Hct-48.9 MCV-82
MCH-25.5* MCHC-31.1* RDW-13.3 RDWSD-39.1 Plt ___
___ 09:30PM BLOOD Neuts-41.5 ___ Monos-10.1 Eos-1.0
Baso-0.7 Im ___ AbsNeut-2.42# AbsLymp-2.64 AbsMono-0.59
AbsEos-0.06 AbsBaso-0.04
___ 06:19AM BLOOD Glucose-97 UreaN-12 Creat-0.8 Na-139
K-3.7 Cl-102 HCO3-25 AnGap-16
___ 06:19AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.0
IMAGING:
CXR ___
Limited exam without overt signs of pneumonia or edema. If
there is further concern a repeat exam with more optimized
technique is advised.
CTA Chest ___:
IMPRESSION:
1. The subsegmental pulmonary arteries are not well opacified,
and a small filling defect cannot be excluded. No large
pulmonary embolism.
2. No focal consolidation concerning for pneumonia. Mild
bibasilar atelectasis.
CXR ___:
No evidence of aspiration or pneumonia.
DISCHARGE LABS:
Brief Hospital Course:
Mr. ___ is a ___ year-old male with NASH, autoimmune
encephalitis, cerebral palsy, OSA not on CPAP, PTSD w/ prior SI
and SA, and h/o aspiration pneumonia who recently presented with
aspiration pneumonia and had another episode of fever despite
being on levofloxacin 750mg daily.
ACTIVE DIAGNOSES:
# Viral Bronchitis: Patient was afebrile during previous
hospitalization and at discharge but now with new fevers. It was
initially felt to be a failure of levofloxacin, and we treated
him with broad spectrum vanc/cefepime IV. On ___, a chest CT
was done which did not show pneumonia. Most likely, he has a
viral bronchitis. Differential also includes aspiration
pneumonitis. No other localizing signs or symptoms of infection.
Urine was clean. Influenza swab negative during recent
admission. He was given supportive treatment. He was afebrile
for over 48 hours off antibiotics on day of discharge. A chest
___ on the day of discharge was clear without evidence of
aspiration pneumonitis or pneumonia.
# History of aspiration: Recent evaluation by speech and swallow
and found to have aspiration risk. Patient continued on soft
diet with small bites and honey-thick liquid and aspiration
precautions. Of note, patient would often sneak thin liquids
from the floor kitchen. He was reminded this is dangerous for
him and encouraged to comply with aspiration diet.
# OSA: Patient has OSA with CPAP. However, unwilling to use CPAP
machine and does not have one at home. Patient monitored on tele
while inpatient and found to have desats to the high 80's at
night.
# Cerebral palsy, h/o ___ Encephalitis, history of
self-harm: Continued on depakote ER
# Depression: Continued on wellbutrin
# HTN: Continued HCTZ
# NASH: Trend LFTs as outpatient
# Asthma, allergies: Continue montelukast, prn albuterol,
fluticasone, loratidine
TRANSITIONAL ISSUES:
- It is recommended that he continue on a diet of nectar thick
liquids and soft/moist chopped solids with meat cut into small
pieces. He should continue to take his pills whole in pudding.
He should take very small sips with all meals and should not use
a straw.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 100 mg PO BID
2. Divalproex (DELayed Release) 1000 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Guaifenesin 15 mL PO Q6H:PRN cough
5. Loratadine 10 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
9. Cal-Citrate (calcium citrate-vitamin D2) 515 mg-200 mg oral
daily
10. Hydrochlorothiazide 12.5 mg PO DAILY
11. Ibuprofen 400 mg PO Q6H:PRN pain
12. Zolpidem Tartrate 5 mg PO QHS
13. Levofloxacin 750 mg PO DAILY
Discharge Medications:
1. BuPROPion (Sustained Release) 100 mg PO BID
2. Divalproex (DELayed Release) 1000 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Guaifenesin 15 mL PO Q6H:PRN cough
5. Hydrochlorothiazide 12.5 mg PO DAILY
6. Ibuprofen 400 mg PO Q6H:PRN pain
7. Montelukast 10 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
10. Cal-Citrate (calcium citrate-vitamin D2) 515 mg-200 mg oral
daily
11. Loratadine 10 mg PO DAILY
12. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Viral bronchitis
Secondary: Autoimmune encephalitis, Cerebral palsy, Obstructive
Sleep Apnea noncompliant with CPAP
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 recent
hospitalization at ___. You were admitted out of concern for
fevers, cough and difficulty breathing. We initially treated you
for pneumonia with antibiotics, but your CT scan on ___
did not show a pneumonia, so we stopped the antibiotics. You
likely have a viral illness that will go away on its own. You
may also have ongoing aspiration "pneumonitis" which is simply
non-infectious inflammation of lung when food and saliva go down
the wrong tube! You do not need antibiotics for that. It is very
important that you eat nectar-thickened liquids and soft foods.
Eat slowly. The Chest ___ that we got on ___ was unremarkable
without evidence of pneumonia.
Please take your medications as prescribed and follow up with
your physicians as below.
We wish you the best,
Your ___ care team
Followup Instructions:
___
|
19793569-DS-8
| 19,793,569 | 27,927,535 |
DS
| 8 |
2144-06-15 00:00:00
|
2144-06-15 16:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
House Dust / Feathers / ragweed
Attending: ___.
Chief Complaint:
productive cough x1 day
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
N.B. This history was obtained from Mr. ___, without his
guardian present.
Mr. ___ is a ___ with cerebral palsy and a hx of autoimmune
encephalitis, recurrent aspiration pneumonia, and asthma now
presenting with a cough x1 day. On ___ night (___), he
was standing while drinking some cough syrup and suddenly began
coughing. He was not able to say why he was drinking cough syrup
in the first place, and he was not able to say whether he felt
like he choked on the cough syrup or whether it "went down the
wrong tube." He said that since then, his coughs have caused him
chest pain and have been productive of green sputum and "clear
vomit." He has not felt short of breath, feverish, nauseated, or
lightheaded, and he has not had a cough or sore throat. He has
had no belly pain or loss of appetite. His last BM was on
___, and it looked and felt normal. It is
typical for him to have a BM every few days. On ___
(___), he began urinating frequently (every 10 minutes),
but without burning, itching, or pain.
In the ED, initial VS were:
Pain 0 T 97.5 HR 116 BP 120/64 RR 22 O2sat 97% RA
Labs:
U/A negative for UTI or hematuria (see OMR)
138 | 99 | 22
----------------< 79
3.9 | 24 | 1.0
Ca: 10.0 Mg: 1.9 P: 4.3
16.3
6.3>------<186
52.4
MCV 81
Lactate 2.7
FluAPCR and FluBPCR were negative
Imaging:
CXR PA/Lat showed a posterior basal consolidation, concerning
for recurrent pneumonia. No pleural effusion. No pneumothorax.
Received: 2L IVF NS, PO Benzonatate 100 mg, IV
___ 4.5 g x2, IV Vancomycin 1000 mg x2.
Transfer VS were:
Pain 0 T 98.2 HR 92 BP 134/72 RR 16 O2sat 99% RA
Decision was made to admit to medicine for further management of
suspected aspiration pneumonia.
On arrival to the floor, patient reports that he is feeling
overall well. He continues to feel afebrile, and his review of
systems continues to be the same as described above.
REVIEW OF SYSTEMS:
All other ___ review negative in detail.
Past Medical History:
Cerebral Palsy (? brain stem)
Autoimmune encephalitis
Recurrent aspiration pneumonia
Nonalcoholic Steatohepatitis with suspected fibrosis
Asthma
Hypertension
Insomnia
Erythrocytosis
Pulmonary Hypertension
OSA
Constipation
Mood disorder (depressive disorder, ADHD, PTSD)
Uses walker for ambulation
Limited speech (reduced and slow, but communicative)
Adenoidectomy
Social History:
___
Family History:
___
Physical Exam:
GENERAL: NAD
HEENT: MMM, EOMI, PERRLA
NECK: no JVD, no LAD
HEART: RRR, no m/r/g
LUNGS: prolonged I:E (~1:2); expiratory and inspiratory ronchi
anteriorly; R lung: diminished breath sounds with faint, diffuse
expiratory crackles; L lung: expiratory wheezes with expiratory
crackles that are worst at the base and extending halfway up;
wet cough productive of pale white/yellow sputum
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ grossly intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION:
___ 01:30AM BLOOD ___
___ Plt ___
___ 01:30AM BLOOD ___
___ Im ___
___
___ 01:30AM BLOOD ___
___
___ 01:30AM BLOOD ___
___ 07:10AM BLOOD ___
___ 07:10AM BLOOD ___
___ 03:48PM BLOOD ___
DISCHARGE:
___ 07:30AM BLOOD ___
___ Plt ___
___ 07:30AM BLOOD ___
___
___ 07:30AM BLOOD ___
Brief Hospital Course:
Mr. ___ is a ___ with cerebral palsy and a history of
autoimmune encephalitis, asthma, OSA, and recurrent aspiration
pneumonia who presented with aspiration pneumonitis.
# Pneumonitis:
The patient's CXR showed a posterior basal consolidation, and he
had a wet cough productive of pale yellow sputum. Because he was
afebrile and did not have a leukocytosis, this was deemed to be
secondary to an aspiration pneumonitis rather than pneumonia. He
was treated with ___ and a
___ liquid diet.
# Aspiration:
The patient has a history of recurrent aspiration pneumonia. He
was ___ with a video oropharygeal swallow, which showed
that he has intermittent aspiration, particularly with thin
liquids. However, he can minimize his aspiration in response to
cues to take smaller bites/sips and eat more slowly. Still, he
___ likely continue to aspirate without a ___. His guardian
(___) made it clear that a ___ is not
consistent with his goals of care. A meeting between Ms.
___, Dr. ___ group home staff, the patient, and the
speech and swallow team established that the patient ___
continue to eat a regular diet with ___ supervision
during meals.
# Asthma
The patient's asthma has been stable. His O2sat has been the
___ ___ on room air, and he has not felt short of
breath. He should continue his regular asthma medications
(Singulair, Albuterol, Loratidine).
# Erythrocytosis
The patient has chronically elevated H/H ___.
Previous PCP notes suggest that this is in reaction to chronic
hypoxia. However, we recommend that the patient be referred to
heme/onc for evaluation as an outpatient.
# Diarrhea
The patient said he had 3 episodes of diarrhea last night. This
was likely ___ his recent diet of ___ liquids (he
has not received any stool softeners on this admission), and it
has since resolved.
# Increased urinary frequency
The patient initially endorsed increased urinary frequency, but
this has resolved. His urine culture did not grow bacteria.
# HTN
The patient's blood pressure has been stable on
hydrochlorothiazide 12.5mg.
# Cerebral Palsy
The patient's cerebral palsy was not assessed during this
admission. Per a recent PCP ___, ___, in
___): "He appears to be doing well at the group home without any
new falls, injuries or concerns. He is still waiting for a new
hospital bed. He would prefer a full size hospital bed to help
with insomnia, sleep more comfortably and avoiding the risk for
falling from a narrower bed."
# OSA
The patient did not use a CPAP while in the hospital, without
incident. Per a recent PCP ___, ___, in
___), patient has declined to use a CPAP at home.
# Nonalcoholic Steatohepatitis with suspected fibrosis
No signs of liver dysfunction on this admission, and normal LFTs
as of ___ (see OMR).
TRANSITIONAL ISSUES:
- ___ PCP outpatient
- ___ hematology/oncology outpatient to w/u erythrocytosis
- ___ care WITH SPEECH THERAPY and ONE TO ONE TEACHING WITH
EATING per speech and swallow recs
- ___ coaching to take small bites and eat slowly during
every meal
- Guardian notes that G tube is not within patient's goals of
care - do not need to contact ___ to discuss
this on future admissions for aspiration. Eating gives patient
joy in life and he is agreeable (as is entire team) with feeding
recs which include:
1.) Safest PO diet: SMALL sips of nectar thick liquids; regular
solids cut into small pieces
2.) PO meds: whole in puree
3.) Strict Aspiration Precautions:
- 1:1 assist to cue for SLOW RATE and SMALL SIPS
- slow rate of intake
- SMALL sips of liquids
- no straws
- minimize distractions during meals/POs (i.e. no TV, no
talking, lights on)
4.) If accepting risk of aspiration, may follow ___ Free
Water protocol ONLY under strict supervision:
- pt may have water (regular, sparkling, or with Crystal
Light ONLY)
- Pt can only have water in between meals
- ONLY after oral care including brushing of his teeth, gums,
tongue and palate, and utilizing a sterilizing mouthwash
#Code Status: full (confirmed)
#Contact = Legal guardian: ___.
___. Supervisor = ___
___.
#CONSULTS: speech/swallow
Medications on Admission:
Prescription:
albuterol sulfate inhaler 90 mcg ___ puffs ___ prn for
cough/wheezing
bupropion HCl extended release 100 mg PO BID
divalproex delayed release 500 mg 2 tablets PO Qdaily
fluticasone 50 mcg/actuation nasal spray 2 sprays in each
nostril QHS
hydrochlorothiazide 12.5 mg tablet PO QAM
montelukast [Singulair] 10 mg tablet PO Qdaily
robitussin 15 ml Q6hrs prn
melatonin 300 mcg QHS prn for insomnia
OTC:
calcium ___ D3 315 ___ unit PO TID
docusate sodium 100 mg PO BID for constipation; hold in more
than 2 bowel movements/day
ibuprofen 200 mg PO 2 tablets Q6hrs prn for aches and pains
loratadine 10 mg tablet PO Qdaily
multivitamin PO Qdaily
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
2. BuPROPion (Sustained Release) 100 mg PO BID
3. ___ (calcium ___ D2) 515 ___ mg oral
daily
4. Divalproex (DELayed Release) 1000 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Guaifenesin 15 mL PO Q6H:PRN cough
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Ibuprofen 400 mg PO Q6H:PRN pain
10. Loratadine 10 mg PO DAILY
11. Montelukast 10 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Aspiration pneumonitis
SECONDARY DIAGNOSIS:
Asthma
Erythrocytosis
Obstructive Sleep Apnea
HTN
Cerebral palsy
Autoimmune encephalitis
___ steatohepatitis with suspected fibrosis
Discharge Condition:
Mental status: Slow speech but mostly coherent
Ambulatory: Requires assistance (___)
Level of Consciousness: Alert and interactive
Discharge Instructions:
Dear Mr. ___,
You were hospitalized at ___ for your aspiration pneumonitis.
This is lung irritation and inflammation that results from food
or drink "going down the wrong tube" into your lungs instead of
your stomach. To help your lungs recover, we gave you a diet of
thickened liquids that are easier to swallow properly. We also
took a video of you swallowing in order to assess how at risk
you are to aspirate again in the future. This video showed that
you are at risk of getting more food and drink into your lungs
in the future. This can make you seriously ill. The only way to
avoid this would be to feed you through a tube. However, you met
with Dr. ___, your guardian ___, your
group home nurses, and the ___ speech and swallow team and
decided that a feeding tube is not within your goals of care.
Instead, you elected to continue eating solid food in spite of
the risk to your lungs. You ___ have a nurse or group home
staff member sit with you at each meal to remind you to take
small bites and eat slowly in order to help the food go into
your stomach and not your lungs. You should continue seeing your
PCP so that he/she can monitor how this is going.
You were also found to have more red blood cells in your blood
than normal. This appears to be something that you have had for
many years. We recommend that you have this evaluated by a blood
specialist (a hematologist/oncologist). Your PCP ___ refer you.
It was our pleasure taking care of you!
Your ___ Team
Followup Instructions:
___
|
19793569-DS-9
| 19,793,569 | 24,978,506 |
DS
| 9 |
2144-08-19 00:00:00
|
2144-08-19 17:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
House Dust / Feathers / ragweed
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with cerebral palsy and a hx of autoimmune
encephalitis, asthma, and recurrent aspiration pneumonia
recently admitted ___ ___ for aspiration pneumonitis,
presenting from group home with concern for aspiration.
The patient is unable to provide detailed history, nor does his
mother have specific details and he is accompanied by no outside
records.
His mother saw him 4 days ago in his group home and he was well.
Yesterday, it appears he started coughing and having some
trouble breathing. The patient states he hasn't had a fever.
Symptoms continued today, and he was brought to the ED.
He reports no chest pain, no abd pain.
In the ED:
T 98.4 104 148/81 18 91% RA
CBC, Chemistry, LFT's unremarkable.
___ negative
CXR noted LLL infiltrate that may be pneumonitis vs. pneumonia.
He was given cefepime 2gm x1 and flagyl 500mg IV x1 and
admitted.
On arrival to the floor, he feels generally well. His mother by
phone reports that he sounds congested. He has no specific
complaints.
ROS:
Per hpi, otherwise rest of 10pt review negative.
Past Medical History:
Cerebral Palsy (? brain stem)
Autoimmune encephalitis
Recurrent aspiration pneumonia
Nonalcoholic Steatohepatitis with suspected fibrosis
Asthma
Hypertension
Insomnia
Erythrocytosis
Pulmonary Hypertension
OSA
Constipation
Mood disorder (depressive disorder, ADHD, PTSD)
Uses walker for ambulation
Limited speech (reduced and slow, but communicative)
Adenoidectomy
Social History:
___
Family History:
___
Physical Exam:
ADMISSION PE
T 97.9 123/78 98 20 94%RA
GEN: Well appearing, sitting up and chatting
HEENT: Moist membranes, typical dentition
NECK: No masses
HEART: RRR, no murmurs
LUNGS: Diffuse ronchi, good air movement, no accessory muscle
use, speaking in full sentences
ABD: Soft, nontender
GU: No foley
EXT: Warm, no edema
NEURO: Alert, answers questions with yes/no
PSYCH: Mood upbeat, laughs easily
Discharge physical exam:
VS: 98.0 ___ 143/96 18 95%RA
General: Well appearing obese young man sitting up in chair in
NAD
Eyes: PERLL, EOMI, sclera anicteric
ENT: MMM, oropharynx clear without exudate or lesions
Respiratory: Transmitted upper airway sounds, intermittent mild
diffuse rhonchi, no wheeze
Cardiovascular: RRR, normal S1 and S2, no murmurs, rubs or
gallops. Mild reproducible diffuse chest tenderness on
palpation.
Gastrointestinal: Soft, nontender, nondistended, +BS, no masses
or HSM
Extremities: Warm and well perfused, no peripheral edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert and oriented x3, motor and sensory exam
grossly intact. Speech somewhat slurred at baseline.
Pertinent Results:
Admission labs:
___ 01:00PM BLOOD ___
___ Plt ___
___ 01:00PM BLOOD ___
___ Im ___
___
___ 01:00PM BLOOD ___
___
___ 01:00PM BLOOD ___ LD(___)-147 ___
___
___ 01:00PM BLOOD ___
Discharge labs:
___ 08:00AM BLOOD ___
___ Plt ___
___ 09:10AM BLOOD ___
___ Plt ___
___ 08:40AM BLOOD ___
___ Plt ___
___ 08:40AM BLOOD ___
___
___ 08:40AM BLOOD ___
Micro:
___ Bcx x2 pending
___ Ucx negative
Imaging:
___ CXR IMPRESSION:
Patchy left lower lobe opacity may reflect aspiration or
infection in the
correct clinical setting
___ CTA Chest
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bibasilar opacities may represent sequelae of aspiration
pneumonitis
superimposed on chronic bronchiectasis.
Brief Hospital Course:
___ with cerebral palsy and a hx of autoimmune encephalitis,
asthma, and recurrent aspiration pneumonia recently
admitted ___ ___ for aspiration pneumonitis, presenting
from group home with concern for aspiration.
# Cough/aspiration pneumonitis/bronchiectasis: Presentation fits
with aspiration pneumonitis without leukocytosis or fever,
satting well on room air with no respiratory distress, very
similar to last admission where he was observed off antibiotics
and discharged with diagnosis of pneumonitis. CXR is
unimpressive
in comparison to old, and clinical exam is relatively
unremarkable without evidence of consolidation. CTA Chest shows
likely pneumonitis superimposed on chronic bronchiectasis, which
is likely a sequela of recurrent aspiration. He is likely
continuing to aspirate, volunteering to overnight admitter that
he knows about it, knows chin tuck method, and again that he
aspirated during this admission. Admitter discussed with his
mother that this is a difficult thing to fix and that he will
likely struggle with aspiration for a long time. He had video
swallow last admission and extensive teaching. Per RN, patient
minimally aspirates and does well if reminded to chew, but has a
tendency to eat very rapidly and inhale food. Discharged off
antibiotics as no fever or notable WBC throughout admission.
Continued reg diet (small pieces) with thickened liquids for
now, with detailed discharge summary documentation of plan for
___ eating ordered. No G tube, in accordance with
___ preferences. Would not recapitulate that workup.
Provided guaifenesin, IS. Rhonchorus at baseline.
#Sinus tachycardia/atypical chest pain: Patient developed sinus
tachycardia (confirmed on EKG and tele) which was persistent. He
has had intermittent tachycardia on prior admissions but given
pleuritic chest pain and dyspnea, concern for PE; however, CTA
Chest shows no evidence of PE. Tachycardia did not improve with
IVF bolus initially. ___ represent inflammatory response to
pneumonitis. Remain less
concerned for infection for reasons listed above. Improved
without intervention prior to discharge with HR in ___. Patient
had reproducible chest pain on night prior to discharge which
partially improved with ibuprofen, with EKG unchanged from
prior, and was similar to pain documented on prior admission.
Increased ibuprofen to 800mg Q8H prn for one week on discharge.
# Asthma: Stable on home albuterol, loratidine, singulair
# CP/h/o Encephalitis: Stable at baseline mental status on home
divalproex ___ daily and wellbutrin 100mg bid
# Erythrocytosis: Chronic, counts are upper limit of normal,
continue to recommended outpatient workup as previously noted on
prior discharge summary.
# HTN: Stable on HCTZ 12.5mg
Transitional issues:
- Patient previously recommended to f/u with hematology/oncology
as outpatient to evaluate erythrocytosis, should discuss with
PCP
- ___ notes that G tube is not within patient's goals of
care - do not need to contact ___ to discuss
this on future admissions for aspiration. Eating gives patient
joy in life and he is agreeable (as is entire team) with feeding
recs which include:
1.) Safest PO diet: SMALL sips of nectar thick liquids; regular
solids cut into small pieces
2.) PO meds: whole in puree
3.) Strict Aspiration Precautions:
- 1:1 assist to cue for SLOW RATE and SMALL SIPS
- slow rate of intake
- SMALL sips of liquids
- no straws
- minimize distractions during meals/POs (i.e. no TV, no
talking, lights on)
4.) If accepting risk of aspiration, may follow ___ Free
Water protocol ONLY under strict supervision:
- pt may have water (regular, sparkling, or with Crystal
Light ONLY)
- Pt can only have water in between meals
- ONLY after oral care including brushing of his teeth, gums,
tongue and palate, and utilizing a sterilizing mouthwash
- Continue ___ coaching to take small bites and eat
slowly during every meal
-During admission patient had sinus tachycardia and atypical
chest pain of unclear etiology with negative CTA Chest and EKGs,
which was similar to that seen on prior admission and largely
___
-Found to have bronchiectasis on CT Chest, likely from chronic
aspiration, referred to his pulmonologist for followup
#Code Status: full (confirmed)
#Contact = Legal ___.
Group home contact ___
>30 min spent on discharge coordination on day of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Guaifenesin 15 mL PO Q6H:PRN cough
2. Ibuprofen 400 mg PO Q6H:PRN pain
3. Zolpidem Tartrate 5 mg PO QHS
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. ___ (calcium ___ D2) 515 ___ mg oral
TID
6. Loratadine 10 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Montelukast 10 mg PO DAILY
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Divalproex (DELayed Release) 1000 mg PO DAILY
12. BuPROPion (Sustained Release) 100 mg PO BID
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
14. Levofloxacin 750 mg PO Q24H
Discharge Medications:
1. Ibuprofen 800 mg PO Q8H:PRN pain
RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*21 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
3. BuPROPion (Sustained Release) 100 mg PO BID
4. ___ (calcium ___ D2) 515 ___ mg oral
TID
5. Divalproex (DELayed Release) 1000 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Guaifenesin 15 mL PO Q6H:PRN cough
9. Hydrochlorothiazide 12.5 mg PO DAILY
10. Loratadine 10 mg PO DAILY
11. Montelukast 10 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Aspiration pneumonitis
Secondary: Bronchiectasis, cerebral palsy, sinus tachycardia,
atypical chest pain, asthma, erythrocytosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for cough and shortness of breath.
There was concern that you had pneumonia, but since you have no
fevers and have done well without antibiotics it looks more like
irritation of your lungs from aspiration. Please make sure to
follow the recommendations to reduce aspiration that were made
on your last admission.
You also had chest pain and a fast heart beat. You had multiple
tests to make sure you don't have a blood clot or heart issues,
but there were no problems found. Your heart rate improved prior
to going home and it seems that the chest pain is probably
related to the muscles in your chest being strained when you
have shortness of breath.
Please follow up with your primary doctor and the lung doctor to
keep track of these issues.
It was a pleasure caring for you,
Your ___ Care Team
Followup Instructions:
___
|
19793604-DS-12
| 19,793,604 | 21,975,094 |
DS
| 12 |
2194-02-11 00:00:00
|
2194-02-11 15:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Methocarbamol / Sporanox / Bactrim / Doxycycline /
Serzone / Vioxx / Vancomycin / GENTAMYCIN
Attending: ___.
Chief Complaint:
abdominal pain, distension, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man with HIV (last CD 4 count 539 in ___ on HAART, OSA
on CPAP who presents 3 days after a recent colonoscopy ___
___ with complaint of abdominal pain, distension, fever to
101 at home. Reports sx began on ___ (2 days post
procedure), started to feel vague abdominal discomfort,
bloating. The next day noted fever to 101.2 at home, chills,
worsening abdominal bloating and pain in right abdomen. Denies
nausea/vomiting. Has had regular nonbloody BM. Has been eating
regular diet.
In ED, VS notable for T 100.0. Currently I am not able to find
documentation of their abdominal exam. Pt reports CT scan
prelim from ED read reported "wall thickening and surrounding
fat stranding of the proximal descending colon, a region of
diverticulosis, as well as a 4 x 15 mm hyperdensity, which could
represent ingested material versus a foreign body related to
recent colonoscopy. It is unclear if these inflammatory changes
are related to diverticulitis versus this foreign body. There is
no intraperitoneal free air. "
His colonoscopy on ___ was notable for polyps in the distal
descending colon and sigmoid colon which were removed.
Otherwise the colonoscopy was normal to the cecum.
ROS: +fever/chills/abdominal pain as above.
Otherwise ROS negative including CP, palpitations, SOB, cough,
URI sx, constipation/diarrhea, urinary frequency or dysuria,
focal motor deficits, HA, other neuro sx, skin changes
Past Medical History:
HIV - Dx ___ Has had CD4 as low as 60; Has had Extensive
h/o STDs including genital herpes, anal warts, GC, syphilis and
chlamydia. Also hospitalized at ___ in ___ for disseminated
zoster. ___: Bactrim prophylaxis
--> rash; switched to Dapsone. Now f/b ___. Stable
counts/ VL;
ABDOMINAL PAIN
ADRENAL MASS
6mm, left ___, incidental finding; reimaging at 6 mos in
___ stable
and c/w likley adenoma, f/u CT ___ with stable L adrenal
ANAL WARTS
HIP PAIN h/o labral tear and mild dysplasia R hip s/p
arthroscopic repair
HSV genital recurrent, prn acyclovir
HYPERCHOLESTEROLEMIA
HYPERLIPASEMIA
HYPOANDROGENISM
KNEE PAIN
LIPOMA
LOW BACK PAIN
OSA mild OSA by sleep study ___
PLEURAL TUMOR ___- Benign Mesothelioma, excised (VATS
___, no complic)
Social History:
___
Family History:
brother - localized melanoma
Physical Exam:
T 98.2 (T 100 in ED), 126/81 HR 66 RR 14 95%RA
comfortable appearing, NAD
anicteric, MMM
neck supple
RRR
Lungs clear bilaterally
Abd soft, nondistended, very minimal tenderness to palpation
right side (middle and RUQ), no guarding, no rebound
Extrem: no edema
Neuro: oriented x 3, face symmetric, moving all extremities well
Psych: pleasant, fluent speech
Discharge Exam:
PHYSICAL EXAM:
VITAL SIGNS: 98.5 99/55 60 18 98% on RA
GEN: NAD
EYES: anicteric
ENT: MMM
CV: Normal rate, regular rhythm
PULM: CTAB
GI: Soft, mild distension, minimal tenderness with palpation of
the LLQ
SKIN: Erythema, blanching over the chest
Pertinent Results:
___ 12:37AM WBC-9.0# RBC-4.21* HGB-13.9 HCT-40.4 MCV-96
MCH-33.0* MCHC-34.4 RDW-12.9 RDWSD-45.0
___ 12:37AM NEUTS-64.1 ___ MONOS-10.0 EOS-2.1
BASOS-0.6 IM ___ AbsNeut-5.74 AbsLymp-2.05 AbsMono-0.90*
AbsEos-0.19 AbsBaso-0.05
___ 12:37AM GLUCOSE-104* UREA N-18 CREAT-1.1 SODIUM-134
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-20* ANION GAP-14
___ 12:47AM LACTATE-1.3
Blood cultures pending
Colonoscopy on ___:
Polyp in the distal descending colon (polypectomy, endoclip)
Polyp in the sigmoid colon (polypectomy)
Diverticulosis of the whole colon
Otherwise normal colonoscopy to cecum
CT abdomen/pelvis with contrast
IMPRESSION:
1. Acute diverticulitis at the splenic flexure.
2. No fluid collection or free air.
3. Endoclip at the proximal descending colon relates to recent
colonoscopy
(placement on ___ per OMR). This lies just distal to the
inflamed segment
and is unlikely related to the acute findings.
Brief Hospital Course:
___ yo man with HIV (last CD 4 count 539 in ___ on HAART, OSA
on CPAP who presents 3 days after a recent colonoscopy ___
___ with complaint of abdominal pain, distension, fever to
101 at home. CT scan notable for a focal area of inflammation
near splenic flexure.
#Diverticulitis vs. post-polypectomy syndrome
- No signs/sx of perforation, abdomen benign, and pt appeared
clinically well despite fever at home. He was treated for
diverticulitis with IV cipro/flagyl initially and transitioned
to PO on discharge. He was seen by GI and they recommended ___
days of treatment. Hi diet was advanced and tolerated well. He
did not have BRBPR or diarrhea on admission and was moving his
bowels normally. He has follow-up with Dr. ___ day
after discharge (___). He was discharged with 13 days of
Cipro/Flagyl.
CHRONIC ISSUES:
#HIV, asymptomatic, CD 4 count 539 in ___
#Hyperlipidemia
statin held on admission; resumed upon discharge
#OSA - continue CPAP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO BID
2. Atorvastatin 10 mg PO DAILY
3. Amphetamine-Dextroamphetamine 10 mg PO DAILY: PRN ADHD
4. Complera (emtricitab-rilpivirine-tenofov) 200-25-300 mg oral
DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Pregabalin 100 mg PO DAILY
7. tadalafil 20 mg oral DAILY: PRN
8. AndroGel (testosterone) 1 % (50 mg/5 gram) transdermal DAILY
9. TraZODone 50 mg PO QHS
10. zaleplon ___ mg oral PRN night awakenings
11. Aspirin 325 mg PO DAILY
12. Cetirizine Dose is Unknown PO DAILY
13. Cromolyn Sodium (Nasal Inhalation) 1 SPRY NU TID:PRN nasal
congestion
14. melatonin 10 mg oral QHS
15. Fish Oil (Omega 3) Dose is Unknown PO DAILY
Discharge Medications:
1. Pregabalin 100 mg PO DAILY
2. TraZODone 50 mg PO QHS
3. Acyclovir 400 mg PO BID
4. Amphetamine-Dextroamphetamine 10 mg PO DAILY: PRN ADHD
5. AndroGel (testosterone) 1 % (50 mg/5 gram) transdermal DAILY
6. Aspirin 325 mg PO DAILY
7. Atorvastatin 10 mg PO DAILY
8. Cetirizine 10 mg PO DAILY
9. Complera (emtricitab-rilpivirine-tenofov) 200-25-300 mg oral
DAILY
10. Cromolyn Sodium (Nasal Inhalation) 1 SPRY NU TID:PRN nasal
congestion
11. Fish Oil (Omega 3) 1000 mg PO DAILY
12. Fluticasone Propionate NASAL 1 SPRY NU DAILY
13. melatonin 10 mg oral QHS
14. tadalafil 20 mg oral DAILY: PRN
15. zaleplon ___ mg oral PRN night awakenings
16. Ciprofloxacin HCl 500 mg PO Q12H Duration: 13 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*26 Tablet Refills:*0
17. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 13 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*39 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Adenomatous polyps
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain and fever a few days after
your recent colonoscopy. CT scan showed possible
diverticulitis, an inflammation or inflammation of diverticuli
(small pouches in the colon wall). You were treated with IV
antibiotics that have now been transitioned to oral. Please
continue to take these antibiotics as prescribed for a total of
two weeks.
As you may recall polyps were removed during your recent
colonoscopy. Pathology shows that the polyps show "adenomas".
There was no cancer in the polyps. However, adenomatous polyps
are the type of polyps that can turn into cancer if not removed.
Your polyps were removed. You may develop more adenomatous
polyps in the future and therefore you should continue to
undergo routine colorectal screening.
Given the number and size of polyps, your next colonoscopy
should
be performed in ___ years or sooner if you develop a change in
your
bowel habits or rectal bleeding.
Followup Instructions:
___
|
19793706-DS-5
| 19,793,706 | 21,469,425 |
DS
| 5 |
2184-09-22 00:00:00
|
2184-09-22 23:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right face/arm numbness and paresthesia,
and right hand weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ man with a history of
hypertension, stage 4 CKD, and stroke without residual (___)
who presented to OSH with right face and arm numbness and
paresthesia, and right hand weakness since 9:30AM this morning.
He had been doing yard work, then went inside his home and
noticed right facial numbness and paresthesia which quickly
spread to include his right arm up to the shoulder. He also
noticed mild weakness in his grip on the right. He looked in a
mirror and did not notice any facial asymmetry. He spoke with
his
girlfriend and specifically asked her if his speech was slurred,
which it was not. He did not have any difficulty comprehending
speech or with word-finding. There was no incoordination, and he
was easily able to walk. He denies headache.
He presented to ___ by 10:30AM and by that time
his
symptoms were quickly improving, with only mild residual right
hand weakness. CT was performed an unremarkable. ___
telestroke
was consulted and tPA was not recommended. He was subsequently
transferred to ___ for stroke work-up.
He reports a history of stroke ___ years ago where he reports
loss of consciousness, but does not believe he had any residual
symptoms upon leaving the hospital. His stage 4 CKD was
discovered around that time and a fistula was placed in his left
arm anticipating the need for dialysis in the near term, however
his kidney function has remained stable since and he has not
initiated dialysis. He has a history of stage 1 colon cancer s/p
partial colectomy ___ years ago with negative surveillance
since.
ROS: Positive as per HPI. On neurological review of systems, the
patient denies headache, confusion, difficulties producing or
comprehending speech, loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
Past Medical History:
Stage 4 CKD ___, stable) secondary to refractory HTN
Unspecified stroke (___)
Stage 1 colon adenocarcinoma s/p sigmoid hemicolectomy (___)
Hypertension
Hyperlipidemia
Aortic root dilation
Chronic diastolic congestive heart failure
Hypertensive heart disease
Social History:
___
Family History:
Multiple paternal aunts with heart disease.
No family history of clotting or bleeding disorders, strokes,
seizures, brain tumors, or other cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
Vitals: T:98.0 HR:78 BP:154/80 RR:20 SaO2:100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: Venous stasis changes in lower legs. Generally dusky,
mildly jaundiced appearance.
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.
Able to name both high and low frequency objects. Able to read
without difficulty. No dysarthria. Able to follow both midline
and appendicular commands. Able to register 3 objects and recall
___ at 5 minutes. Calculation ability intact. 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 speech.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
* Excellent strength in confrontational testing of right hand,
however had mildly slowed repetitive and sequential finger
tapping.
-Sensory: No deficits to light touch or pinprick throughout.
Graphestheia intact in both hands. No extinction to DSS. Romberg
absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 1 2 2
R 2 1 2 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Slowed finger tap on right.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
DISCHARGE PHYSICAL EXAM
=======================
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx.
Neck: Supple.
Pulmonary: Normal work of breathing.
Cardiac: RRR, warm, well-perfused.
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
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.
Able to name both high and low frequency objects. Able to read
without difficulty. No dysarthria. Able to follow both midline
and appendicular commands. 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 speech.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
-Motor: Normal bulk and tone throughout. No pronator drift. No
adventitious movements, such as tremor or asterixis noted.
[___]
L 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch or pinprick throughout.
Graphestheia intact in both hands. No extinction to DSS. Romberg
absent.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 1 2 2
R 2 1 2 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Slowed finger tap on right.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based
Pertinent Results:
IMAGING
========
___ TTE:
1) No specific echocardiographic evdence of cardiac source of
embolus. However patient has severe left atrial dilation in
setting of grade II LV diastolic dysfunction in addition to
significant cardiac calcification on mitral and aortic valve. 2)
There is Lambl's excrescence on left coronary cusp.
CAROTID SERIES COMPLETEStudy Date of ___
LEFT:
The left carotid vasculature has mild atherosclerotic plaque.
The peak systolic velocity in the left common carotid artery is
86 cm/sec.
The peak systolic velocities in the proximal, mid, and distal
left internal
carotid artery are 50, 75, and 60 cm/sec, respectively. The
peak end
diastolic velocity in the left internal carotid artery is 70
cm/sec.
The ICA/CCA ratio is 0.87.
The external carotid artery has peak systolic velocity of 117
cm/sec.
The vertebral artery is patent with antegrade flow.
IMPRESSION:
< 40% stenosis of the right internal carotid artery.
< 40% stenosis of the left internal carotid artery.
MR HEAD W/O CONTRASTStudy Date of ___
FINDINGS:
MR BRAIN:
There is linear gyriform cortical restricted diffusion involving
primarily the
posterior aspect of the precentral gyrus but also likely a small
area of the
anterior aspect of the postcentral gyrus (see series 7 images
24, 25, 26 ___s series 6, images 24, 25, 26). There is no definite
corresponding
FLAIR signal abnormality in these areas. There is no evidence
of additional
infarction elsewhere. A few foci of brainstem and basal
ganglia, as well as a
right temporal lobe, focus of susceptibility likely relates to
small foci of
chronic microhemorrhage, possibly related to hypertension given
distribution
(series 13 images 14 and 10). Elsewhere, there is no evidence
of intracranial
hemorrhage, edema, mass or mass effect. The ventricles and
sulci are
prominent consistent with moderate global involutional changes.
Periventricular and scattered bilateral deep and subcortical
white matter foci
of T2/FLAIR signal hyperintensity are nonspecific but compatible
with moderate
changes of chronic white matter microangiopathy. The visualized
paranasal
sinuses and mastoid air cells appear clear. The globes and
orbits are
unremarkable.
MRA BRAIN:
The circle of ___ vasculature and principal intracranial
branches
demonstrate normal flow related enhancement without evidence of
significant
stenosis, occlusion, or aneurysm.
IMPRESSION:
1. Cortically-based gyriform restricted diffusion along the
posterior aspect
of the left precentral gyrus, with a small similar area along
the anterior
aspect of the postcentral gyrus, consistent with acute infarct.
2. A few small foci of left basal ganglia, right temporal lobe,
and right
brainstem microhemorrhage likely relate to chronic hypertension.
Otherwise,
no intracranial hemorrhage.
3. Unremarkable MRA brain. Patent circle of ___ vasculature.
4. Chronic findings include moderate global involutional changes
and moderate
changes of chronic white matter microangiopathy.
ADMISSION LABS
===============
___ 02:00PM BLOOD WBC-10.0 RBC-4.95 Hgb-14.1 Hct-44.7
MCV-90 MCH-28.5 MCHC-31.5* RDW-14.6 RDWSD-47.5* Plt ___
___ 02:00PM BLOOD Neuts-73.4* Lymphs-16.1* Monos-6.7
Eos-2.8 Baso-0.6 Im ___ AbsNeut-7.37* AbsLymp-1.61
AbsMono-0.67 AbsEos-0.28 AbsBaso-0.06
___ 02:00PM BLOOD Plt ___
___ 02:00PM BLOOD ___ PTT-38.1* ___
___ 02:00PM BLOOD Glucose-118* UreaN-51* Creat-3.7* Na-140
K-5.2 Cl-105 HCO3-21* AnGap-14
___ 02:00PM BLOOD ALT-10 AST-13 AlkPhos-99 TotBili-0.3
___ 02:00PM BLOOD Lipase-28
___ 02:00PM BLOOD cTropnT-0.04*
___ 02:00PM BLOOD Albumin-3.9 Calcium-9.1 Phos-2.9 Mg-2.2
Cholest-192
___ 02:58PM BLOOD %HbA1c-5.4 eAG-108
___ 02:00PM BLOOD Triglyc-233* HDL-37* CHOL/HD-5.2
LDLcalc-108
___ 02:00PM BLOOD TSH-3.0
___ 02:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
DISCHARGE LABS
===============
___ 04:35AM BLOOD WBC-8.9 RBC-4.58* Hgb-13.7 Hct-41.5
MCV-91 MCH-29.9 MCHC-33.0 RDW-14.7 RDWSD-48.3* Plt ___
___ 04:35AM BLOOD Plt ___
___ 04:35AM BLOOD Glucose-101* UreaN-55* Creat-4.2* Na-140
K-4.3 Cl-103 HCO3-22 AnGap-15
___ 10:50AM BLOOD cTropnT-0.06*
___ 04:35AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.1 Cholest-175
___ 04:35AM BLOOD Triglyc-241* HDL-33* CHOL/HD-5.3
LDLcalc-94
Brief Hospital Course:
Mr. ___ is a ___ year old right-handed man with a history
of hypertension, stage 4 CKD, and self reported stroke without
residual deficits (___) who presented to OSH with right face
and arm numbness and paresthesia, and right hand weakness. He
was found to have acute ischemic stroke.
#Acute ischemic stroke:
Developed right facial/arm/hand numbness, right hand weakness
while performing yard work at home. Presented to ___
approximately 1 hour after symptom onset. By that time, symptoms
were already improving. CT was unremarkable, telestroke was
activated and tPA was not recommended. He was transferred to
___ for stroke workup. Upon arrival to ___, his symptoms
nearly entirely resolved, NIHSS was 0, and his neurologic exam
was notable only for mildly slowed finger tapping on right hand.
MR without contrast demonstrated left gyral hyperintensity in
MCA distribution not seen on flare. Neck vessel imaging was
deferred to avoid contrast load in setting of CKD. As such,
carotid dopplers were performed, demonstrating <40% stenosis
bilaterally. TTE demonstrated severe left atrial dilation.
Etiology most likely embolic given cortical location, and
rapidity of symptom onset and resolution. Given his left atrial
dilation, there is a suspicion for atrial fibrillation. Stroke
risk factors were notable for: HgA1C: 5.4, LDL 108. Initiated
aspirin 81 mg daily. Continued home atorvastatin 80 mg daily.
Prior to discharge, patient had some mild slowness in right
finger-tapping. Was provided a script for outpatient
occupational therapy. Physical therapy was not consulted as he
was at his functional baseline on arrival to ___.
#HTN:
BP range 107-130s/60-70s. Continued home amlodipine, labetalol,
hydralazine.
#CKD Stage IV:
Creatinine remained at baseline (3.7-4.2). Did not administer
any contrast for imaging as above. Continued home calcitriol,
calcium acetate. Held home kayexelate, vitamin D, resumed at
discharge.
#Troponemia:
Troponin 0.04 uptrended to 0.05 and 0.06. Notably, his
creatinine was also fluctuant and the rate of trend is likely
thought to be secondary to his renal function. Patient without
chest pain.
#Chronic diastolic heart failure:
Euvolemic with no evidence of decompensation. Continued home
furosemide. Continued home antihypertensives as above.
TRANSITIONAL ISSUES:
======================
[] initiated aspirin 81 daily
[] continue to monitor right hand dexterity
[] discharged with order for ___ of hearts monitor x4 weeks,
monitor results
[] continue to monitor troponin trend, thought to be elevated in
setting of CKD, low suspicion for acute coronary syndrome
[] f/u urine culture pending at discharge
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 = 108 ) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - () 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?
() Yes - (x) No. If no, why not? (I.e. patient at baseline
functional status) PATIENT AT BASELINE FUNCTIONAL STATUS
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO QHS
2. Calcium Acetate 667 mg PO QID W/ MEALS
3. Calcitriol 0.25 mcg PO BID WITH FOOD (AM AND NOON)
4. Furosemide 80 mg PO BID (AM AND NOON)
5. Labetalol 300 mg PO Q6H (AM, NOON, DINNER, QHS)
6. HydrALAZINE 100 mg PO Q6H (AM, NOON, DINNER, QHS)
7. Atorvastatin 80 mg PO QPM
8. Vitamin D 1000 UNIT PO DAILY
9. Sodium Polystyrene Sulfonate 45 gm PO 3X WEEKLY (MWF)
10. Ferrous Sulfate 65 mg PO HS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. amLODIPine 5 mg PO QHS
3. Atorvastatin 80 mg PO QPM
4. Calcitriol 0.25 mcg PO BID WITH FOOD (AM AND NOON)
5. Calcium Acetate 667 mg PO QID W/ MEALS
6. Ferrous Sulfate 65 mg PO HS
7. Furosemide 80 mg PO BID (AM AND NOON)
8. HydrALAZINE 100 mg PO Q6H (AM, NOON, DINNER, QHS)
9. Labetalol 300 mg PO Q6H (AM, NOON, DINNER, QHS)
10. Sodium Polystyrene Sulfonate 45 gm PO 3X WEEKLY (MWF)
11. Vitamin D 1000 UNIT PO DAILY
12.Outpatient Occupational Therapy
s/p stroke with R hand weakness/clumsiness. Please evaluate and
treat.
Discharge Disposition:
Home
Discharge Diagnosis:
#acute ischemic stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of numbness and weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
1) high cholesterol
2) high blood pressure
We started you on a medication called "aspirin" which will help
keep your blood thin and prevent you from getting future
strokes.
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19794065-DS-18
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DS
| 18 |
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|
2189-10-05 07:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
erythromycin base
Attending: ___
Chief Complaint:
Fevers, chills, left flank pain
Major Surgical or Invasive Procedure:
Left ureteral stent placement
History of Present Illness:
Patient is a ___ male who recently presented earlier this
month with severe left flank pain and was found to have an
obstructing L UPJ stone. His pain improved and he was discharged
for a trial of stone passage.
The patient followed up with Dr. ___ in the office and
there was discussion about possible treatment in the coming
weeks. He then called the office today with new symptoms of
increasing pain, fever to 102, and rigors. At that time, he was
urged to come to the ED for evaluation.
Currently, he endorses a throbbing L flank pain which as been
constant for some time now and nausea. Denies hematuria,
dysuria,
and incomplete emptying.
Past Medical History:
HTN
Social History:
___
Family History:
n/a
Physical Exam:
Gem: NAD
HEENT: EMOI
CV: RR
PULM: no respiratory distress
Abd: soft, nontender
No CVA tenderness
GU: foley removed before discharge
Ext: warm, well perfused, no edema no cyanosis
Pertinent Results:
___ 06:05AM BLOOD Glucose-101* UreaN-19 Creat-1.3* Na-143
K-4.0 Cl-105 HCO3-26 AnGap-12
___ 06:05AM BLOOD WBC-5.6 RBC-4.74 Hgb-13.7 Hct-40.0 MCV-84
MCH-28.9 MCHC-34.3 RDW-12.3 RDWSD-37.2 Plt ___
Brief Hospital Course:
Mr. ___ was admitted to the Urology service for
nephrolithiasis management with a known large left UPJ stone and
fevers to 102 at home . He underwent cystoscopy and placement
of a left ureteral stent upon admission.
He tolerated the procedure well and recovered in the PACU before
transfer to the general surgical floor. See the dictated
operative note for full details. Overnight, the patient was
hydrated with intravenous fluids and received appropriate
perioperative antibiotics. On POD1, catheter was removed and he
voided without difficulty. He remained afebrile for the
remainder of his hospital course.
At discharge on POD1, patients pain was controlled with oral
pain medications, tolerating regular diet, ambulating without
assistance, and voiding without difficulty.
Patient was explicitly advised to follow up as directed for
definitive stone management with Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 10 mg PO DAILY
Discharge Medications:
1. Oxybutynin 5 mg PO TID PRN bladder spasms
2. Phenazopyridine 100 mg PO TID:PRN urinary pain Duration: 3
Days
3. Sulfameth/Trimethoprim DS 1 TAB PO BID UTI Duration: 7 Days
4. Citalopram 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Obstructing left ureteral stone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent (if there is one).
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-You may be given prescriptions for a stool softener and/or a
gentle laxative. These are over-the-counter medications that
may be health care spending account reimbursable.
-Colace (docusate sodium) may have been prescribed to avoid
post-surgical constipation or constipation related to use of
narcotic pain medications. Discontinue if loose stool or
diarrhea develops. Colace is a stool-softener, NOT a laxative.
-Senokot (or any gentle laxative) may have been prescribed to
further minimize your risk of constipation.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
Followup Instructions:
___
|
19794378-DS-17
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DS
| 17 |
2142-01-15 00:00:00
|
2142-01-15 12:27:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left Olecranon Fracture
Major Surgical or Invasive Procedure:
Splint application
History of Present Illness:
___ right-hand-dominant female who presents with a left
transverse olecranon fracture status post a fall on ___.
Past Medical History:
ABNORMAL MAMMOGRAM AND BREAST U/S
BREAST PAPILLOMA
VITREAL DETACHMENT
EXTERNAL HEMORRHOIDS
CERVICAL POLYP
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: AFVSS
General: Well-appearing female in no acute distress.
Left upper extremity:
Focused exam the left elbow was performed. Patient is tender to
palpation over the tip of the olecranon. She has 1+ effusion in
the left elbow joint. Diffuse ecchymosis posteriorly. Range of
motion deferred secondary to pain. Sensation intact light touch
throughout ulnar, median, radial nerve distribution. Fires FPL,
EPL, DIO. 2+ radial artery pulse, good capillary refill in all
digits.
Pertinent Results:
___ 07:37PM BLOOD WBC-5.7 RBC-4.04 Hgb-12.0 Hct-36.2 MCV-90
MCH-29.7 MCHC-33.1 RDW-12.1 RDWSD-39.8 Plt ___
___ 07:37PM BLOOD Glucose-118* UreaN-10 Creat-0.7 Na-141
K-4.0 Cl-101 HCO3-27 AnGap-13
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 olecranon fracture and was admitted to the
orthopedic surgery service. The patient was splinted in the
___ ED and placed in a sling. Due to OR scheduling conflicts,
the patient was unable to undergo surgery this hospitalization
and will return for elective ORIF of the her olecranon fracture.
The patient's pain was well controlled during this
hospitalization. The ___ hospital course was otherwise
unremarkable.
Medications on Admission:
TACROLIMUS - tacrolimus 0.1 % topical ointment. Apply thin layer
to affected areas around eyes twice a day x ___ weeks
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Discharge Disposition:
Home
Discharge Diagnosis:
Left Olecranon Fracture
Discharge Condition:
AVSS
NAD, A&Ox3
LUE: Dressing clean and dry. Fires EPL/FPL/FDP/FDS/EDC/DIO. SILT
radial/median/ulnar n distributions. 1+ radial pulse, wwp
distally.
Discharge Instructions:
MEDICATIONS:
- Please remain in the splint until you are seen in clinic.
- Please do not bear weight through the left upper arm.
- 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.
Treatments Frequency:
Please remain in the splint until follow-up appointment. Please
keep your splint dry. If you have concerns regarding your
splint, please call the clinic at the number provided.
Followup Instructions:
___
|
19794590-DS-17
| 19,794,590 | 25,978,232 |
DS
| 17 |
2171-07-21 00:00:00
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2171-07-23 10:39:00
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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Unasyn / Ampicillin / Optiray 160 / shrimp / adhesive tape
Attending: ___.
Chief Complaint:
hiccups and abdominal pain
Major Surgical or Invasive Procedure:
___ EGD
History of Present Illness:
HPI: Mr. ___ is a ___ yo with PMH sig for HBV on Entacavir and
Tenofivir and hx of HCC currently treated on FOLFOX chemotherapy
last cycle received on ___. He presented to the ED
complaining of intractable hiccups, abdominal pain mainly
localized to the mid epigastric pain, constant and burning,
radiating to his back (bar-like distribution) and to his chest,
rated ___ for over 3 days associated to nausea and "black"
emesis and flatulance. He reports being unable to tolerate any
PO intake since ___, has had last BM on ___ and denies
any BRPR or melena. He states that his pain mildly improves with
Morphine (going from 8 to 4). No particular food make pain
worse, but lying supine makes sxs worse.
.
Recently he was admitted for similar complaints. At that time a
CT abdomen showed retroperitoneal stranding surrounding the
duodenum and pancreatic head consistent with duodenitis. The
etiology of this inflammation was not entirely
clear but thought to be possibly related to chemotherapy, short
course of dex and NSAIDs use. Pt had EGD on ___, showing
mild esophagitis with no bleeding was seen in the and
gastroesophageal junction, 2 cords of grade I varices were seen
in the lower third of the esophagus (not bleeding), normal
stomach, and diffuse continuous moderate duodenitis of the
mucosa with no bleeding was noted in the second part of the
duodenum and third part of the duodenum compatible with possibly
from previous radiation. H Pylori was negative. Pt was treated
with PPI with significant improvement and sent home on
Omeprazole 40 mg.
.
In the ED hiccups were treated succesfully with vagal maneuvers.
He was more confortable and received a dose of Zofran. Oncology
fellow was consulted and recommended CT scan and admission due
to inability to tolerate PO. radiology felt that MRCP would be
beneficial over CT scan in setting of looking for liver/pancreas
etiologuy of abd pain. Patient was then transferred to the
floor.
In the ED VS: Pain ___ T99 HR 103 BP 128/81 RR 18 O2 sats 98%
RA. He had a negative guaiac test.
.
.
ROS - Constitutional: no f/c/s, no weight loss;
Ears/Nose/Mouth/Throat: no oral ulcerations, no dysphagia or
odinophagia;
Cardiovascular: no chest pain, palpitation or PND or orthopnea;
Respiratory: no cough/SOB;
Gastrointestinal: as per HPI;
GU: no polyuria, no dysuria, no increased urgency, no change in
the stream, no incontinence
Musculoskeletal: no joint or muscle pain;
Skin: no rashes;
Neuro: no headaches, no visual changes (blurry vision, seeing
double), no numbness
Heme: no easy bruising or bleeding.
Past Medical History:
# HBV infection -- diagnosed in ___
-- HBe antigen positive with high viral load
-- treated with Entacavir with good response
--recently added tenofovir due to virus reactivation
# Hepatocellular Carcinoma
-- s/p TACEx4, RFAx2, cyberknife x2 followed by sorafenib for 10
weeks ending on ___ (d/c ___ grade 3 hand/foot syndrome
symptoms)
--enrolled on protocol ___ Everolimus 7.5 mg Daily (3 x 2.5
mg
tabs) or placebo from ___ - ___.
--Recently, b/o disease progression, was started on FOLFOX
chemotherapy on ___ (cicle C3, day 15 on ___. he
received all meds of his regimen: Oxaliplatin, ___ and
Leucovorin. Doses were moderately reduced. he had received no
oxaliplatin for previous 2 weeks)
-- ___: screening ultrasound negative for HCC
-- ___: rise in AFP, MRI with six lesions suspicious for ___
-- ___: biopsy confirms HCC, well differentiated
.
# Choleylithiasis
# Duodenitis
Social History:
___
Family History:
# Mother: HBV positive
# Father: died of HCC at the age of ___
# Siblings: HBV positive
Physical Exam:
VS: 98.7 BP114/82 ___ RR18 O2 sats 96% on RA
General - Alert and oriented to person, place and time; in mild
acute distress
HEENT - normocephalic, atraumatic, pupils equal round reactive
to light, extra-ocular muscles intact, mild scleral iscterus,
dry mucous membranes, no evidence of muscositis in his buccal
mucosa
Neck - No lymphadenopathy, no carotid bruit
Chest - rt port w/o any evidence of infection, clear to
auscultation bilaterally, no wheezes, rhonchi or crackles
Heart - Reg rate and rhythm, s1 and s2 heard;
Abd - active bowel sounds, soft, nontender with teh exception of
mid epigastric tenderness without any rebound, nondistended, no
masses, no hepatosplenomegaly was appreciated. ___ sign
negative
Extremities - No clubbing cyanosis or edema, good peripheral
pulses
Neuro: non focal
Pertinent Results:
___ 01:57PM GLUCOSE-113* UREA N-13 CREAT-0.5 SODIUM-136
POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-30 ANION GAP-10
___ 01:57PM estGFR-Using this
___ 01:57PM ALT(SGPT)-102* AST(SGOT)-55* ALK PHOS-89 TOT
BILI-1.4
___ 01:57PM LIPASE-12
___ 01:57PM ALBUMIN-4.3 CALCIUM-9.0 PHOSPHATE-2.9
MAGNESIUM-2.1
___ 01:57PM OSMOLAL-283
___ 01:57PM WBC-4.6 RBC-4.89 HGB-15.5 HCT-43.8 MCV-89
MCH-31.7 MCHC-35.4* RDW-15.8*
___ 01:57PM NEUTS-77.7* LYMPHS-15.4* MONOS-3.2 EOS-3.4
BASOS-0.3
___ 01:57PM PLT COUNT-125*
..
..
___ EGD:
Esophagus: Mucosa: Diffuse erythema, friability, and denuded
mucosa with contact bleeding were noted in the middle third of
the esophagus and lower third of the esophagus. These findings
are compatible with severe esophagitis. Cold forceps biopsies
were performed for histology at the middle third of the
esophagus and lower third of the esophagus.
Stomach: Mucosa: Erythema and mosaic appearance of the mucosa
were noted in the stomach body and antrum. These findings are
compatible with portal gastropathy.
Duodenum: Normal duodenum.
Impression: Erythema, friability with contact bleeding, and
denuded mucosa in the middle third of the esophagus and lower
third of the esophagus compatible with severe esophagitis
(biopsy). Erythema and mosaic appearance in the stomach body and
antrum compatible with portal gastropathy Otherwise normal EGD
to third part of the duodenum
Recommendations: Follow-up biopsy results
Soft diet. PPI BID. Suggest adding carafate slurry QID.
.
___ CXR: Tiny bilateral pleural effusions seen best on the
lateral view are new, not necessarily of any clinical
significance. Lungs are clear, and the heart size is normal. An
infusion port ends in the low SVC.
.
___ KUB: Two frontal views of the abdomen, upright and
supine, show no distention of large or small bowel. Although the
left colon is not distended with formed stool, there is more
than the general amount of formed stool in the right colon
suggesting some chronic constipation. No free subdiaphragmatic
gas or mass effect. The spleen is enlarged. Granulomatous
calcifications in the liver are longstanding.
.
Previous recent reports:
..
USG ___:
IMPRESSION:
1. To and fro flow within a patent main portal vein which can be
seen with
portal hypertension. Atrophy of the left hepatic lobe with
nonvisualization of left portal vein, similar to prior CT. No
evidence of acute portal venous thrombosis.
2. Multiple hepatic lesions, better characterized on the prior
multiphasic CT of ___.
3. Cholelithiasis.
.
CT abd ___:
IMPRESSION:
1. New retroperitoneal fat stranding surrounding the duodenum
and adjacent to the pancreatic head. In the setting of a normal
lipase, this may represent a duodenitis. No evidence of
perforation.
2. Multiple known hepatic lesions, better evaluated on recent
multiphasic CT, with known marked atrophy of the left hepatic
lobe.
.
EGD ___
Mild esophagitis at the gastroesophageal junction. Two cords of
grade I varices at the lower third of the esophagus. Stomach
seemed to be normal with intact mucosa. Moderate duodenitis in
the second and third part of the duodenum possibly from previous
radiation to the area. Gastric biopsies take for H.Pylori.
Duodenal biopsies were also taken. (biopsy, biopsy). Otherwise
normal EGD to third part of the duodenum.
.
___ Duodenum bx;
Duodenum:
Chronic active duodenitis with prominent regenerative changes.
.
Brief Hospital Course:
Assessment/Plan: ___ man with PMH significant for HBV and HCC
on chemotherapy FolFOX last received on ___ Currently Cycle3
Day21-22. Presented to the ED for intractable hiccups and
recurrent mid epigastric pain with nausea and vomiting with
black flecks for 3 days. Hiccups resolved with valsalva in ER.
Pain improved overnight on NPO and morphine prn with IV proton
pump inhibitor (PPI) twice daily. The patient had no further
nausea and vomiting after arriving on the floor. He was seen in
consultation with the gastroenterology (GI) service who
recommended that he be kept on a liquid diet and taken to EGD in
the morning. EGD on ___ showed severe esophagitis for which
the patient was treated with mechanical soft diet, increase in
his PPI from once daily to twice daily, starting carafate
suspension one gram four times daily.
.
# Esophagitis with severe odynophagia on PPI: symptoms improved
from admission and stable overnight. Required IV morpine
initially and transitioned to morphine elixir by discharge. Seen
in consultation with GI and taken to EGD on ___. Findings
with severe esophagitis as above. Treated with mechanical soft
diet, increase in his PPI from once daily to twice daily
(prescription given), starting carafate suspension one gram four
times daily(prescription given).
.
# Pancytopenia: Likely myelosuppression from his FOLFOX. ANC was
1300 morning of discharge prior to EGD. Platlets were adequate
for EGD. Hematocrit decrease attributable to hemodilution with
IVF and dehydration. No evidence of blood loss while
hospitalized.
.
# Midepigastric pain: Resolved overnight with NPO, IVF and pain
meds. Patient with evidence of duodenitis and varices on recent
EGD one month prior to admission. No frank GI bleeding during
his hospitalization but he does reported black flecks in his
vomitus prior to admisssion. Liver function was at baseline.
.
# Nausea and vomiting: IV antiemetics prn. Etiology was unclear.
Doubt symptoms were related to his chemotherapy. No frank GI
bleeding and HCT was stable. No findings of pancreatitis. He
reported some black flecks in his vomitus. Continued on oral
Zofran ODT and Ativan at discharge.
.
# Tachycardia: Present on admission. Resolved with IVF, likely
hypovolemia due to dehydration and poor pain control.
.
# Hepatocellular cancer: C3D22 FOLFOX on day of discharge. His
WBC was adeqate this am but falling. He will follow up in 4 days
as an outpatient for evaluation.
.
# Hepatitis B: Continued entacavir. Continued tenofovir.
.
# Pain: Baseline RUQ pain controlled with MS contin and Morphine
___. Continue MS ___ po. ___ IV given for odynophagia
then changed to morphine elixir prn at discharge.
.
# Hypophosphatemia: Repleted with po neutraphos after EGD
.
Medications on Admission:
Medications - Prescription
ENTECAVIR [BARACLUDE] - 0.5 mg Tablet - One Tablet(s) by mouth
daily
LIDOCAINE HCL - (Not Taking as Prescribed: mouth sores have
resolved, has not used recently) - 20 mg/mL Solution - swish and
spit 10 ml before meals ___ not to exceed 60 ml/day
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth three times a day
as needed for nausea
MORPHINE - 15 mg Tablet - ___ Tablet(s) by mouth every ___ hours
as needed for pain take if pain not controlled by the long
acting
morphine
MORPHINE [MS CONTIN] - 30 mg Tablet Extended Release - 1
Tablet(s) by mouth every twelve (12) hours
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s)
by mouth once a day
ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth
every 8 hours as needed for severe nausea/vomiting
ORAL WOUND CARE PRODUCTS [GELCLAIR] - (Not Taking as
Prescribed:
never filled) - Gel in Packet - thin layer to affected area(s)
BID to TID as needed for pain
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every ___ hr as needed for mild to moderate nausea/vomiting
TENOFOVIR DISOPROXIL FUMARATE [VIREAD] - 300 mg Tablet - 1
Tablet(s) by mouth daily
Medications - OTC
DIPHENHYDRAMINE HCL - 25 mg Capsule - 1 Capsule(s) by mouth for
sleep as needed
PECTIN-CMCELLULOSE NA-GELATIN [ORABASE PLAIN] - (Not Taking as
Prescribed: not using) - Paste - apply to affected area every
six (6) hours
PYRIDOXINE - 100 mg Tablet - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. entecavir 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ativan 1 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
Disp:*60 Tablet(s)* Refills:*0*
3. morphine 10 mg/5 mL Solution Sig: ___ ml PO Q3 hours: prn as
needed for pain.
Disp:*300 ml* Refills:*0*
4. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours) as needed for pain for
4 days.
Disp:*8 Tablet Extended Release(s)* Refills:*0*
5. morphine 15 mg Tablet Sig: ___ Tablets PO Q3Hours: prn as
needed for pain.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for severe
nausea/vomiting.
8. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every ___ hours as needed for mild to moderate nausea and
vomiting.
9. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO at
bedtime as needed for insomnia.
11. pyridoxine 100 mg Tablet Sig: One (1) Tablet PO once a day.
12. Orabase Plain Paste Sig: One (1) application Mucous
membrane every six (6) hours as needed for pain.
13. Lidocaine Viscous Mucous membrane
14. Carafate 100 mg/mL Suspension Sig: Ten (10) ml PO four times
a day: take until your throat pain is improved.
Disp:*600 ml* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Esophagitis (throat inflammation)
Pancytopenia (low blood counts)
Nausea and vomiting
Abdominal pain
Hepatitis B
Tachycardia (fast heart rate)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with nausea, vomiting and severe throat pain
that was treated with IV pain medication. Your tests included an
EGD that showed severe inflammation of your throat. You should
eat only soft foods until your pain improves. You should
increase your omeprazole medication to twice daily for the next
two months and you should start using sucralfate suspension 4
times daily until your throat is less sore.
.
The following changes were made to your medications:
INCREASE Omeprazole to 40 mg twice daily for at least 2 months
START Carafate suspension 10 ml four times daily until your
throat pain has improved
SUBSTITUTE Morphine liquid for short acting morphine pills until
your throat pain has improved. You can take ___ ml every 3
hours as needed for pain
CONTINUE your long acting Morphine (called Ms ___ 30 mg
every 12 hours
Followup Instructions:
___
|
19794649-DS-14
| 19,794,649 | 28,050,258 |
DS
| 14 |
2144-04-21 00:00:00
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2144-04-21 10:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea, Lethargy
Major Surgical or Invasive Procedure:
ICU care
History of Present Illness:
Ms. ___ is a ___ year old woman with hx of CHF, DVT, afib
on apixiban, ? reactive airway disease who presents with
dyspnea, lethargy from ___ where she was found to have
worsening pulmonary congestion and worsening fatigue over last
day. She was given 60mg torsemide this am and was started on po
levaquin. Flu A and B negative from swabs yesterday. Patient
reported to have worsening pulmonary congestion on chest x-ray
there.
Patient is accompanied by her daughter as well as her
granddaughter who translated for her. Patient is confirmed
DNR/DNI, but okay for noninvasive ventilation.
She presented to the ED in acute respiratory distress, with
oxygen saturation in the ___ though to be possible exacerbation
of reactive airway disease or volume overload. She was started
on NIV with Bipap with improvement in her respiratory status and
given steroids and was started on broad-spectrum IV antibiotics
given patient's need for ICU level of care with
vanc/zosyn/azithromycin.
In the ED, initial vitals: 98 |90 |102/76 |24 |98% RA
Exam notable for:
Tachypneic, somewhat confused, lethargic, bilateral pedal edema
up to the knees 1+, diffuse rales lung fields, diffuse
intermittent wheezes
Labs notable for:
12:00 pH 7.23 |pCO2 91 |pO2 50 |HCO3 40 |Base XS 6
14:10 pH 7.29| pCO2 71 | pO2 45 |HCO3 36 |BaseXS 4
14:46: pH 7.30| pCO2 76 |pO2 40 |HCO3 39 |BaseXS 7
12.9 >- 12.1/40.3--< 184
N:83.4 L:6.9 M:8.1 E:0.0 Bas:0.4 Nrbc: 0.2 ___: 1.2 Absneut:
10.78 Abslymp: 0.89 Absmono: 1.05 Abseos: 0.00 Absbaso: 0.05
141 | 97 | 25
----------------< 84 AGap=14
6.1 | 30 | 1.2
Whole blood K:3.6
___: 20.7 PTT: 41.6 INR: 1.9
Trop-T: <0.01
ALT: 16
AST: 57
AP: 122
Tbili: 0.6
Alb: 3.1
proBNP: 2752
Imaging:
Bedside echo shows small pericardial effusion without evidence
of tamponade.
CXR ___:
Low lung volumes. No focal consolidation. No evidence of
pulmonary edema.
Patient received:
___ 13:30 IV Vancomycin
___ 14:25 IV Piperacillin-Tazobactam
___ 14:25 IV MethylPREDNISolone Sodium Succ 125 mg
___ 15:01 IV Acetaminophen IV 1000 mg
Consults:
Vitals on transfer:
102.8 |87 |95/59 | 64% bipap
Upon arrival to FICU, patient with labored breathing, found to
be hypotensive to 67/40s. Family at bedside report patient had
URI earlier this week and took a turn for the worse 3 days prior
to admission with worsened respiratory status. They confirm she
is DNR/DNI and are still unsure about other invasive procedures
including central venous access.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise
Past Medical History:
Atrial fibrillation
CKD, stage III
Obesity
HTN
HLD
Osteoarthritis
Gout
hx of endometrial ___
CHF
Dementia
PVD
GERD
Glaucoma
Social History:
___
Family History:
Non contributory
Physical Exam:
GENERAL: Lethargic, ill-appearing elderly woman
HEENT: Sclera anicteric, PERRLA, EOMI
LUNGS: Sounds of airway secretions on anterior fields
CV: Irregular rhythm
ABD: soft, non-tender, non-distended, bowel sounds present
EXT: Warm, well perfused, 2+ pulses
SKIN: Sacral decub
NEURO: Lethargic but awakens to voice. Oriented to person,
general place. Sleeping most of the day
Pertinent Results:
___ 11:55AM BLOOD WBC-12.9* RBC-4.00 Hgb-12.1 Hct-40.3
MCV-101* MCH-30.3 MCHC-30.0* RDW-17.0* RDWSD-62.3* Plt ___
___ 11:55AM BLOOD Neuts-83.4* Lymphs-6.9* Monos-8.1
Eos-0.0* Baso-0.4 NRBC-0.2* Im ___ AbsNeut-10.78*
AbsLymp-0.89* AbsMono-1.05* AbsEos-0.00* AbsBaso-0.05
___ 12:19PM BLOOD ___ PTT-41.6* ___
___ 11:55AM BLOOD Glucose-84 UreaN-25* Creat-1.2* Na-141
K-6.1* Cl-97 HCO3-30 AnGap-14
___ 11:55AM BLOOD ALT-16 AST-57* CK(CPK)-115 AlkPhos-122*
TotBili-0.6
___ 11:55AM BLOOD Albumin-3.1* Calcium-8.7 Phos-5.3* Mg-1.9
___ 12:11PM BLOOD Type-ART pO2-50* pCO2-91* pH-7.23*
calTCO2-40* Base XS-6
___ 08:05AM BLOOD WBC-11.2* RBC-4.04 Hgb-12.1 Hct-40.2
MCV-100* MCH-30.0 MCHC-30.1* RDW-16.9* RDWSD-61.0* Plt ___
___ 08:05AM BLOOD Glucose-121* UreaN-21* Creat-0.6 Na-153*
K-3.9 Cl-106 HCO3-35* AnGap-12
___ 09:40AM BLOOD ALT-39 AST-14 AlkPhos-140* TotBili-0.7
CXR: There are hazy opacities at the lung bases, possibly
atelectasis with
bilateral pleural effusions, larger on the right. The heart is
enlarged.
There is pulmonary vascular congestion. Degenerative changes
are seen in the
right shoulder and spine. The bones are somewhat osteopenic.
There is S
shaped scoliosis of the thoracolumbar spine.
TTE: Suboptimal image quality. Normal LV systolic function.
Biatrial enlargement. Mild dilated RV with at least moderate
free wall hypokinesis. Mild mitral regurgitation. Moderate to
severe TR. At least moderate pulmonary hypertension though may
be underestimated. Elevated PCWP. Mildly dilated ascending
aorta.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with hx of HFpEF 60%, DVT,
afib on apixiban who presents with acute respiratory failure and
shock.
# Critical illness deconditioning
# Severe protein-calorie malnutrition: Her recent, severe
illness has left the patient severely deconditioned compared to
her previous baseline. Prior to presentation she had limited
mobility but did feed herself. The patient herself feels like
she is too weak to recover and that is will continue to decline.
Her appetite is poor, and she has expressed her desire to be
comfortable, sleep more, and return to her previous living
situation.
We reviewed with granddaughter our sense that patient would
want care focused on giving PRIORITY to comfort and dignity,
with return to ___, but as long as she is continuing to
appreciate each day, then if there are non-burdensome
interventions that will (a) make that day or the next better for
her and/or (b) increase the likelihood that she will have
additional enjoyable days, then those should continue for now.
If at any time in the future she no longer appears to be
enjoying each day, then the focus will transition to a SOLE
focus on comfort and dignity, NOT then continuing interventions
that contribute to likelihood of longer time that patient is
unable to enjoy.
As a practical matter this means:
1. Gentle encouragement of po intake, but prioritizing pleasure
over concerns about adequacy of calories or fluids.
2. NO artificial nutrition/hydration.
3. Antibiotics if she develops signs of early infection for
which antibiotics may (a) improve comfort and/or (b) give her
additional time that she would enjoy, but ONLY if (c) they can
be administered in non-burdensome ways.
4. No plans for re-hospitalization here, since the above goals
can almost certainly be achieved at ___, without the
burdens of ambulance/transfer/ED/re-hospitalization.
Her granddaughter affirmed complete agreement with this
approach. She stressed that her grandmother would want to return
to her familiar room at ___, but also that she believes her
grandmother will need a greater level of services than in the
past. Dr. ___ I agreed to pass this request on to our
case manager, and to staff at ___.
We were in touch with ___ palliative care team, who know
patient and await her return.
#Acute hypercarbic/hypoxemic respiratory failure; Initially
treated for PNA with levaquin and then for CHF exacerbation with
increased diuresis at rehab. Of note patient was receiving
morphine at rehab for dyspnea and was quite lethargic on
presentation which could have contributed to CO2 retention. ___
have a viral URI vs. PNA which triggered CHF leading to
respiratory distress. Also unclear if underlying lung disease
(mod pulm htn on ___ TTE may suggest underlying lung disease).
Improved and no longer required BiPAP. On the floor, patient did
well from respiratory standpoint, with only ___ O2 requirement,
but often had significant wheezing and prolonged expiratory
phase on exam. This was most concerning for COPD/reactive airway
disease/bronchitis. She was treated with steroids and nebs with
gradual improvement. As far as possible CHF exacerbation, she
appeared dry/hypovolemic on coming out of the ICU. She was
gradually given back fluids gently with improvement in her ___
and volume status and without worsening of her oxygenation.
Ultimately, suspect she had a viral bronchitis +/- pneumonia,
and hypercarbic +/- hypoxic respiratory failure due to
combination of the acute lung issue and morphine-induced
hypoventilation. ___ possibly due to hypotension initially,
then inappropriate diuresis in setting of poor PO intake &
hypotension.
#Shock suspected septic shock
#Staph epi bacteremia
#Possible LLL PNA
Pressures on arrival to ___ in the 60-70s/40-50s. Initially
febrile (102) with mild leukocytosis (12) and recent URI sxs,
and warm on exam, concerning for septic shock. CXR without
evidence of consolidation, UA negative, unclear source, possible
viral URI (flu negative) but improved with abx. ___ have a
cardiogenic component in the setting of CHF and volume overload
on exam. Now with one blood culture bottle with GPCs. Exam c/f
LLL PNA. Legionella and strep pneumoniae uringe ag negative.
Urine cx negative. Will continue broad spectrum antibiotics
while further evaluating etiology of shock. Now weaned off
phenylephrine. Continued vanc/zosyn/azithromycin for until
speciation of GPC to Staph epi. ID was consulted, advised
completing total course of 5 days of abx to cover for pneumonia
and the Staph epi bacteremia. Last day of abx was ___.
#Acute on chronic CHF, presumed preserve EF: Hx of diastolic
CHF; reported TTE ___ with EF 60% and moderate pulmonary HTN.
Over the past three days has been treated for CHF exacerbation
with increase in torsemide from 10mg to 60mg daily and
metolazone 2.5mg prn over the past day for worsening SOB. BNP
elevated at 2752 with unclear baseline. Elevated JVD on exam
with diffuse crackles concerning for CHF exacerbation. Effusions
on CXR. Held on diuresis due to concern for septic shock and
later because of poor oral intake and rising bicarb (out of
proportion to compensation for respiratory acidosis).
___
Patient w/ hx of CKD with baseline Cr ~1. Now up to 1.8.
Pre-renal vs. ATN in setting of hypovolemia on arrival to ICU.
Cr peaked at 2.1. BUN peaked at 84. FENa < 1% suggestive of
prerenal etiologies and patient did not appear to be in acute
heart failure or decompensated cirrhosis, so gave fluids back
and renal function stabilized, then improved.
#Ischemic hepatitis:
Transaminases and alk phos were elevated likely secondary to
congestive hepatopathy vs. ischemic hepatitis in the setting of
hypotension and shock on arrival to the ICU. Home atorvastatin
was held. LFTs peaked and then trended back to normal.
#Atrial fibrillation with RVR
Upon initiation of levophed for pressure support patient went
into RVR. Levophed switched to phenylephrine with improvement in
HRs. Improved to baseline with phenylephrine.
#GERD: Discontinued home omeprazole
# Dementia:
At baseline per family orientation but sleeping more. Holding
home olanzapine 5mg daily.
#Glaucoma: held home acetazolamide for now given question of
effect on bicarb and acid base status. Continued home
latanoprost
# Pressure ulcers
Of note, patient has a stage III pressure ulcer on the bridge of
her nose from BiPAP as well as a deep tissue injury to her
coccyx, which her daughter confirms was present at rehab.
Commercial wound cleanser or normal saline to cleanse wounds.
apply mepilex to sacral coccyx tissue. Change dressing q 3 days.
We have continued a foley to minimize urine irritation of wound
bed as turning frequently is causing her more distress. Based on
aforementioned wishes, this plan may be altered as needed to
ensure patient comfort is maintained.
Ms. ___ was seen and examined on the day of discharge and
is clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
today was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Omeprazole 20 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Acetaminophen 650 mg PO BID
5. Senna 17.2 mg PO BID
6. Vitamin D ___ UNIT PO 1X/WEEK (WE)
7. Apixaban 2.5 mg PO BID
8. AcetaZOLamide 62.5 mg PO Q2D
9. Potassium Chloride 10 mEq PO DAILY
10. Allopurinol ___ mg PO DAILY
11. OLANZapine 5 mg PO DAILY
12. Ferrous GLUCONATE 324 mg PO Q2D
13. Torsemide 20 mg PO DAILY
14. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
15. Bisacodyl 10 mg PR QHS
16. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
17. Lactulose 10 gm PO DAILY:PRN CONSTIPATION
18. TraZODone 25 mg PO QHS:PRN insomnia
19. GuaiFENesin 100 mg PO Q4H:PRN cough
20. Metolazone 2.5 mg PO DAILY: PRN SOB
21. LORazepam Oral Solution 0.5 mg PO BID:PRN anxiety
22. Glycerin Supps 1 SUPP PR PRN constipation
23. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
24. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
25. Chloraseptic Throat Spray 1 SPRY PO Q2H:PRN sore throat
26. Morphine Sulfate (Oral Solution) 2 mg/mL 4 mg PO Q6H:PRN
dyspnea
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
puff twice a day Disp #*1 Disk Refills:*3
2. Miconazole Powder 2% 1 Appl TP TID:PRN affected area
RX *miconazole nitrate [Miconazorb AF] 2 % 1 Appl TID:PRN Disp
#*1 Package Refills:*0
3. Ramelteon 8 mg PO QHS:PRN insomnia
Should be given 30 minutes before bedtime
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth QHS PRN Disp
#*30 Tablet Refills:*3
4. Acetaminophen 650 mg PO BID
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
6. Allopurinol ___ mg PO DAILY
7. Apixaban 2.5 mg PO BID
8. Bisacodyl 10 mg PR QHS
9. Chloraseptic Throat Spray 1 SPRY PO Q2H:PRN sore throat
10. Cyanocobalamin 1000 mcg PO DAILY
11. Ferrous GLUCONATE 324 mg PO Q2D
12. Glycerin Supps 1 SUPP PR PRN constipation
13. GuaiFENesin 100 mg PO Q4H:PRN cough
14. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
15. Lactulose 10 gm PO DAILY:PRN CONSTIPATION
16. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
17. LORazepam Oral Solution 0.5 mg PO BID:PRN anxiety
18. Morphine Sulfate (Oral Solution) 2 mg/mL 4 mg PO Q6H:PRN
dyspnea
19. Senna 17.2 mg PO BID
20. TraZODone 25 mg PO QHS:PRN insomnia
21. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID
22. Vitamin D ___ UNIT PO 1X/WEEK (WE)
23. HELD- AcetaZOLamide 62.5 mg PO Q2D This medication was
held. Do not restart AcetaZOLamide until your doctors at ___
say otherwise
24. HELD- Atorvastatin 40 mg PO QPM This medication was held.
Do not restart Atorvastatin until your doctors at ___ say
otherwise
25. HELD- Metolazone 2.5 mg PO DAILY: PRN SOB This medication
was held. Do not restart Metolazone until your doctors at ___
say otherwise
26. HELD- OLANZapine 5 mg PO DAILY This medication was held. Do
not restart OLANZapine until your doctors at ___ say
otherwise
27. HELD- Potassium Chloride 10 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until your doctors
at ___ say otherwise
28. HELD- Torsemide 20 mg PO DAILY This medication was held. Do
not restart Torsemide until your doctors at ___ say otherwise
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute hypoxic and hypercapneic respiratory failure
Septis
Critical illness deconditioning
Severe protein-calorie malnutrition
Staph epi bacteremia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Ms. ___,
You were admitted to ___ for difficulty breathing and
infection. We treated you with antibiotics and steroids. After
our discussions you have said that you would want your care
focused on giving PRIORITY to comfort and dignity, with return
to HRCA.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19794689-DS-2
| 19,794,689 | 21,650,727 |
DS
| 2 |
2162-08-22 00:00:00
|
2162-08-25 21:14:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Period of diminished level of consciousness
Major Surgical or Invasive Procedure:
___: AV junction ablation and pacemaker placement with
Accolade L310.
History of Present Illness:
___ y/o male with PMH A-fib, HFpEF, HTD, HLD presents via EMS
following a possible syncopal episode. Pt states that in the
afternoon of presentation, he was observed "contorting" his head
to the side. Period described as lasting approx. 20 seconds. He
denies any loss of consciousness, lightheadedness, chest pain,
palpitations, He then presented to ___.
Of note, he did report recent URI symptoms including mild cough
and phlegm production for the past ___ days. He denied any
fever.
In the ___ initial vitals were: T 98.1 P ___ BP 106/48 RR 18 O2
96% RA. He was found to be in rapid afib at rates 150s-160s.
Received Diltiazam 45mg IV followed by 10mg/hr infusion with no
change in rate after first hour. No consistent change in
patient's heart rate despite total 0.5mg Digoxin and total
approx. 50mg Diltiazem. Esmolol drip started with 50mg bolus
then 5mg/min, still with no significant change in HR, and was
transferred to ___. Here, he was continued on esmolol drip,
with HRs 140-150s and SBPs 100-110s. Cardiology was consulted
and recommended stopping esmolol and starting Amiodarone 150 mg
IV bolus and drip at 1mg/kg x 6 hours. His INR was also found to
be supratherapeutic at 4.7.
On arrival to the CCU: No complaints of CP or SOB.
Well-appearing.
REVIEW OF SYSTEMS:
Positive per HPI.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
palpitations, syncope, or presyncope.
On further review of systems, denies fevers or chills. Denies
any prior history of stroke, TIA, deep venous thrombosis,
pulmonary embolism, bleeding at the time of surgery, myalgias,
joint pains, cough, hemoptysis, black stools or red stools.
Denies exertional buttock or calf pain. All of the other review
of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Atrial fibrillation
- Diastolic dysfunction on echo
- Moderate-severe aortic stenosis
3. OTHER PAST MEDICAL HISTORY
- Basal cell carcinoma
- Peripheral neuropathy
- Skin cancer removal
- Left hip replacement
- Knee replacement
- Benign prostatic hypertrophy
Social History:
___
Family History:
Father died of unspecified heart disease at ___.
Physical Exam:
====================
ADMISSION EXAM
====================
VS: T 98.3 BP 124/91 HR 145 RR 23 O2 SAT 96%
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP of 12 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Irregularly irregular rhythm. Normal S1, S2. No murmurs,
rubs, or gallops.
LUNGS: No chest wall deformities or 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. 1+ pitting edema b/l lower
extremities, R>L
SKIN: Numerous SKs.
PULSES: Distal pulses palpable and symmetric.
====================
DISCHARGE EXAM
====================
VS: 98.3, 100-117/69-81, 79-80, ___, 95-98% RA
I/O: 200/350(8 hours), 1500/1100(24 hours)
Wt: 102.8 < 102.2 < 102.6 < 104.9
TELEMETRY: NSVT to 160s in afternoon
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Mucous membranes moist.
NECK: Supple with JVP <10 cm
CARDIAC: RRR, ___ systolic murmur loudest at base. Pacemaker in
left upper anterior chest with mild tenderness to palpation,
dressing c/d/i, no erythema. Area of skin irritation/ecchymosis
anterior to axilla, non-tender to palpation.
LUNGS: Resp unlabored, no accessory muscle use. CTAB, faint
crackles at bases, no wheezes or rhonchi.
ABDOMEN: Soft, non-tender to palpation, non-distended
EXTREMITIES: No lower extremity edema. Right groin access site
c/d/i, no bruits, no hematoma, no tenderness to palpation.
Distal pedal pulses intact.
Pertinent Results:
=====================
ADMISSION LABS
=====================
___ 12:50AM BLOOD WBC-7.2 RBC-4.27* Hgb-13.8 Hct-41.3
MCV-97 MCH-32.3* MCHC-33.4 RDW-14.2 RDWSD-49.9* Plt ___
___ 12:50AM BLOOD Neuts-72.1* Lymphs-16.1* Monos-10.0
Eos-0.4* Baso-0.4 Im ___ AbsNeut-5.21 AbsLymp-1.16*
AbsMono-0.72 AbsEos-0.03* AbsBaso-0.03
___ 12:50AM BLOOD ___ PTT-43.6* ___
___ 12:50AM BLOOD ALT-35 AST-34 AlkPhos-114 TotBili-1.7*
___ 05:21AM BLOOD CK-MB-3 cTropnT-<0.01
___ 12:50AM BLOOD Calcium-9.0 Phos-3.3 Mg-2.0
___ 12:50AM BLOOD TSH-3.0
___ 12:50AM BLOOD Digoxin-2.2*
=====================
PERTINENT LAB RESULTS
=====================
___ 03:42AM BLOOD FreeKap-24.3* ___ Fr K/L-1.21
___ ANGIOTENSIN 1 CONVERTING ENZYME, SERUM 45, Ref Range
___ U/L
___ 03:42PM BLOOD calTIBC-218* Ferritn-351 TRF-168*
___ 12:50AM BLOOD TSH-3.0
___ 12:50AM BLOOD Digoxin-2.2*
=====================
DISCHARGE LABS
=====================
___ 06:25AM BLOOD WBC-8.1 RBC-4.36* Hgb-13.8 Hct-42.6
MCV-98 MCH-31.7 MCHC-32.4 RDW-14.5 RDWSD-51.7* Plt ___
___ 06:25AM BLOOD Glucose-100 UreaN-13 Creat-1.0 Na-138
K-4.1 Cl-99 HCO3-32 AnGap-11
___ 06:25AM BLOOD Calcium-8.7 Phos-2.2* Mg-1.9
=====================
IMAGING/STUDIES
=====================
Echocardiogram ___: The left atrium is moderately dilated.
The right atrium is markedly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is severe symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated. There is severe global left ventricular hypokinesis
(LVEF = 20 %). No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. The right
ventricular cavity is moderately dilated with moderate global
free wall hypokinesis. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets are moderately thickened.
There is probably moderate (low output/low gradient) aortic
valve stenosis (valve area 1.0-1.2cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
Chest x-ray ___: In comparison with the study of ___,
there is a moderate right and probably small left pleural
effusion. Continued substantial enlargement of the cardiac
silhouette without appreciable vascular congestion, a
discordance that suggests underlying cardiomyopathy or even
pericardial effusion. There is pacemaker with single lead
extending to the apex of the right ventricle. No evidence of
pneumothorax. Hyperexpansion of the lungs with some coarseness
of interstitial markings
raises the possibility of chronic pulmonary disease. No acute
focal
pneumonia.
CHEST (PA & LAT) ___
IMPRESSION:
In comparison with the study of ___, there is a moderate
right and
probably small left pleural effusion. Continued substantial
enlargement of
the cardiac silhouette without appreciable vascular congestion,
a discordance that suggests underlying cardiomyopathy or even
pericardial effusion. There is pacemaker with single lead
extending to the apex of the right ventricle. No evidence of
pneumothorax. Hyperexpansion of the lungs with some coarseness
of interstitial markings raises the possibility of chronic
pulmonary disease. No acute focal pneumonia.
=====================
MICROBIOLOGY
=====================
None.
Brief Hospital Course:
Mr. ___ is a ___ year old male with past medical history
significant for HFpEF, afib on warfarin, and HTN who presented
to an outside hospital after a brief presyncopal episode, and
was found to be in afib with RVR to 160s requiring esmolol gtt,
now s/p ablation and PPM on ___. Hospital course complicated
by new HFrEF with EF of 20%.
# Acute on Chronic HF: Patient with a previously preserved EF,
however now found to have a newly depressed LVEF of 20% with
aortic stenosis. For preload reduction he was diuresed with
Lasix as appropriate. For afterload reduction, he was started on
Lisinopril 5mg daily. For contractility, he underwent ablation
and ICD placement as above. His metoprolol succinate was held
but reinstated after the procedure. His home digoxin was held
while admitted. On discharge patient was clinically euvolemic on
exam. His discharge weight was 102.8 kg (226.6 punds) His acute
on chronic HF likely secondary to tachyarrhythmia although
etiology remains unclear. Tachycardia controlled, unlikely
ischemia mediated. Recommend repeat ECHO in ___ months after
optimal medical therapy and control of tachyarrhythmia. For his
preload he was discharged on Lasix 30mg IV daily, and
spironolactone 12.5mg daily. For his afterload he was discharged
on lisinopril 5mg, and for his contractility his home metoprolol
was changed to Metoprolol Succinate XL 75 mg PO DAILY. His home
digoxin was held this hospitalization.
# Permanent atrial fibrillation with RVR s/p AVJ ablation and
PPM on ___: Unclear duration of afib with RVR or
precipitant. His Afib was difficult to control throughout his
hospital course. He was initially trialed on several rate
controlling drugs, including Diltiazem, Amiodarone, and
Verapamil. His heart rate was not able to be controlled with
these. A basic infectious work-up was unremarkable; he did not
have an elevated WBC count during admission. His TSH and LFTs
were checked and were normal. He underwent and AV node ablation
and pacemaker placement on ___. On telemetry he had
occasional episodes of NSVT with ___ beats that was
asymptomatic. His home diltiazem, digoxin, and metoprolol were
held. After his ablation and pacemaker placement he was started
on metoprolol succinate XL and discharged on a dose of 75mg
daily. His home warfarin schedule is 5 mg x 5d, 2.5 mg MF. He
was found to have a supratherapeutic INR to 4.8 on ___ (goal
INR 2.0-3.0) and his dose was reduced to 2.5mg daily. This was
continued during his hospitalization. On ___ he received an
increased dose of 5mg for an INR of 2.1, and then was dropped
back to a dose of 2.5mg daily. His INR was 2.4 on discharge.
Recommend recheck of INR in ___ days after discharge. He should
follow up with Dr. ___ at ___ regarding his INR and
warfarin dose adjustments.
#Urinary retention | BPH: During hospitalization, he
occasionally was noted to have poor urine output. Bladder scan
showed 685 cc in the bladder, he was subsequently straight
cath'd. This was somewhat difficult and produced moderate
hematuria due to traumatic catheterization. It was felt that the
urinary retention was likely secondary to his known BPH. He was
maintained on his home dose of finasteride, and started on
Tamsulosin 0.4mg daily. His foley was removed on ___. Upon
discharge he was able to urinate independently with no retained
urine.
#Mild ___. Creatinine increased to as high as 1.4 This was felt
to be due to his urinary retention. His creatinine improved to
1.0 upon discharge.
#Hypertension. Controlled with Metoprolol and Diltiazem as
above.
#Hyperlipidemia. He was continued on his home statin.
TRANSITIONAL ISSUES
==================
- Discharge weight: 102.8
- Discharge diuretic regimen: Furosemide 20 mg PO/NG DAILY,
spironolactone 12.5mg daily
- Pacemaker placed ___. Patient will need to be seen in
device clinic for follow up in 1 week.
- Recommend repeat ECHO in ___ months after optimal medical
therapy and control of tachyarrhythmia.
- Recommend close follow up of aortic stenosis to see if EF
recovers. Please follow up on aortic valve area in a few months.
- He should be evaluated for obstructive sleep apnea as an
outpatient. He was observed to have several apneic episodes
overnight while admitted.
- Foley catheter removed on ___, please monitor for urinary
retention. Patient was sent home on his home finasteride, and
started on tamsulosin in the hospital to help with his urinary
retention. Upon discharge he was able to urinate independently
with no retained urine.
- Warfarin dose changed to 2.5mg daily given supratherapeutic
INR on admission. INR 2.4 on day of discharge. He was discharged
home on 2.5mg warfarin daily. Recommend recheck of INR in ___
days with Dr. ___ at ___ with follow up for dose
adjustment.
- Some medications were changed/added:
STARTED:
*Lisinopril 5 mg PO DAILY
*Spironolactone 12.5 mg PO DAILY
*Tamsulosin 0.4 mg PO QHS.
CHANGED:
*Warfarin 5 mg PO 5X/WEEK (___) to Warfarin 2.5 mg PO
DAILY given supratherapeutic INR on admission
*metoprolol tartrate 200mg QAM and 100mg QPM to metoprolol
succinate 75mg daily s/p ablation and PPM.
DISCONTINUED:
*Digoxin 0.125mg PO DAILY
*Diltiazem Extended-Release 360mg Daily
- CODE: Full
- CONTACT: Patient, ___ (wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 200 mg PO QAM
2. Diltiazem Extended-Release 360 mg PO DAILY
3. Furosemide 30 mg PO DAILY
4. Warfarin 2.5 mg PO 2X/WEEK (MO,FR)
5. Digoxin 0.125 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Metoprolol Tartrate 100 mg PO QPM
8. Atorvastatin 40 mg PO QPM
9. Warfarin 5 mg PO 5X/WEEK (___)
Discharge Medications:
1. Lisinopril 5 mg PO DAILY
Hold if SBP <90
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
3. Spironolactone 12.5 mg PO DAILY
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*20 Tablet Refills:*0
4. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth nightly Disp #*30
Capsule Refills:*0
5. Warfarin 2.5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
6. Atorvastatin 40 mg PO QPM
7. Finasteride 5 mg PO DAILY
8. Furosemide 30 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Atrial fibrillation with rapid ventricular response
SECONDARY
Supratherapeutic INR
Heart failure with preserved ejection fraction, chronic
Hypertension
Hyperlipidemia
Benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
You were admitted to the hospital because your heart was beating
very rapidly. This, in combination with your atrial
fibrillation, required treatment with medicines to try to slow
the heart rate down. When this did not work, you had a procedure
called an ablation, and also had a pacemaker inserted.
It will be important for you to follow up in the pacemaker
clinic in one week to have your device checked. This is to
ensure there are no problems with the device.
Best wishes,
Your ___ team
Followup Instructions:
___
|
19794706-DS-7
| 19,794,706 | 25,918,863 |
DS
| 7 |
2196-02-26 00:00:00
|
2196-02-26 14:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Erythromycin Base / Meperidine / Latex / Hydrocodone / Vicodin
Attending: ___.
Chief Complaint:
Right lower quadrant pain
Major Surgical or Invasive Procedure:
___ Laparoscopic Appendectomy
History of Present Illness:
The patient is a ___ year old female with complaint of
right-sided abdominal/flank pain x2 days associated with nausea
and emesis. The patient initially attributed this complaint to
renal calculai- given a history of multiple prior episodes -
however imaging studies done at ___ did not
demonstrate any renal findings that could explain her symptoms.
As the abdominal discomfort persisted and her pain eventually
migrated to the right lower quadrant, the patient's PCP
recommended that she present to the ED for further evaluation.
The patient has had no further episodes of emesis and her nausea
has resovled for the past day, however she has had anorexia
since
the onset of pain and subjective fevers and chills.
The patient also endorses some dysuria and increased urinary
frequency/urgency
ACS has now been consulted for possible appendicitis
Past Medical History:
PMH:
Asthma
Depression
Multiple renal calculi
PSH:
Laparoscopic cholecystectomy
Lithotripsy of right renal calculus
Social History:
___
Family History:
Non contributory
Physical Exam:
Physical Exam upon admission:
Vitals: Temp: 97.3 HR: 80 BP: 118/70 RR: 16 SaO2: 97%
General: No acute distress; alert and oriented
Cardiac: Regular rate and rhythm; normal S1 and S2; no
appreciable murmur
Pulmonary: Lungs clear to auscultation bilaterally
Abdomen: Soft, mildly obese, non-distended; tender to palpation
in the right lower quadrant; no rebound or gaurding; (+) Rovsing
and (+) Psoas signs
Extremities: Warm and well perfused
Physical Exam upon discharge:
VS: 97.4, 86, 115/72, 14, 96/RA
Gen: NAD, resting in bed.
Heent: EOMI, MMM
Cardiac: Normal S1, S2. RRR
Pulm: Lungs CTAB No W/R/R
Abdomen: Soft/nondistended/mildy tender at lap sites
Ext: + pedal pulses. No CCE
Neuro: AAOx4, normal mentation.
Pertinent Results:
___ 04:18PM BLOOD WBC-7.3 RBC-4.34 Hgb-13.3 Hct-39.5 MCV-91
MCH-30.6 MCHC-33.6 RDW-11.9 Plt ___
___ 04:18PM BLOOD Neuts-57.6 ___ Monos-7.1 Eos-5.7*
Baso-0.9
___ 07:49PM BLOOD ___ PTT-26.0 ___
___ 04:18PM BLOOD Plt ___
___ 04:18PM BLOOD Glucose-90 UreaN-9 Creat-0.7 Na-136 K-3.8
Cl-103 HCO3-22 AnGap-15
___BD & PELVIS WITH CO
Fluid-filled mildly dilated appendiceal tip to 9 mm with mild
adjacent stranding. The finding is little changed from CTs
___ and
___, and may represent a relapsing and remitting acute tip
appendicitis or chronic appendicitis, depending on the clinical
setting. Correlation with clinical information including
physical findings is recommended to help assess for whether the
finding is clinically significant, particularly noting the lack
of chance since prior studies.
Brief Hospital Course:
Mrs. ___ was admitted on ___ under the acute care surgery
service for management of her acute appendicitis. Cat scan
demonstrated "Fluid-filled mildly dilated appendiceal tip to 9
mm with mild adjacent stranding". She 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. She was
subsequently taken to the PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which he was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up in
___ clinic as well as with her PCP.
Medications on Admission:
Doxepin 50'
ATivan 1'
Xanax 2'
Zoloft 50'
Lamictal 500';
Proair PRN
Discharge Medications:
1. Sertraline 50 mg PO DAILY
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*35 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN pain
4. ALPRAZolam 2 mg PO QHS
5. Doxepin HCl 50 mg PO HS
6. Lorazepam 1 mg PO HS:PRN Anxiety
7. LaMOTrigine 500 mg PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*6 Tablet Refills:*0
9. Senna 1 TAB PO BID:PRN constipation
10. Docusate Sodium 100 mg PO BID
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:
___
|
19795491-DS-8
| 19,795,491 | 28,728,416 |
DS
| 8 |
2179-06-19 00:00:00
|
2179-06-19 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:
DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with history of brittle diabetes due to
pancreatic insufficiency secondary to Whipple procedure and
eventual total pancreatectomy, and s/p splenectomy who presents
with hyperglycemia. She originally went to ___ by ambulance on ___, sugars 500s, no infection
found,
discharged home after getting fluids. Things went well on
___, then blood sugars started going up again. He
has
been doing urine dipsticks at home with ketones noted in urine.
Patient and wife also notes he saw Dr. ___ at ___ on ___
and increased Creon - has improved stool consistency, but has
contributed to increased blood sugar. He was tested for C diff
last week by PCP and was negative. His current insulin glargine
regimen is 48 units in the AM and 53 units in the ___, as well as
standing 14 units of Novolog with meals, and insulin sliding
scale. On presentation, he endorses thirst, cough and
rhinorrhea
for a couple of weeks, above history. Otherwise ROS negative for
productive cough, chills, CP, N/V/D, ___ swelling, rashes.
In the ED, initial vitals were 98.3 66 123/80 18 97% RA. Labs
showed hyponatremia and hyperkalemia, finger stick 454, anion
gap
30, 80 ketones in urine, glucose 1000. CXR was unremarkable.
___ was consulted and patient was placed on an insulin gtt
for
___ hours. Anion gap closed to 10, last finger stick 171.
Sodium was 136, K 5.1. Blood and urine cultures were sent. ECG
showed a T wave inversion in III and aVF, as well as LVH.
Patient received 53 units Lantus in the ED, as well as 3 liters
NS. Flu swab was negative.
Currently, patient is feeling much better. He is concerned that
an infection has been causing the lability in his blood sugars.
He reports drinking 6 beers per day, but has not had a drink in
the last four days.
Review of systems:
Past Medical History:
1. Type 2 diabetes, now brittle diabetes
2. Pancreatic tumor (non-malignant), treated with a Whipple
3. Pancreatic insufficiency
4. s/p Splenectomy
5. Hypertension
6. C. difficile colitis ___ - sepsis at ___, without any bug
Social History:
___
Family History:
Mother died of lymphoma, unsure what type.
Physical Exam:
Admission Exam:
Vitals: 98.4PO 145/82 84 18 96 RA
GEN: Alert, oriented to name, place and situation. Fatigued
appearing but comfortable, no acute signs of distress.
HEENT: NCAT, Pupils equal and reactive, sclerae anicteric, OP
clear, MMM.
Neck: Supple, no JVD
Lymph nodes: No cervical, supraclavicular LAD.
CV: S1S2, reg rate and rhythm, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, non-tender, non-distended, + bowel sounds.
EXTR: No lower leg edema, no clubbing or cyanosis
DERM: No active rash.
Neuro: moving all four extremities purposefully, non-focal.
PSYCH: Appropriate and calm.
Discharge Exam:
VS: 97.7 PO 163 / 98 60 18 97 RA
___ - 77 - ___ - 132
Gen - sitting up in bed, comfortable
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normal bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses; mild erythema at ___
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
Admission Labs
___ 11:02PM BLOOD WBC-7.9 RBC-4.19* Hgb-12.6* Hct-36.6*
MCV-87 MCH-30.1 MCHC-34.4 RDW-14.2 RDWSD-45.6 Plt ___
___ 11:02PM BLOOD Neuts-50.1 ___ Monos-16.1*
Eos-2.3 Baso-0.6 Im ___ AbsNeut-3.97 AbsLymp-2.42
AbsMono-1.28* AbsEos-0.18 AbsBaso-0.05
___ 02:08AM BLOOD ___ PTT-36.7* ___
___ 11:10AM BLOOD Glucose-593* UreaN-25* Creat-1.2 Na-126*
K-7.0* Cl-83* HCO3-13* AnGap-30*
___ 11:02PM BLOOD ALT-28 AST-29 AlkPhos-83 TotBili-0.5
___ 11:10AM BLOOD Calcium-8.9 Phos-5.5* Mg-2.0
Imaging:
CXR on admission:
No acute intrathoracic abnormality.
Discharge Labs:
___ 02:08AM BLOOD WBC-7.9 RBC-4.16* Hgb-12.5* Hct-36.5*
MCV-88 MCH-30.0 MCHC-34.2 RDW-14.1 RDWSD-45.5 Plt ___
___ 06:40AM BLOOD Glucose-80 UreaN-15 Creat-0.6 Na-141
K-4.1 Cl-100 HCO3-30 AnGap-11
Brief Hospital Course:
This is a ___ year old male with history of type 2 diabetes
secondary to pancreatic insufficiency following a whipple
procedure, surgically asplenic, hypertension admitted ___
with DKA and hyperkalemia, course complicated by hypoglycemia,
seen by ___ Diabetes consult service and started on modified
insulin regimen, subsequently stable and able to be discharged
home
# Diabetes secondary to surgery complicated by diabetic
ketoacidosis
# Hyperkalemia
Patient presented with hyperkalemia, hyperglycemia and labs
consistent with DKA. He was treated with IV fluids and IV
insulin in the ED, with closing of gap and ability to admit
patient to the medical floor. Patient denied recent medication
compliance issues and workup did not reveal any signs of
infection or ischemia to suggest etiology. Likely contributing
factors were felt to be alcohol use (he reported 6 drinks per
day) and recent uptitration of creon. Patient was seen by
___ consult service--over subsequent 48 hours patient course
was notable for hypoglycemia requiring downtitration of insulin
regimen. Patient subsequently stabilized with improved ___
control. Patient was very eager to leave the hospital, stating
"I am leaving either way today". Coordinated with patient and
___ service to determine what would be the safest regimen and
discharge plan for patient that would meet his requirement for
discharge. Discharged on new regimen, notable for dose
reductions in long-acting insulin: Glargine 30 Units Bedtime,
Humalog 6 Units Breakfast/Lunch/Dinner + Humalog sliding scale.
Patient instructed to keep log of fingersticks and contact
___ for sustained fingersticks > 250. He had previously
follow-up scheduled for week following discharge--patient to
keep this appointment.
# Alcohol use disorder
Patient reported drinking 6 alcoholic beverages per day, and has
been trying to cut back. Possibly contributed to hyperglycemia
above. Patient not willing to set specific dates or define what
"cutting back" meant. Counseled on reduction in alcohol intake.
No signs withdrawal this admission.
# Pancretic insufficiency
Continued home Creon
# Hypertension
Continued lisinopril. Given heart rates in the ___, held
diltiazem this admission. Could consider restarting at
follow-up.
Transitional issues
- Discharged home
- Diltiazem held on admission; continued to hold at discharge
given normal heart rate (~60bpm) at time of discharge
> 30 minutes spent on this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Creon 12 2 CAP PO QIDWMHS
2. Lisinopril 10 mg PO DAILY
3. Diltiazem Extended-Release 90 mg PO DAILY
4. Glargine 48 Units Breakfast
Glargine 53 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Glargine 30 Units Bedtime
Humalog 6 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. Creon 12 2 CAP PO QIDWMHS
3. Lisinopril 10 mg PO DAILY
4. HELD- Diltiazem Extended-Release 90 mg PO DAILY This
medication was held. Do not restart Diltiazem Extended-Release
until you see your primary care doctor
Discharge Disposition:
Home
Discharge Diagnosis:
# Diabetes secondary to surgery complicated by diabetic
ketoacidosis
# Alcohol use disorder
# Pancretic insufficiency
# Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with HIGH blood sugars and diabetic ketoacidosis. You were
treated with insulin and improved.
You were seen by diabetes specialists from the ___ who helped
formulate a new insulin regimen for you. This regimen is
actually LOWER than what you were on before--this is in response
to your LOW blood sugars in the hospital.
The recommended that you continue to check your fingersticks,
and asked that you call them if your fingersticks are higher
than 250 and do not improve with insulin.
Followup Instructions:
___
|
19795607-DS-11
| 19,795,607 | 23,640,075 |
DS
| 11 |
2176-07-22 00:00:00
|
2176-07-22 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:
Left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
REASON FOR CONSULTATION: left sided weakness
___ Stroke Scale score was : 3
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 1
5a. Motor arm, left: 1
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 1
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 0
HPI:
Ms. ___ is a ___ old woman with a history of HTN and
IDDM
who presents with left sided weakness and coordination deficits.
Patient awoke at 4am to use the bathroom. She felt the urge to
urinate, but when she went to stand up from the bed, she
couldn't. Her legs wouldn't do what she wanted them to do. She
tried standing but slid onto her butt and urinated on herself.
She was unable to get herself off the floor so she spent the
next
2 hours waiting for someone to check on her and help her. Her
daughter, who lives with her, came in the room at 6am and found
her on the ground. She got her husband to help pick the patient
up and they cleaned her up and put her back to bed. At that
point, she could stand on her own but felt "shaky."
Later in the morning, she tried to get up again to use the
bathroom but she was unable to make it due to weakness and
urinated on herself again. Her daughter cleaned her up again and
then helped her to the couch. She noticed that she was slumped
to
the left and then called EMS. On EMS arrival, the daughter
noticed a left facial droop as well.
Notably, on ___, patient reports an episode of vertigo and
word finding difficulty as well as difficulty writing with her
right hand, lasting 30 minutes.
She has felt generally weak recently and has had about 7 falls
in
the last 3 weeks, including one on ___ for which she sustained
a
wrist fracture. She had this surgically repaired yesterday. She
has been off her home Aspirin in preparation for the surgery for
the past week.
Lastly, she does report a history of stroke "back in the ___
causing left sided weakness, though she is not sure what caused
it.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
comprehending speech. Denies focal numbness, parasthesiae. No
bowel incontinence or retention.
PMH:
Problems (Last Verified ___ by ___, MD):
DEPRESSION
DIABETES MELLITUS
HEPATITIS C
HYPERTENSION
NARCOTICS AGREEMENT
PANIC DISORDER
RIGHT SHOULDER PAIN
TOBACCO ABUSE
SHOULDER PAIN
DIABETIC NEPHROPATHY
LABIAL ABSCESS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
HEALTH MAINTENANCE
H/O KNEE PAIN
Home Medications:
--------------- --------------- --------------- ---------------
Active Medication list as of ___:
Medications - Prescription
ALBUTEROL SULFATE - albuterol sulfate HFA 90 mcg/actuation
aerosol inhaler. ___ HFA(s) inhaled every ___ hours as needed
for
shortness of breath or wheezing
CITALOPRAM - citalopram 40 mg tablet. take 1 Tablet(s) by mouth
qam
DILTIAZEM HCL [CARDIZEM CD] - Cardizem CD 240 mg
capsule,extended
release. 1 (One) Capsule, Sust. Release 24 hr(s) by mouth once a
day
FENTANYL - fentanyl 25 mcg/hr transdermal patch. apply
transdermally. every 72 hours. do not fill until ___
HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. 1
tablet(s) by mouth once a day
INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL subcutaneous
solution. 30 units sc with breakfast daily
INSULIN LISPRO [HUMALOG] - Humalog 100 unit/mL subcutaneous
cartridge. ___ units sc daily according to sliding scale as
directed (see note ___ for ___ sliding scale)
LOSARTAN - losartan 50 mg tablet. take 1 tablet(s) by mouth qam
NORTRIPTYLINE - nortriptyline 50 mg capsule. take 1 capsule(s)
by
mouth at bedtime
OXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth q4-6 as
needed for pain ___ increase to 2 tabs q4
PREGABALIN [LYRICA] - Lyrica 75 mg capsule. take 1 capsule(s) by
mouth twice a day
ZOLPIDEM [AMBIEN] - Ambien 10 mg tablet. 1 (One) Tablet(s) by
mouth at bedtime as needed for insomnia
Medications - OTC
ALCOHOL SWABS [ALCOHOL PADS] - Alcohol Pads. for use when
administering insulin daily
ASCORBIC ACID (VITAMIN C) [VITAMIN C] - Dosage uncertain -
(Prescribed by Other Provider)
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 tablet(s) by
mouth daily last dose pre-op ___ per surgeon's order -
(Prescribed by Other Provider)
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - FreeStyle Lite
Strips. use for blood sugar testing ___ times a day before using
sliding scale Dx: Diabetes Mellitus type II E11.65
BLOOD-GLUCOSE METER [FREESTYLE FREEDOM LITE] - FreeStyle Freedom
Lite kit. use for blood sugar testing twice a day Dx: Diabetes
Mellitus II (E11.65)
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Dosage uncertain -
(Prescribed by Other Provider)
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - Dosage uncertain
-
(Prescribed by Other Provider)
GARLIC - Dosage uncertain - (Prescribed by Other Provider)
LANCETS [FREESTYLE UNISTIK 2] - FreeStyle Unistik 2. use as
directed for b.s. testing twice a day Dx: Diabetes Mellitus II
(E11.8)
--------------- --------------- --------------- ---------------
Allergies: NKDA
Social Hx:
Social History (Last Verified ___ by ___,
MD):
Marital status: Single
Children: Yes
Lives with: Other: daughter and her family
Work: ___
Domestic violence: Denies
Contraception: N/A
Tobacco use: Heavy tobacco smoker (10+ cigarettes per
day)
Smoking cessation Yes
counseling offered:
Alcohol use: Denies
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
- Modified Rankin Scale:
[] 0: No symptoms
[x] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Past Medical History:
PMH:
DEPRESSION
DIABETES MELLITUS
HEPATITIS C
HYPERTENSION
NARCOTICS AGREEMENT
PANIC DISORDER
RIGHT SHOULDER PAIN
TOBACCO ABUSE
SHOULDER PAIN
DIABETIC NEPHROPATHY
LABIAL ABSCESS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
HEALTH MAINTENANCE
H/O KNEE PAIN
Social History:
Social Hx:
___
Family History:
Father and grandfather with stroke.
Physical Exam:
Admission Physical Exam:
Physical Exam:
Vitals: T: 98.4 P: 84 R: 16 BP: 172/100 SaO2: 96% RA BG 365
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. Left arm is in brace.
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.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Left facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. Left pronator drift.
No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 4- 4 2 ** ___ 4- 5- 5 5
R * ___ 5- 4+ 5 5 5 5 5
*not tested due to rotator cuff injury
**not tested due to arm brace
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: Slow and irregular finger tap on the left, even
accounting for injury. Dysmetria on FNF on the left even when
arm
held antigravity.
-Gait: Deferred
Discharge Physical Exam:
Vitals: T 98.7, BP 117/72, HR 86, RR 18, O2 97 Ra
General physical Exam:
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Neck: Supple with no pain to flexion or extension
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Neurologic:
Mental status:
Patient is alert and oriented to name, date, and location.
Patient is able to hold conversation with examiner without
difficulty and able to follow commands during examination. Her
speech is without frank language deficit.
Cranial Nerves:
II, III, IV, VI: PERRL 4 to 2and brisk. EOMI without
nystagmus.
V: Facial sensation intact to light touch.
VII: No facial asymmetry.
VIII: Hearing intact to conversation
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions.
Motor:
Patient in both upper and lower extremities is able to freely
use
extremities and is able to provide resistance at the deltoid,
biceps, triceps, wrist extensors, finger extensors/flexors,
iliopsoas, hamstrings, gastrocnemius, tibialis anterior. There
is
some limitation due to pain in shoulder joints, but she is full
strength throughout, effort improved since admission.
Sensory:
Intact to light touch
DTRs:
___
___:
No dysmetria, no sway with sitting on bed, able to accurately
fix head band on hair and ___ hospital gown. Stands up from bed
easily.
Gait: Takes cautious steps and is slow to walk but with fluid
movements. Left foot slightly everted but wide-based gait
continues to improve since admission. Slightly swings left leg
rotationally outwards when turns for steadiness. Able to walk
straight without sway.
Pertinent Results:
Blood:
___ 05:00AM BLOOD WBC-7.6 RBC-4.53 Hgb-12.7 Hct-39.8 MCV-88
MCH-28.0 MCHC-31.9* RDW-13.5 RDWSD-43.7 Plt ___
___ 07:53AM BLOOD WBC-9.0 RBC-4.66 Hgb-12.6 Hct-40.4 MCV-87
MCH-27.0 MCHC-31.2* RDW-13.4 RDWSD-42.0 Plt ___
___ 07:15AM BLOOD WBC-9.3 RBC-5.05 Hgb-14.0 Hct-43.7 MCV-87
MCH-27.7 MCHC-32.0 RDW-13.4 RDWSD-41.6 Plt ___
___ 04:35AM BLOOD WBC-9.4 RBC-4.99 Hgb-13.8 Hct-43.0 MCV-86
MCH-27.7 MCHC-32.1 RDW-13.3 RDWSD-41.5 Plt ___
___ 04:35AM BLOOD WBC-9.3 RBC-4.71 Hgb-12.9 Hct-41.0 MCV-87
MCH-27.4 MCHC-31.5* RDW-13.2 RDWSD-41.6 Plt ___
___ 02:20PM BLOOD WBC-8.8 RBC-4.87 Hgb-13.6 Hct-42.5 MCV-87
MCH-27.9 MCHC-32.0 RDW-13.2 RDWSD-42.3 Plt ___
___ 02:20PM BLOOD Neuts-70.6 ___ Monos-6.0 Eos-0.8*
Baso-0.5 Im ___ AbsNeut-6.24* AbsLymp-1.91 AbsMono-0.53
AbsEos-0.07 AbsBaso-0.04
___ 05:00AM BLOOD Plt ___
___ 07:53AM BLOOD Plt ___
___ 07:15AM BLOOD Plt ___
___ 04:35AM BLOOD Plt ___
___ 04:35AM BLOOD Plt ___
___ 04:35AM BLOOD ___ PTT-27.5 ___
___ 02:20PM BLOOD Plt ___
___ 02:20PM BLOOD ___ PTT-28.4 ___
___ 05:00AM BLOOD Glucose-202* UreaN-29* Creat-1.0 Na-139
K-3.7 Cl-99 HCO3-27 AnGap-13
___ 07:53AM BLOOD Glucose-192* UreaN-23* Creat-1.0 Na-141
K-3.9 Cl-101 HCO3-27 AnGap-13
___ 07:15AM BLOOD Glucose-219* UreaN-19 Creat-0.9 Na-139
K-4.6 Cl-97 HCO3-25 AnGap-17
___ 04:35AM BLOOD Glucose-158* UreaN-14 Creat-0.8 Na-140
K-3.8 Cl-98 HCO3-29 AnGap-13
___ 04:35AM BLOOD Glucose-292* UreaN-11 Creat-0.8 Na-140
K-4.1 Cl-97 HCO3-33* AnGap-10
___ 02:20PM BLOOD Glucose-384* UreaN-12 Creat-0.8 Na-141
K-4.5 Cl-95* HCO3-32 AnGap-14
___ 02:20PM BLOOD ALT-39 AST-52* AlkPhos-218* TotBili-0.4
___ 02:20PM BLOOD Lipase-44
___ 02:20PM BLOOD cTropnT-<0.01
___ 05:00AM BLOOD Calcium-9.8 Phos-3.7 Mg-1.8
___ 07:53AM BLOOD Calcium-9.8 Phos-3.6 Mg-1.7
___ 07:15AM BLOOD Calcium-9.9 Phos-3.9 Mg-1.7
___ 04:35AM BLOOD Calcium-9.8 Phos-3.2 Mg-1.5*
___ 04:35AM BLOOD Calcium-9.7 Phos-2.4* Mg-1.5* Cholest-136
___ 02:20PM BLOOD Albumin-3.4* Calcium-10.1 Phos-2.8 Mg-1.7
___ 04:35AM BLOOD %HbA1c-10.2* eAG-246*
___ 04:35AM BLOOD Triglyc-145 HDL-54 CHOL/HD-2.5 LDLcalc-53
___ 04:35AM BLOOD TSH-0.62
___ 02:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 08:07PM BLOOD Lactate-2.3*
___ 02:32PM BLOOD Lactate-3.2*
Urine:
___ 06:10PM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-1000* Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG
___ 06:10PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-4
___ 06:10PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-POS* mthdone-NEG
___ 6:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Imaging:
CT/CTA w/ and w/o contrast (___):
IMPRESSION:
1. No evidence of hemorrhage or recent infarction.
2. A 3 mm left supraclinoid ICA aneurysm.
3. No evidence of aneurysm, dissection or significant stenosis
of the neck.
No internal carotid artery stenosis by NASCET criteria.
4. Evidence of moderate white matter chronic small vessel
ischemic disease.
5. Unchanged right posterior frontal encephalomalacia with
associated linear
cortical calcification possibly representing sequela of an old
infarct or
prior traumatic insult.
MRI Brain (___):
IMPRESSION:
1. There are no acute infarcts.
2. Chronic infarcts, stable.
3. Severe chronic small vessel ischemic changes.
4. Moderate opacification right mastoids.
Brief Hospital Course:
Ms. ___ is a ___ old woman with a history of HTN, IDDM,
remote stroke, whom presented with left sided weakness and
coordination deficits concerning for lacunar stroke with
ataxic-hemiparesis. Her MRI was negative for acute stroke and we
currently believe that she experienced recrudescence of her old
stroke symptoms in the setting of hyperglycemia and poorly
controlled diabetes. Patient's left sided weakness improved as
her glucose because
more appropriately managed. Imaging did show an old infarct that
appears to involve the R pre and post central gyri, which would
go along with her symptoms. She was assessed by physical
therapy, whom after working with her for several sessions felt
it was safe for her to go home.
Transitional issues
#prior stroke - Resumed aspirin 81 mg for risk reduction
#diabetes - insulin regimen modified by ___.
Started metformin 500 mg XR per recs on discharge. Follow up
glucose control. A1c was 10% this admission
# Outpatient physical therapy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
2. Citalopram 40 mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Glargine 30 Units Breakfast
6. Losartan Potassium 50 mg PO DAILY
7. Nortriptyline 50 mg PO QHS
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
9. Pregabalin 75 mg PO BID
10. Zolpidem Tartrate 10 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Glargine 34 Units Breakfast
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
4. Citalopram 40 mg PO DAILY
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. Nortriptyline 50 mg PO QHS
9. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
10. Pregabalin 75 mg PO BID
11. Zolpidem Tartrate 10 mg PO QHS
12.Outpatient Physical Therapy
Please evaluate for outpatient physical therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Recrudescence of prior stroke symptoms
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized because of left sided weakness. You had a
MRI done which did not show a stroke. We believe that your
symptoms occurred because of your high blood sugar. When your
body is stressed by a variety of causes, high blood sugar,
infection, then symptoms that you have had from past strokes
that you recovered from can recur. You should make sure that
your diabetes is under good control and that your blood sugar
does not get too high to avoid this.
You were started on aspirin 81 mg to help reduce your risk of
having a stroke and metformin 500 mg XR to help better control
your diabetes.
Thank you for allowing us to care for you,
___ Neurology Team
Followup Instructions:
___
|
19795930-DS-11
| 19,795,930 | 25,622,483 |
DS
| 11 |
2166-06-09 00:00:00
|
2166-06-09 21:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / morphine
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH significant for CAD s/p CABG x 4 ___ ___), recent NSTEMI ___ with 3 VD s/p PCI, severe AS
dx'd during last hospitalization in ___, sick sinus syndrome
with 3rd degree heart block s/p dual-chamber PPM, HTN, HLD, and
DM who presented with chest heaviness. Pt states that her
substernal, predominantly L sided chest heaviness started
immediately upon getting out of bed yesterday morning and lasted
for several hours, before resolving around noon. The sx did not
recur even when pt took a stroll, but she became alarmed when
experiencing the same chest heaviness around 4:30 ___. She states
that even with her h/o heart disease and NSTEMI, the chest
heaviness did not feel like anything she's experienced in the
past. The patient presented to ___. EKG
showed T wave inversions, unchanged from prior. Troponin was
negative x 1.
In the ED, initial vitals were: T98.2 P80 BP121/61 RR16 100% RA.
Labs were notable for H/H 10.3/31.0, K 4.2, Mg 1.6, Cr 0.9.
Troponin < 0.01. Cardiology was consulted in the ED and patient
requested to be admitted for second troponin and further
observation.
Past Medical History:
- CAD s/p CABG in ___
- Severe AS on TTE ___ <1.0cm2, peak gradient 64mmHg, peak
velocity 4.0m/s)
- S/p PPM placement for SSS w/ third degree heart block
- HTN
- HLD
- T2DM
Social History:
___
Family History:
Father died of complications of MI at age ___
Mother -bladder ca.
Physical Exam:
Vitals: T 98.4, BP 121/70, HR 70, RR 18, 96 on RA
___: in no apparent distress; watching TV, sitting upright
HEENT: non-icteric, moist mucous membranes.
CV: regular rate and rhythm; systolic murmur that radiates to
carotids
Lungs: clear to auscultation bilaterally-- decreased breath
sounds ___ effort and body habitus
Abdomen: soft, nondistended. No tenderness to deep palpation in
any quadrants. +BS
Ext: 2+ radial pulses; 1+ dorsalis pedis. Trace pre-tibial
pitting edema.
Pertinent Results:
ADMISSION LABS
___ 10:12PM BLOOD cTropnT-<0.01
___ 10:12PM BLOOD Glucose-133* UreaN-20 Creat-0.9 Na-136
K-4.2 Cl-101 HCO3-22 AnGap-17
___ 10:12PM BLOOD Neuts-62.3 ___ Monos-6.3 Eos-2.0
Baso-0.9
___ 10:12PM BLOOD WBC-8.9 RBC-3.68* Hgb-10.3* Hct-31.0*
MCV-84 MCH-27.9 MCHC-33.1 RDW-13.1 Plt ___
DISCHARGE LABS
___ 07:35AM BLOOD Calcium-9.8 Phos-3.9 Mg-1.6
___ 10:12AM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:12AM BLOOD Glucose-183* UreaN-16 Creat-0.8 Na-135
K-4.3 Cl-97 HCO3-31 AnGap-11
___ 07:35AM BLOOD Glucose-161* UreaN-17 Creat-0.8 Na-134
K-4.7 Cl-96 HCO3-28 AnGap-15
___ 10:12AM BLOOD WBC-7.1 RBC-3.97* Hgb-11.0* Hct-33.5*
MCV-84 MCH-27.8 MCHC-32.9 RDW-13.2 Plt ___ EKG
Sinus rhythm. Possible anterior myocardial infarction with
extensive
precordial T wave inversions. Consider ischemia. There are
pacing artifacts
at the beginning of the QRS complexes that do not appear to
capture the
ventricle. On the previous tracing of ___, the pacing
artifact was not
present. T wave inversions in leads I and aVL are now more
prominent. Lateral
precordial lead T wave abnormality is now less prominent.
Clinical correlation
is suggested.
___ CXR
IMPRESSION:
1. No acute cardiopulmonary process.
2. Fullness in the right upper mediastinum is noted, which may
reflect a
goiter. Physical exam is recommended with consideration to
additional imaging
if clinically indicated.
Brief Hospital Course:
Ms. ___ presented with the chief complaint of chest
pain/heaviness. By the day of her discharge, she had complete
resolution of the chest heaviness. She also denied having any
shortness of breath, abdominal pain, and palpitations. Her vital
signs were stable. Her problems were managed as follows:
# Chest heaviness - Since pt had a significant cardiac hixtory
including valvular and vessel disease, the initial differential
for her presentation included symptomatic aortic stenosis v.
ischemia. Her EKG on admission was comparable to that from one
month prior and her troponins x 3 were non-elevated. Pt's echo
from ___ was also referenced. Given recent stent, it was
concluded that her pain stemmed from symptomatic aortic
stenosis. Pt was monitored on tele, w/o any arrythmias. She was
ambulated without chest pressure. Given the negative enzymes and
need for dental work pre AVR she will be discharged to on her
home cardiac meds (lisinopril 40 mg, lasix 40 mg, lopressor 100
mg BID, amlodipine 10 mg daily for AS + 20 mg crestor and 81 mg
aspirin for CAD) and she is due to see her dentist day after
discharge for cleaning and extractions the following week. Dr.
___ was updated and the patent will call to
schedule surgery soon after the extractions. .
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Ezetimibe 10 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Tartrate 100 mg PO BID
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL ASDIR chest pain
8. Furosemide 40 mg PO DAILY
9. MetFORMIN (Glucophage) 850 mg PO BID
10. Levemir 20 Units Bedtime
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Ezetimibe 10 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Levemir 20 Units Bedtime
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Tartrate 100 mg PO BID
8. Nitroglycerin SL 0.4 mg SL ASDIR chest pain
9. Rosuvastatin Calcium 20 mg PO DAILY
10. MetFORMIN (Glucophage) 850 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Aortic stenosis
Type 2 DM
HTN
HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ has been a pleasure to participate in your care. You came to
the emergency department with new chest heaviness. Since you've
been in the hospital, we've looked at your blood to make sure
there were no enzyme leaks associated with cell death (as we
talked about). It's most likely that your chest heaviness
happened because of the valve problem you were told about during
your last hospitalization (also known as aortic stenosis).
You are scheduled for sugery, as treatment of this valve
problem. Before then, you need to follow up with your dentist to
have teeth extraction.
Followup Instructions:
___
|
19796013-DS-15
| 19,796,013 | 27,527,723 |
DS
| 15 |
2147-06-25 00:00:00
|
2147-06-25 12:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chief Complaint: BRBPR
Reason for MICU transfer: Anemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a PMHx of COPD, afib (on coumadin),
recent hospitalization for severe flu PNA (course c/b ARDS,
requiring trach/PEG, ATN and PICC line-associated DVT), who
presents with BRBPR.
Pt was admitted to FICU ___ (transferred from OS___ where he
was admitted on ___. He was diagnosed with influenza A. He
developed ARDS and required intubation, paralysis. He received
Pt given vanc/zosyn (___), tamiflu (___) and then
zanamavir (___). He was also treated with methylpored. TTE
did not show RV dysfunction. Trach and PEG were placed on ___.
Pt also developed ___ and required CRRT and HD. A tunnelled HD
line was placed. He briefly required vasopressors for HoTN,
though to be ___ sepsis. He also developed a fever with sputum
Cx growing serratia and received CTX -> bactrim + cipro
___ for tracheitis. Lastly, pt was noted to have an
extensive RUE PICC-associated DVT.
Pt was re-admitted ___ for BRBPR x 2 at rehab. He
presented with tachycardia, hypoxia and tachypnea. He received
5U PRBC, 2U FFP. Per pt, prior CS was in ___ and showed
polyps. EGD showed an antral ulcer which was not thought to be
the culprit source. CTA did not show active bleeding but did
show diverticulosis. On re-read of CTA, there was extravasation
in the sigmoid. Warfarin was re-started on ___.
On day of admission, he endorsed one episode of BRBPR, without
stool that happened ___. He has been lightheaded since then
but denies CP/SOB, no f/c, no N/V/D or abdominal pain.
In the ED, initial VS were 98.6 100-110s 106/70 29 91% trach
mask. No abdominal pain, saline PEG lavage without evidence of
blood. Rectal exam with copious bright red blood in vault.
Access obtained (18G, 20G, 22G) and 1L NS started. Labs notable
for INR 2.1, BUN/Cr ___, Na 146, HCO3 36, HCT 21.8. Received
Pantoprazole 40 IV x1, Vitamin K 10 mg IV x1, 2U FFP and 2U
PRBCs.
On arrival to the MICU, pt reports lightheadedness and diplopia.
He had 2 dark red bms.
Review of systems:
(+) Per HPI
(-) CP, abd pain, SOB, nausea, vomiting. 10-point ROS otherwise
negative.
Past Medical History:
- Influenza PNA with course complicated by ARDS (sp PEG/Trach),
___ (requiring HD)
- H/O serratia tracheitis
- IDDM
- Paroxysmal afib
- HTN
- Peripheral neuropathy
- HLD
- COPD
- HFpEF
Social History:
___
Family History:
Mother - colon cancer.
Father - stroke and diabetic.
PGM - DM.
Physical Exam:
Admission Physical Exam:
Vitals: T: 99.1 BP: 108/66 P: 114 R: 18 O2: 87% on 10L
General- Alert, oriented, no acute distress, communicates by
writing
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD, sp trach draining thick
white sputum
Lungs- Diffuse rhonchi.
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, mild ttp in RUQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly;
+PEG site c/d/i
GU- foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
.
Discharge Physical Exam:
AF HR 111
General- Alert, oriented, no acute distress, communicates by
writing
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD, sp trach draining thick
white sputum
Lungs- Diffuse rhonchi.
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, mild ttp in RUQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly;
+PEG site c/d/i
GU- foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
=====================================
LABS ON ADMISSION:
=====================================
___ 07:45AM BLOOD WBC-12.6* RBC-2.39* Hgb-6.9* Hct-21.8*
MCV-91 MCH-28.7 MCHC-31.5 RDW-15.6* Plt ___
___ 07:45AM BLOOD Neuts-70.4* ___ Monos-5.6 Eos-1.2
Baso-0.6
___ 07:45AM BLOOD ___ PTT-47.3* ___
___ 07:45AM BLOOD Glucose-119* UreaN-25* Creat-0.8 Na-146*
K-5.0 Cl-104 HCO3-36* AnGap-11
___ 07:13PM BLOOD Calcium-7.8* Phos-4.3 Mg-1.6
___ 07:45AM BLOOD ALT-4 AST-16 LD(LDH)-258* AlkPhos-81
TotBili-0.1
=====================================
LABS ON DISCHARGE:
=====================================
___ 09:05AM BLOOD WBC-10.4 RBC-3.30* Hgb-9.7* Hct-30.3*
MCV-92 MCH-29.2 MCHC-31.8 RDW-15.0 Plt ___
___ 09:05AM BLOOD Plt ___
___ 09:05AM BLOOD ___
___ 09:05AM BLOOD Glucose-168* UreaN-11 Creat-0.6 Na-139
K-3.9 Cl-99 HCO3-35* AnGap-9
___ 09:05AM BLOOD Mg-1.6
___ 09:05AM BLOOD TSH-11*
___ 09:05AM BLOOD Free T4-0.97
=====================================
OTHER RESULTS:
=====================================
GNR's on BAL on ___.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). ~4000/ML. FURTHER WORKUP ON
REQUEST ONLY.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
10,000-100,000 ORGANISMS/ML..
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
=====================================
IMAGING:
=====================================
Bronchoscopy (___): Airways visualized to subsegmental level
bilaterally. There were thick secretions noted in the airways
throughout (right worse than left) that cleared with suctioning.
No endobronchial lesions were seen. A BAL was done in the
posterior subsegment of the right upper lobe with 90 mL
instilled and 30 mL of cloudy aspirate returned. There was a
whitish plaque over the posterior wall of the trachea at the
edge of the distal tip of the tracheostomy tube that did not
clear with suctioning or manipulation.
TTE with bubble study (___): The left atrium is elongated. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. The estimated
right atrial pressure is at least 15 mmHg. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF 55-60%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. The estimated cardiac index is high
(>4.0L/min/m2). Doppler parameters are indeterminate for left
ventricular diastolic function. No mid-cavitary gradient is
identified. Right ventricular chamber size is normal with
borderline normal free wall function. The aortic valve leaflets
are mildly thickened (?#). There is no aortic valve stenosis.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal global left ventricular and
borderline right ventricular systolic function. Mild pulmonary
hypertension. No intracardiac shunt identified.
CT chest (___): 1. Severe multifocal pneumonia, worsened since ___. Recurrent pneumonia could be due to a
tracheoesophageal fistula, which could be assessed with
fluroscopic swallowing study. 2. Enlarged mediastinal lymph
nodes, likely reactive in etiology. 3. Bilateral pleural
thickening and calcification are similar to prior and may be
related to prior asbestos exposure.
Tagged RBC scan (___): No evidence of active GI bleeding.
Mesenteric angiogram (___): Uncomplicated mesenteric angiogram
without evidence of active extravasation.
CTA abdomen (___): 1. No identifiable source of active bleeding
within the abdomen or pelvis. 2. Bibasilar opacities, right
greater than left, likely represents atelectasis but
superimposed infection cannot be excluded.
CXR (___): Right pleural thickening and right lung opacities
remain
concerning for aspiration or infection that is relatively
unchanged since
___.
Brief Hospital Course:
Mr. ___ is a ___ with a PMHx of COPD, afib (on coumadin),
recent hospitalization for severe flu PNA (course c/b ARDS,
requiring trach/PEG, ATN and PICC line-associated DVT), who
presented with BRBPR thought to be a diverticular bleed.
.
# Lower GI Bleed secondary to Diverticuli:
Pt presented with BRBPR and anemia. HCT is 21.8 from 27 on ___.
Pt was symptomatic and tachycardic but normotensive. Pt with
known gastric ulcer and diverticulosis with area suspicious for
extravasation on recent CTA. Patient underwent an extensive
evaluation including CTA, mesenteric angiogram in ___, and tagged
RBC scan without identifying a source of bleeding. Despite this,
patient continued to have bloody bowel movements. His last
bloody bowel movement occurred on evening of ___. He required 8
units pRBCs and 2 units FFP. This resulted in increase in Hct to
___. Hct stable in the 36 hours prior to transfer to the
floor. GI and Colorectal Surgery followed while in hospital.
Both declined to intervene either diagnostically or
therapeutically. His bleeding stopped 48 hours prior to transfer
to floor, after which his HCT remained stable until discharge to
rehab. He was continued on IV PPI BID at time of discharge.
His coumadin was held with plan for GI to see as outpatient to
decide when to resume, and if any further procedures are needed.
.
# HAEMOPHILUS INFLUENZAE PNA:
Pt presented with tachypena and elevated O2 requirement.
Initially thought to be at baseline with multifactorial etiology
(COPD, dCHF, recent severe PNA, recent trachitis). Per record,
pt is on tach mask at 60% during the day and has scheduled
night-time ventilation of A/C with tidal volume 450ml and rate
of 16/minute at an FiO2 of 40%. Samples from bronchoscopy,
however, grew GNRs and patient was started on cefepime ___.
Speciation revealed Beta-Lactamses Haemophilus and he was
switched to Augmentin on ___ to be continued until ___.
.
# Trach Care: Patient was seen by the ENT (fellow and attending)
prior to discharge given prior question of vocal cord avulsion
on left. Recommendation was made that if trach is able to be
capped for 24hrs, then can move toward decanulation by pulmonary
team.
.
# Paroxysmal afib/aflutter:
EKG throughout admission demonstrated sinus tachycardia. CHADS2
score is 3 but pt with active GIB and so coumadin and aspirin
held. Diltiazem also held given sinus rhythm. At time of
discharge, his coumadin was held. Diltiazem (QID instead of
daily) was restarted on discharge. This should be re-evaluated
as an outpatient. ASA held given protential procedures at rehab.
.
# RUE PICC-associated DVT:
U/S on ___ revealed extensive clot extending up to R IJ. Pt was
started on coumadin with a planned 3 months of anticoagulation.
Unfortunately, warfarin had to be held in setting of signficant,
active GIB.
# T2DM: Pt. continued on insulin glargine 5 units at bedtime
with HISS.
# COPD: Per previous documentation, baseline PaCO2 in the ___
mmHg. Pt. continued on spiriva and advair.
# Diastolic CHF: EF 50-60% on ___. Volume maintained with
furosemdie 80IV as needed.
# Hyperlipidemia: Held pravastatin while in house.
# Transitional issues:
- CT Chest noted "bilateral pleural thickening and calcification
... may be related to prior asbestos exposure." Pt. will need to
follow-up with IP for potential biopsy. (Has appt with ___
___
- GI appt to determine if further procedures are needed and ?
restarting coumadin
- Communication: ___, mother: ___ ___
___, brother, HCP: cell, ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain, light
headache
2. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eye
3. Diltiazem 60 mg PO QID
4. Detemir 12 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Warfarin 5 mg PO DAILY16
6. Heparin 5000 UNIT SC TID
7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
8. Docusate Sodium (Liquid) 100 mg PO BID
9. Guaifenesin ___ mL PO Q6H
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN Constipation
12. Omeprazole 40 mg PO BID
13. budesonide 0.5 mg inhalation bid
14. ipratropium-albuterol ___ mcg/actuation inhalation 2 puff
q4h prn SOB
15. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
16. Simvastatin 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever, pain, light
headache
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
3. Artificial Tear Ointment 1 Appl BOTH EYES PRN dry eye
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Docusate Sodium (Liquid) 100 mg PO BID
6. Guaifenesin ___ mL PO Q6H
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Ipratropium Bromide Neb 1 NEB IH Q6H
11. budesonide 0.5 mg inhalation bid
12. Diltiazem 60 mg PO QID
13. Detemir 12 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
14. ipratropium-albuterol ___ mcg/actuation inhalation 2 puff
q4h prn SOB
15. Polyethylene Glycol 17 g PO DAILY:PRN constipation
16. Senna 8.6 mg PO BID:PRN Constipation
17. Simvastatin 5 mg PO DAILY
18. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
19. Omeprazole 40 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnosis
- Diverticular Bleed in setting of anticoagulation
Secondary Diagnoses
- Respiratory Failure
- Paroxysmal Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___,
You were admitted for a GI bleed. We were unable to exactly
determine its source, however we provided several blood
transfusions to stabilize your bleed. Your bleeding stopped for
several days prior to discharge to rehab. You should
discontinue taking coumadin until you see GI as an outpatient to
decide when to restart this.
Your rehab will also continue to give an antibiotic until
___.
You will also need to see pulmonary as an outpatient to help
manage your tracheostomy. You will also need to have your
feeding tube removed once you are able to maintain your
nutrition.
They may also recommend further procedures given some findings
that were noticed on your chest imaging.
Followup Instructions:
___
|
19796013-DS-16
| 19,796,013 | 20,568,116 |
DS
| 16 |
2150-12-04 00:00:00
|
2150-12-07 18:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH COPD, DM, ESRD on HD ___, afib on Plavix s/p
ablation p/w hyperglycemia and AGMA, fall, and dyspnea.
Patient reports symptoms began ___ days ago with cough,
minimally productive, with concurrent dyspnea. No fever, chills.
No dysuria. Subsequently 1d ago developed nausea with vomiting,
NB/NB. Patient also reports a fall due to feeling lightheaded on
standing up this morning; reports he came in in part because of
concern for possible bleed while on Plavix. Lightheadedness
resolved rapidly, fall was from standing. Initially presented to
___ with FSBG in 500s, bicarb 19, with UA with elevated glucose
but no ketones (no vbg reported). Started on an insulin GTT and
35 GTT. CXR demonstrated RLL infiltrate, and patient was given
ctx/doxy and transferred to ___ for further management. CT
head without acute process.
In the ED, initial vitals: 97.7 153/100 69 22 90/NC; FSG 143
- Exam notable for: RRR, diffuse wheeze, rll crackles, normal
trauma exam
- Labs notable for: WBC 16.7 12 bands, K 7.0, Cr 6.0, bicarb 19,
lactate 1.5, benign UA, pH 7.26, pCO2 51, AG 23
- Imaging notable for:
--CXR: RLL opacity
--CT head: no acute process
--ekg: First-degree heart block no acute ischemia and normal
sinus rhythm prominent but not peaked T waves
- Pt given:
___ 09:20 IV Piperacillin-Tazobactam ___
Started
___ 09:23 IH Albuterol 0.083% Neb Soln 1 NEB
___
___ 09:23 IH Ipratropium Bromide Neb 1 NEB ___
___ 09:49 SC Insulin 2 Units ___
___ 09:50 IV Piperacillin-Tazobactam 4.5 g ___
Stopped (___)
___ 09:53 IV Levofloxacin 750 mg ___
- Consults:
--Renal: He is due for HD today, will arrange for HD and f/u
during admission.
On the floor, patient reports ongoing resolution of
lightheadedness, with no ongoing nausea or vomiting. Denies
abdominal pain, change in bowel or bladder habits (is blind so
cannot see appearance of stool). Ongoing cough, some mild
dyspnea.
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:
- Influenza PNA with course complicated by ARDS (sp PEG/Trach),
___ (requiring HD)
- H/O serratia tracheitis
- IDDM
- Paroxysmal afib
- HTN
- Peripheral neuropathy
- HLD
- COPD
- HFpEF
Social History:
___
Family History:
Mother - colon cancer.
Father - stroke and diabetic.
PGM - DM.
Physical Exam:
ADMISSION PHYSICAL EXAM
================== =========
VITALS: 97.9 165/78 83 20 95/2L
GENERAL: Alert, oriented, no acute distress, oddly related
HEENT: Sclerae anicteric, oropharynx clear, EOMI, PERRL, neck
supple, JVP not elevated, no LAD
CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
LUNGS: bilateral rhonchi at lung bases, no increased WOB
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
NEURO: CN ___ intact, strength ___ and sensation intact
throughout; blind
DISCHARGE PHYSICAL EXAM
===========================
Vitals: 98.5 113/79 121 18 97/2L nc
GENERAL: Alert, oriented, no acute distress, oddly related
HEENT: Sclerae anicteric, oropharynx clear, EOMI, anisocoria L>R
pupil
CARDIOVASCULAR: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
LUNGS: bilateral rhonchi at lung bases, no increased WOB
ABDOMEN: Soft, mildly distended, no rebound or guarding
EXTREMITIES: Warm, well perfused, no edema
NEURO: blind, left facial droop; moving all four extremities
with purpose; refusing full neuro exam
Pertinent Results:
ADMISSION LABS
==================
___ 09:00AM BLOOD WBC-16.7*# RBC-3.39* Hgb-10.4* Hct-32.0*
MCV-94 MCH-30.7 MCHC-32.5 RDW-16.7* RDWSD-55.7* Plt ___
___ 09:00AM BLOOD Neuts-74* Bands-1 Lymphs-12* Monos-12
Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-12.53*
AbsLymp-2.00 AbsMono-2.00* AbsEos-0.00* AbsBaso-0.00*
___ 09:00AM BLOOD Hypochr-OCCASIONAL Anisocy-1+* Poiklo-1+*
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-1+* Tear
___ Acantho-OCCASIONAL Ellipto-1+*
___ 09:00AM BLOOD ___ PTT-23.4* ___
___ 09:00AM BLOOD Glucose-140* UreaN-92* Creat-6.0*# Na-140
K-7.0* Cl-98 HCO3-19* AnGap-23*
___ 09:00AM BLOOD CK(CPK)-79
___ 09:00AM BLOOD CK-MB-6 cTropnT-0.12* ___
___ 09:00AM BLOOD Calcium-10.1 Phos-8.4* Mg-2.8*
___ 09:10AM BLOOD ___ pO2-55* pCO2-51* pH-7.26*
calTCO2-24 Base XS--4
___ 09:09AM BLOOD Lactate-1.5 Na-136 K-5.9* Cl-103
___ 09:10AM BLOOD O2 Sat-82
___ 09:52AM URINE Color-Straw Appear-Clear Sp ___
___ 09:52AM URINE Blood-TR* Nitrite-NEG Protein-100*
Glucose-70* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:52AM URINE RBC-4* WBC-1 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 09:52AM URINE Mucous-RARE*
INTERVAL LABS
=================
___ 07:12PM BLOOD WBC-15.2* RBC-3.70* Hgb-10.8* Hct-34.8*
MCV-94 MCH-29.2 MCHC-31.0* RDW-16.9* RDWSD-54.9* Plt ___
___ 07:12PM BLOOD Glucose-214* UreaN-35* Creat-3.1*# Na-142
K-3.7 Cl-96 HCO3-26 AnGap-20*
___ 07:12PM BLOOD cTropnT-0.14*
___ 07:12PM BLOOD Calcium-9.0 Phos-3.4 Mg-2.1
___ 08:02PM BLOOD pO2-199* pCO2-33* pH-7.47* calTCO2-25
Base XS-1
___ 08:02PM BLOOD Lactate-2.8* Na-139 K-3.7 Cl-99
DISCHARGE LABS
===================
___ 06:14AM BLOOD WBC-10.9* RBC-3.59* Hgb-10.6* Hct-35.1*
MCV-98 MCH-29.5 MCHC-30.2* RDW-17.4* RDWSD-57.1* Plt ___
___ 06:14AM BLOOD Glucose-213* UreaN-52* Creat-4.2*# Na-143
K-4.5 Cl-99 HCO3-26 AnGap-18*
___ 06:14AM BLOOD Calcium-8.9 Phos-5.6* Mg-2.4
___ 06:53AM BLOOD pO2-64* pCO2-55* pH-7.32* calTCO2-30 Base
XS-0 Comment-GREEN TOP
MICRO
==========
___ 03:39AM URINE Streptococcus pneumoniae Antigen
Detection-PND</b>
___ 3:39 am URINE Legionella Urinary Antigen-PND</b>
___ 9:52 am URINE CULTURE (Final ___: NO GROWTH.
___ 9:07 am BLOOD CULTURE Blood Culture, Routine
(Pending):
___ 9:00 am BLOOD CULTURE Blood Culture, Routine (Pending):
Brief Hospital Course:
BRIEF SUMMARY
=================
___ year old male with PMH of COPD on 2L home O2, IDDM, ESRD on
HD ___, Afib on Plavix s/p ___ transferred from
___ (___) for management of hyperglycemia and
AGMA, fall, and dyspnea with significant electrolyte
derangements with OSH imaging c/w PNA.
PROBLEM-BASED SUMMARY
=========================
# Pneumonia
# COPD
CXR AP/Lat ___ from ___ reviewed with radiographic evidence of
consolidation in RLL and L lingua. In context of leukocytosis
and bandemia clinical picture overall consistent with pneumonia.
Initially covered with broad spectrum IV antibiotics
vanc/cefepime/azithro on ___, given he is on chronic dialysis.
BCx, urine strep/legionella sent from ED, results pending at
time of discharge; though low suspicion given patient is
clinically well-appearing. No steroids were administered for the
same reason. In observing him over the next ___ hours he
continued to be afebrile with stable lung exam and improving
leukocytosis. He was subsequently transitioned to PO
levofloxacin (750 mg loading dose ___ 500mg q48h (renally
dosed given ESRD) and received 1st dose on ___ before
discharge. Throughout hospitalization he had no significant e/o
concurrent COPD exacerbation; he was continued on
duonebs/albuterol PRN and fluticasone (Anoro Ellipta
[umeclidinium-vilanterol] not on formulary so was held) as well
as 2L home O2.
# AGMA w/ concurrent metabolic alkalosis
# C/f DKA versus HHS
# IDDM w/ hyperglycemia
Per report on arrival to ___ patient's glucose was 658 prompting
concerned for DKA therefore patient was transferred here on D5
and insulin gtts. In ___ ED, urine ketones negative, glucose
140, lactate 1.5--overall inconsistent with DKA. Insulin gtt was
discontinued, and he was resumed on 10U Lantus with
sliding-scale Humalog (of which he required 9U over 24h). He
received HD per renal prior to transfer up to the medicine flow
(as below), after which repeat labs were checked but
demonstrating persistent gap but narrowed to 19, no residual
acidosis, normal bicarb, but his lactate was mildly elevated to
2.8 without evidence of hypoperfusion. Overnight of ___, the
patient refused further workup of his AGMA including QACHS
finger-stick glucose. On ___ his 8am glucose was measured at
289, after which he received his home dose of 10U Lantus; given
he continued to refuse QACHS he did not receive more Humalog
prior to discharge. Overall, we felt his clinical picture was
most c/w a mild HHS in the setting of acute pneumonia and though
we ideally would have liked to monitor his blood sugars to
normalize over another 24 hours, the patient felt strongly about
returning home as soon as possible. We therefore recommended
that he returns to his home Lantus regimen upon discharge and to
follow-up with his PCP within the next ___ days.
# ESRD
On HD T/R/Sa, presenting with electrolyte derangements including
hyperkalemia without significant concerning EKG findings. Renal
consulted in ED, received HD on ___ prior to coming to floor
with resolution of hyperkalemia. While hospitalized, all
medications were renally dosed.
# Fall (on Plavix)
# L facial droop and anisocoria
Per report, NCCT ___ at ___ negative for acute intracranial
processes. The images were not available for review prior to L
facial droop and anisocoria was noted on exam. When questioned,
the patient reported a history of an implant in his left eye and
Bell's palsy; but he refused to cooperate with a full neurologic
exam. Given this and his history of fall while on Plavix, we
obtained a repeat NCCT on ___ which was again negative for
hemorrhagic stroke.
# HFpEF
LVEF 55% to 60% ___, unclear dry weight. Patient without
evidence of significant overload on admission despite BNP
elevated to ___ iso ESRD. Clinical exam not indicating volume
overload. During this admission, his home furosemide was held in
the setting of infection.
# CAD
No prior history of intervention, normal ECG in the ED;
troponins x2 were 0.12 and 0.14 though iso ESRD this appeared
stable. Upon transfer to the medicine floor, the patient refused
monitoring on telemetry. He repeatedly denied chest pain.
Continued on SL nitro, Plavix MWF (no doses given here). Patient
reports intolerance to ASA.
# Chronic
- pAfib: NSR on arrival, continued on home diltiazem, metoprolol
- HLD: continued on home simvastatin
TRANSITIONAL ISSUES
======================
- finish levofloxacin 500mg q48h x5 day course (___): he
will need two more doses on ___ and ___
- please check sugars in 1 week's time and adjust insulin as
needed, please f/u HbA1C
- continue outpatient dialysis on ___ and
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Meclizine 12.5 mg PO TID
2. Furosemide 40 mg PO BID
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Diltiazem Extended-Release 360 mg PO DAILY
5. Simvastatin 20 mg PO QPM
6. Glargine 10 Units Lunch
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
9. Ethyl Chloride 100% Spray 1 spray topically 3X/WEEK BEFORE
DIALYSIS
10. Prilolid (lidocaine-prilocaine) 2.5-2.5 % topical ___
prior to dialysis
11. LOPERamide 4 mg PO TID:PRN loose stools
12. Fluticasone Propionate 110mcg 1 PUFF IH BID
13. Ipratropium-Albuterol Neb 1 NEB NEB TID
14. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. Clopidogrel 75 mg PO 3X/WEEK (___)
17. sevelamer CARBONATE 1600 mg PO TID W/MEALS
18. Metoprolol Succinate XL 50 mg PO BID
Discharge Medications:
1. Levofloxacin 500 mg PO Q48H
RX *levofloxacin 500 mg 1 tablet(s) by mouth Q48H Disp #*2
Tablet Refills:*0
2. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour nicotine 14 mg/24 hr daily
transdermal patch Daily Disp #*30 Patch Refills:*0
3. Glargine 10 Units Lunch
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
6. Clopidogrel 75 mg PO 3X/WEEK (___)
7. Diltiazem Extended-Release 360 mg PO DAILY
8. Ethyl Chloride 100% Spray 1 spray topically 3X/WEEK BEFORE
DIALYSIS
9. Fluticasone Propionate 110mcg 1 PUFF IH BID
10. Furosemide 40 mg PO BID
11. Ipratropium-Albuterol Neb 1 NEB NEB TID
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. LOPERamide 4 mg PO TID:PRN loose stools
14. Meclizine 12.5 mg PO TID
15. Metoprolol Succinate XL 50 mg PO BID
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
17. Prilolid (lidocaine-prilocaine) 2.5-2.5 % topical ___
prior to dialysis
18. sevelamer CARBONATE 1600 mg PO TID W/MEALS
19. Simvastatin 20 mg PO QPM
20. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=====================
Pneumonia
Hyperosmotic hyperglycemic state
Secondary Diagnoses
=====================
End-stage renal disease
Insulin-dependent type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
Please see below for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
=============================
- you were feeling ill with a cough, and you were found to have
a pneumonia
- your ___ measured high blood sugars at home and in the
emergency room your electrolytes appeared abnormal so we were
worried about a medical condition called hyperosmolar
hyperglycemic state
- you had a fall at home and because you take Plavix we were
worried you could have a brain bleed
WHAT HAPPENED IN THE HOSPITAL?
=================================
- you received dialysis on ___ after which your
electrolytes were measured and appeared close to your baseline
- you received IV antibiotics called vancomycin, cefepime, and
azithromycin initially; we then switched you to an antibiotics
by mouth called levofloxacin, which you should continue to take
at home every other day for 2 more doses
- you received IV fluids and insulin to treat your high blood
sugar, we continued to monitor your blood sugars which came down
to the low to mid ___ range
- you had head imaging which did not show any bleeding into the
brain
WHAT SHOULD I DO WHEN I GO HOME?
==================================
- please continue to take your antibiotic levofloxacin, your
next two doses will be on ___ and ___
- please resume your outpatient dialysis on ___
and ___
- please resume your home insulin regimen of glargine (Lantus)
10U per day, and your ___ will continue to check your blood
sugars
- please follow up with your PCP ___ this
hospitalization
We wish you the best!
-Your Care Team at ___
Followup Instructions:
___
|
19796209-DS-5
| 19,796,209 | 22,308,595 |
DS
| 5 |
2120-08-31 00:00:00
|
2120-08-31 16:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Polytrauma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p MVC head on collision, intoxicated, ETOH level 246,
front seat passenger died and backseat passenger on floor at
___, found to have right frontal subgaleal, aortic hematoma
that was stable on repeat imaging, T10-T11 chance fracture,
initially read as osteophyte fracture, and bilateral rib
fractures Rt ___ and lt ___. He is able to pull 1250cc on IS on
admission. He complains of pain at level of rib fractures.
Past Medical History:
PMH: CAD, t2dm
PSH: coronary stent, ___, plavix since
Social History:
___
Family History:
non-contributory
Physical Exam:
AF, VSS
Gen: AOx3, NAD, comfortalbe
CV: RRR s1s2nl
Resp: CTAB, non-labored respiration, R ct to seal with variation
and no air leak
Abd: soft, non-tender, non-distended, normoactive bowel sounds
Extremities: R knee in ___, WWP, no CCE
Pertinent Results:
___ 06:15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
___ 03:38AM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ CT AP: aortic hematoma, t10-11 chance fx, R ___, L ___
rib fx, R adrenal hemorrhage, R hemothorax
___ Non-contrast head CT: R frontal subgaleal hematoma
without other injury
___ R knee: no fracture
Brief Hospital Course:
The patient was admitted to the TSICU initially.
Neuro: The patient was awake and alert, and had no neurological
impairment. His pain was controlled with PO medications.
CV: The patient remained hemodynamically stable during his
stay in the trauma SICU.
Resp: The patient had adequate oxygen saturations during his
stay in the TSICU and received only nasal canula oxygen
initially. His pain was well controlled and his tidal volumes,
as assessed by IS were more than adequate. On HD 2, a chest
tube was placed in the right side for increasing o2 requirement
and concern for R hemothorax. The tube returned 700cc of
serosanguenous fluid with output tailing off after this. There
was no pneumothorax post-placement.
Abd/GI: The patient was appropriately advanced to a regular diet
on hospital day 1.
Renal/GU: The patient's urine output was monitored.
Endo: The patient's blood sugars were monitored and he was on
an insulin sliding scale.
Heme: His plavix was held on admission and SQH was held
starting HD 1 for conern for ongoing bleeding. His aspirin was
continued. There was an initial concern that the patient may
have a small ___ hematoma and vascular surgery was
consulted. They recommended avoidence of systemic
anti-coagulation and a repeat CT scan prior to discharge. The
patient also had a hematocrit drop from 37.8 on admission to
27.7 on HD 1. A right sided chest tube was placed and a
significant amount of blood returned though this tailed off as
the day went on. On HD 3, the patient's Hct dropped to 21.1
and he was transfused 1U PRBC. A repeat CTA was also obtained
which did not show any evidence of bleeding in the chest or
abdomen as well as a stable appearance of the ___
hematoma. On HD 4, he was transfused 2U PRBC for HCT of 22 with
a plan to go to the OR with spine for surgical fixation of his
t10-11 chance fracture.
ID: The patient's temperature curve was monitored as was his
white blood cell count.
MSK: A fracture of an anterior osteophyte between T10 and T11
was noticed on initial imaging. Spine was consulted who
requested standing plain films of the T-spine when the patient
was able. The patient was also noted to have a R knee
hemearthrosis and Ortho Trauma was consulted. They recommended
___ brace soft tissue injury and he may follow up with
them as an outpatient. On HD 2, the CT c-spine was over-read as
a t10-11 chance fracture. The patient was kept bed-rest until
TLSO fitted and on HD 3, spine decided to perform operative
intervention. On HD 4, the patient refused operative
intervention and requested a second opinion.
The patient was transferred to the floor on ___. Per his
request, he was transferred in stable condition to an outside
hospital for a second opinion and ongoing treatment of his
injuries.
Medications on Admission:
metformin, Plavix 75', ASA 325', metoprolol, lisinopril
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 325 mg PO DAILY
3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC TID
6. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN pain
7. Insulin SC
Sliding Scale
Fingerstick QPC2H, HS, QAM
Insulin SC Sliding Scale using HUM Insulin
8. Metoprolol Tartrate 5 mg IV Q4H:PRN SBP>150, HR>100
9. Metoprolol Tartrate 25 mg PO Q6H
10. Multivitamins 1 TAB PO DAILY
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
12. Senna 1 TAB PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Polytrauma:
bilateral rib fx,
aortic hematoma (now resolved),
T10-11 chance fx,
R knee hemarthrosis,
R hemothorax s/p chest tube placement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. Needs TLSO brace to be OOB, R knee ___ brace -
WBAT RLE.
Discharge Instructions:
Please continue to receive care from the trauma and spine
services until you are ready to be discharged.
You should follow up with a spine surgeon and an orthopedic
surgeon after you leave the hospital.
Followup Instructions:
___
|
19796262-DS-16
| 19,796,262 | 22,999,855 |
DS
| 16 |
2121-02-19 00:00:00
|
2121-02-19 12:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
___ bedside debridement of sternal wound and vac placement
by plastic surgery service
History of Present Illness:
Ms. ___ is a ___ year old female with a history of
hypertension,
hyperlipidemia, diabetes mellitus type I (on insulin pump) who
underwent coronary artery bypass grafting x4 on ___ with Dr.
___. She presents to ___ emergency department this evening
with increasing dyspnea on exertion for the past 24 hours.
Cardiac surgery consulted given recent CABG.
Of note, post-operatively patient had an acute bump in her
creatinine(1.8 from baseline 1.5), returned to baseline by day
of
discharge. She developed hyperkalemia requiring Insulin
management with good response. Her post-op course was otherwise
uneventful and she was discharged home on ___. On ___ she
noticed increase dyspnea walking up a flight of stair. Today she
feels short of breath walking short distances around her home.
She denies shortness of breath at rest, increase peripheral
edema, cough, fever, chills.
Upon evaluation in the emergency room, patient is
hemodynamically
stable, on room air with o2sat 100%. She is able to speak in
full
sentences without and shortness of breath. Per ED report,
bedside
echo demonstrated trace pericardial effusion. Chest xray reveals
a moderate left pleural effusion, which appears increased from
prior cxr on ___.
Past Medical History:
Chronic Kidney Disease (baseline Cre 1.3-1.5)
Coronary Artery Disease
Diabetes Mellitus, Type I on insulin pump
Hyperlipidemia
Hypertension
Social History:
___
Family History:
Father - had CABG at age ___, alive, age ___
Mother - died of lung cancer at age ___
Siblings - 1 brother and 2 sisters apparently
Physical ___:
Admission Exam:
Pulse: 85 Resp:18 O2 sat:100% room air
B/P ___
General:
Skin: Dry [x] intact [x]
Sternal: CDI, no erythema or drainage. Tape burns surrounding
incision. Sternum stable.
Lower extremity: Right [x] CDI [x]
HEENT: PERRL [x]
Chest: Diminished LLL.
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [x] trace
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
DP Right:p Left:p
___ Right:p Left:p
.
Discharge Exam:
98.0
PO 120 / 68 63 18 95 Ra
.
General: NAD
Neurological: A/O x3 non-focal
Cardiovascular: RRR
Respiratory: CTA. No resp distress
GI/Abdomen: Bowel sounds present Soft ND NT
Extremities:
Right Upper extremity Warm Edema
Left Upper extremity Warm Edema
Right Lower extremity Warm Edema none
Left Lower extremity Warm Edema none
Pulses:
DP Right: p Left:p
___ Right: p Left:p
Sternal: Inferior pole with VAC plced ___, wound otherwise
c/d/I without erythema or drainage
Sternum stable
Pertinent Results:
___ Pleural fluid
CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: PLEURAL FLUID
DIAGNOSIS:
Pleural fluid, left:
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, histiocytes, and numerous lymphocytes.
SPECIMEN DESCRIPTION:
Received: 1000 ml, bloody fluid.
Prepared: 1 monolayer, ___ FFPE cell block
CLINICAL HISTORY:
Left pleural fluid.
Fellow(s): ___, MD
By his/her signature, the senior physician certifies that he/she
personally conducted a gross and/or microscopic examination of
the described
specimen(s) and rendered or confirmed the diagnosis(es) related
thereto.
Immunohistochemistry test(s), if applicable, were developed and
their performance characteristics were determined by the
Department of Pathology at ___, ___. They have not been
cleared or approved by the ___. Food and Drug Administration.
The FDA has
determined that such clearance or approval is not necessary.
These tests are used for clinical purposes. They should not be
regarded as Investigational or for
research. This laboratory is certified under the Clinical
Laboratory Improvement Amendments of ___ (___-88) as qualified
to perform high complexity
clinical laboratory testing. Unless otherwise specified, all
histochemical and immunohistochemical controls are adequate.
***** Electronically Signed Out *****
Screened By: ___, CT(___)
Diagnosed By: ___, MD, PHD
Signed Out: ___ 16:43
.
CXR ___
Final Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with s/p cabg// eval for effusion
TECHNIQUE: PA and lateral chest radiographs
COMPARISON: Chest radiograph dated ___ated ___
FINDINGS:
Lung volumes are normal. Small partially loculated left pleural
effusion is
mildly decreased from prior radiograph and CT. No evidence of
pneumonia or
pneumothorax. Unchanged moderate cardiomegaly. Mediastinal
silhouette is
unchanged.
IMPRESSION:
Mildly decreased small partially loculated left pleural
effusion.
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 ___
4:33 ___
Imaging Lab
Report History
___ 4:33 ___
by INFORMATION,SYSTEMS
.
Chest CT ___
IMPRESSION:
1. Slight cortical offset of the manubrial osteotomy, which may
be within
normal limits. The body of the sternum is well opposed.
2. A small fluid collection in the anterior mediastinum deep to
the sternum
as well as a small fluid collection anterior to the manubrium
sternum, as
described above. Evaluation for infection is limited without
contrast. No
gas locules to suggest infection.
3. Loculated left pleural effusion. Suspected associated left
lower lobe
atelectasis.
.
.
___ 05:18AM BLOOD WBC-9.4 RBC-3.05* Hgb-8.4* Hct-27.3*
MCV-90 MCH-27.5 MCHC-30.8* RDW-15.0 RDWSD-49.1* Plt ___
___ 08:45AM BLOOD WBC-14.1* RBC-3.37* Hgb-9.5* Hct-29.4*
MCV-87 MCH-28.2 MCHC-32.3 RDW-15.3 RDWSD-48.6* Plt ___
___ 09:35PM BLOOD ___ PTT-28.3 ___
___ 05:18AM BLOOD Glucose-142* UreaN-32* Creat-1.6* Na-143
K-5.4 Cl-105 HCO3-25 AnGap-13
___ 04:52AM BLOOD Glucose-126* UreaN-35* Creat-1.7* Na-136
K-5.2 Cl-102 HCO3-23 AnGap-11
___ 05:19AM BLOOD CK(CPK)-91
___ 05:18AM BLOOD Calcium-10.0 Mg-1.9
Brief Hospital Course:
Mrs. ___ was admitted for further management of her left sided
pleural effusion. The IP service was consulted and performed
thoracentesis on ___ for yield of 900mL. Cytology negative
for malignant cells. Micro negative for AFB or any other growth.
Symptoms improved significantly.
Sternal wound was noted to be superficially dehisced. Plastic
Surgery consulted. They performed bedside superficial
debridement on ___ and placed wound vac. The patient was
initiated on IV antibiotics. Wound cultures sent from
debridement and resulted with mixed bacterial flora. She will
be discharged with 1 week of Bactrim and wound vac. She will
follow-up with Dr. ___ week.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Docusate Sodium 100 mg PO BID
5. Ranitidine 150 mg PO DAILY
6. Calcitriol 0.25 mcg PO DAILY
7. Gabapentin 100 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY
9. Valsartan 80 mg PO DAILY
10. Furosemide 20 mg PO DAILY
11. Metoprolol Tartrate 25 mg PO TID
12. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN
Discharge Medications:
1. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal rate minimum: 12a-7a 0.7; 7a-10a .85; 10a-11p .8, 11p-12a
0.85 units/hr units/hr
Bolus minimum: ICHO ratio 1:10 units units
Target glucose: ___
Fingersticks: QAC and HS
Use of ___ medical equipment: Insulin pump
Reason for use: medically necessary and justified as ___
cannot provide this type of equipment or suitable alternative
not appropriate.
Provider acknowledges patient competent
2. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
5. Metoprolol Tartrate 50 mg PO BID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
6. Valsartan 40 mg PO BID
RX *valsartan 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
7. Aspirin EC 81 mg PO DAILY
8. Atorvastatin 10 mg PO QPM
9. Calcitriol 0.25 mcg PO DAILY
10. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
11. Gabapentin 100 mg PO BID
12. Ranitidine 150 mg PO DAILY
13. TraMADol 50 mg PO Q6H:PRN BREAKTHROUGH PAIN
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pleural Effusion
Superficial sternal wound dehiscence
PMH:
Coronary Artery Disease
Chronic Kidney Disease (baseline Cre 1.3-1.5)
Diabetes Mellitus, Type I on insulin pump
Hyperlipidemia
Hypertension
Discharge Condition:
alert and oriented x3 non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - vac to inferior 3'
Edema: none
Discharge Instructions:
Please shower on vac change days, prior to vac change
-wash incisions gently with mild soap, no baths or swimming,
look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
___
|
19796676-DS-8
| 19,796,676 | 25,694,273 |
DS
| 8 |
2172-10-16 00:00:00
|
2172-10-24 13:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Colonoscopy with biopsies
History of Present Illness:
___ who presents with one week of constipation which she
attributes to eating ___ seed pudding last ___. She
reports
rectal tenesmus but is unable to pass any stool despite using
multiple laxative agents including: Dulcolax, miralax, mild of
magnesia, fleet enemas, soap suds enema. She also reports nausea
and vomiting today. She is passing flatus. Her last colonoscopy
was done in ___ but the report is not available online.
Past Medical History:
PMH: Fibroadenoma, herpes labialis, allergic rhinitis
PSH: Lap CCY, knee surgery
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
T 97.4 HR 94 BP 145/61 RR 18 SatO2 95% RA
NAD
Alert and oriented
RRR
CTA bil
Abdomen soft, non-tender, non-distended
Extremities no edema
Rectal exam: normal tone, no impacted stool
Discharge Physical Exam:
VS: 98.2, 116/55, 69, 18, 93 Ra
Gen: A&O x3, ambulating in room, NAD
CV: HRR
Pulm: LS ctab
Abd: soft, NT/ND
Ext: WWP no edema
Pertinent Results:
___ 05:34AM BLOOD WBC-6.0 RBC-3.60* Hgb-11.2 Hct-34.2
MCV-95 MCH-31.1 MCHC-32.7 RDW-13.0 RDWSD-45.1 Plt ___
___ 08:23PM BLOOD WBC-14.0* RBC-4.27 Hgb-13.3 Hct-39.7
MCV-93 MCH-31.1 MCHC-33.5 RDW-13.0 RDWSD-44.1 Plt ___
___ 05:34AM BLOOD Glucose-93 UreaN-10 Creat-0.9 Na-144
K-4.5 Cl-110* HCO3-25 AnGap-9*
___ 08:23PM BLOOD Glucose-127* UreaN-14 Creat-0.9 Na-142
K-3.9 Cl-99 HCO3-26 AnGap-17
___ 05:34AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.0
___ 08:23PM BLOOD Albumin-4.5 Calcium-9.0 Phos-2.5* Mg-3.0*
CT A/P
1. Sigmoid and distal descending colon wall thickening
consistent
with colitis. Degree of large bowel distension proximally is
consistent with at least partial large bowel obstruction. Given
focal irregularity of the distal sigmoid colon, consider
colonoscopy after treatment.
2. Abnormal endometrial thickening measuring approximately 7 mm.
Recommend nonemergent pelvic ultrasound for further evaluation.
3. Partially imaged T7 compression deformity. Recommend
correlation with symptoms and physical exam.
___: Colonoscopy:
Severe diverticulosis. Patchy areas of erythema, erosion, edema,
decreased vascularity in descending colon
PATHOLOGIC DIAGNOSIS:
Distal descending colon, biopsy:
- Colonic mucosa with focal acute inflammation, nonspecific
finding.
Brief Hospital Course:
___ presenting with one week of constipation and abdominal pain.
CT scan showed an area of thickening and stranding around the
sigmoid consistent with sigmoid colitis, and what appeared to be
a partial large bowel obstruction. ___ noted to be 14. She was
otherwise hemodynamically stable and in no acute distress. She
was admitted for bowel rest, IV fluids, IV antibiotics.
Gastroenterology was consulted. The patient was prepped and went
for sigmoidoscopy / colonoscopy with biopsies taken. There was
no evidence of an obstruction. There was evidence of colitis.
After the colonoscopy, the patient was doing well.
Diet was progressively advanced as tolerated to a regular diet
with good tolerability and she continued to have good bowel
function. The patient voided without problem. During this
hospitalization, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. She was given a prescription to complete a
course of antibiotics and had follow-up scheduled with GI.
Medications on Admission:
DICLOFENAC SODIUM [VOLTAREN] - Voltaren 1 % topical gel. APPLY
4G
OF GEL TO AFFECTED KNEE 4 TIMES A DAY FOR MAX DOSE OF 16G TOANY
SINGLE JOINT
FAMCICLOVIR - famciclovir 500 mg tablet. 3 tablets by mouth at
onset of cold sore
PENCICLOVIR [DENAVIR] - Denavir 1 % topical cream. APPLY 4 TIMES
A DAY AS NEEDED AS DIRECTED
VALACYCLOVIR - valacyclovir 1 gram tablet. 2 tablet(s) by mouth
bid x 2 days as needed for earliest sign of cold sore
ACETAMINOPHEN - acetaminophen 500 mg tablet. 2 tablet(s) by
mouth
three times a day
CALCIUM CARBONATE-VITAMIN D3 [OS-CAL 500 + D3] - Dosage
uncertain
FEXOFENADINE - fexofenadine 180 mg tablet. tablet(s) by mouth -
LACTOBACILLUS COMBINATION NO.4 [PROBIOTIC] - Dosage uncertain -
MAGNESIUM CITRATE - magnesium citrate oral solution. 296 ml by
mouth use once - (___)
MULTIVITAMIN - Dosage uncertain - (Prescribed by Other
Provider)
OMEGA-3 FATTY ACIDS - Dosage uncertain - (___)
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*10 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Colitis
Partial large 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 ___ with abdominal pain and were found on
CT scan to have sigmoid and distal descending colon wall
thickening consistent with colitis, as well as a partial large
bowel obstruction. You were treated non-operatively with
antibiotics, bowel rest and IV fluids. The Gastroenterology
service was consulted, and recommended a colonoscopy. After
bowel-prepping, you were taken on ___ for a colonoscopy. They
saw in the distal descending colon there were patches of
erosive, erythematous tissue, which was biopsied. However, due
to poor prep, they could not complete the colonoscopy. They
recommend a low residue / low fiber diet for 5 days and an
extensive 2-day prep for a repeat colonoscopy with magnesium
citrate.
You are now tolerating a regular diet and continuing to have
bowel function. You are ready to be discharged home to continue
your recovery.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please 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
You
Followup Instructions:
___
|
19796941-DS-3
| 19,796,941 | 29,318,537 |
DS
| 3 |
2127-03-15 00:00:00
|
2127-03-15 08:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
HPI:
___ w/h/o of depression on escitalopram who is s/p recent R ACL
repair on ___ in presents with pyelonephritis.
.
She initially presented to ED on ___ with bilateral lower
lumbar pain and left flank pain. She also noted some trouble
with constipation and abdominal pain in the setting of taking
oxycodone for her knee pain. She denied any dysuria or
hematuria. She had a fever of 101 and presented to the ED where
UA was c/w UTI/Pyelonephritis with +nitrates, +WBC, and
+bacteria. She had no significant leukocytosis.She was also
reviewed by ortho who noted R knee nontender with reassuring
AROM and PROM of R knee. No evidence of infection on exam. She
was d/c'ed from the ED on cipro yesterday. No Ucx were sent.
This morning she represented back pain, vomiting and
tachycardia. Triage vitals were 100.2 138 115 18 100% . Labs
were notable for neutrophil predominant leukocytosis to 25K,
lactate 2.7. She was managed in the ED with IV NS 2L, PO
ondasternon, IV ketorolac, PO acetaminophen and was given IV
ampicillin 1g.
.
Of ___ she has h/o a previous UTI in ___ with Ucx + for
pansensitive e.coli and enterococcal species which was treated
with macrobid.
.
On arrival to the ward she reports feeling tired and sweaty.
Pain in right flank is mild. No pain in knee. Was having nausea
for the past 24h. Was able to take PO until last night when had
several episodes of vomiting. Has ongoing subjective fevers and
chills. She is on ___ and on day 11 of current pack. She denies
any pelvic pain. Her constipation resolved yesterday with two
bowl movements after started Colace. Her post surgical right
knee pain is well controlled denies any worsening in pain or
swelling of her knee. She has no previous history of GU problems
except single episode of UTI as above.
ROS:
[x] 12 Point ROS reviewed. All other symptoms negative except as
noted above.
Past Medical History:
- Depression
- ACL rupture, s/p repair ___
Social History:
___
Family History:
NA
Physical Exam:
Admission EXAM
98.9 104/65 95 15 100%
Patient is tearful expressing frustration at being ill. "I want
to remember what it feels like to feel normal". She however does
not appear otherwise uncomfortable or in severe pain. She is in
NAD, no pallor, lungs are clear, s1,s2, rrr, abdomen soft NTND,
BS+X4Q, she has right CVA tenderness, no vertebral tenderness.
right knee is in brace with mild swelling and effusion but no
warmth and no significant tenderness with reasonable post
surgical ROM. Anterior surgical wounds look c/d/I. No edema and
no signs of DVT. Her distal ___ are WWP.
DISCHARGE EXAM:
VS: 99 98.4 ___ 18 100% on RA
Gen - No acute distress
Eyes - anicteric, EOMI, PERRL
ENT - moist mucous membranes, no nasal discharge, oropharynx
clear
Cardiovascular - RR, s1s2 nl, no m/r/g, no edema
Respiratory - breathing comfortably, no accessory muscle
use,CTAB with no wheezing, rhonchi or crackles
GI - soft, nontender, not distended, bowel sounds present
Back - no CVA tenderness
Skin - warm, dry, with no rash
MSK - right knee immobilizer in place; surgical wound healing
well without significant drainage or erythema; otherwise normal
strength throughout
Neuro - oriented to person, place, time, and reason for
hospitalization; moving all 4 extremities; speech is fluent; no
facial droop
Psych - alert, mildly anxious
Pertinent Results:
Admission Labs:
___ 05:52AM BLOOD WBC-25.6*# RBC-3.46* Hgb-10.9* Hct-32.6*
MCV-94 MCH-31.5 MCHC-33.4 RDW-12.1 RDWSD-42.2 Plt ___
___ 05:52AM BLOOD Neuts-87.4* Lymphs-4.8* Monos-5.6
Eos-0.0* Baso-0.2 Im ___ AbsNeut-22.35*# AbsLymp-1.23
AbsMono-1.42* AbsEos-0.01* AbsBaso-0.05
___ 05:52AM BLOOD Glucose-147* UreaN-5* Creat-0.7 Na-134
K-3.7 Cl-96 HCO3-23 AnGap-19
___ 05:52AM BLOOD ALT-12 AST-15 AlkPhos-76 TotBili-0.3
___ 05:52AM BLOOD Albumin-4.0 Calcium-9.3 Phos-3.4 Mg-2.0
___ 05:56AM BLOOD Lactate-2.7*
EKG:
EKG from ED sinus tach 133, normal axis, QTc 0.44, diffuse non
specific ST-T changes with NTW L3, V3, V4 and flat/biphasic T
waves in AVF, V5, V6, which are not seen on EKG from day prior
___.
Notable Labs During Hospitalization:
___ Hapto-236* Ferritn-172*
___ BLOOD Ret Aut-3.0* Abs Ret-0.09
Discharge Labs:
___ WBC-11.1* RBC-2.98* Hgb-9.2* Hct-27.8* MCV-93 MCH-30.9
MCHC-33.1 RDW-12.3 RDWSD-42.2 Plt ___
___ Glucose-90 UreaN-4* Creat-0.6 Na-138 K-3.7 Cl-105
HCO3-23 AnGap-14
___ Calcium-8.5 Phos-2.9 Mg-2.1
Microbio:
___ URINE CULTURE (Final ___: <10,000 organisms/ml.
___ BLOOD CULTURE: NGTD, final result pending at time of
discharge.
Notable Imaging:
___ Renal u/s
*FINDINGS: The right kidney measures 12.8 cm. The left kidney
measures 12.1 cm. There is no hydronephrosis, stones, or masses
bilaterally. Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally. The bladder is only
minimally distended and can not be fully assessed on the current
study.
*IMPRESSION: Unremarkable renal ultrasound. No stone or
hydronephrosis.
Brief Hospital Course:
___ y/o F w/ recent right ACL surgery and chronic depression
presented with nausea, vomiting, left flank pain, pyuria and
sepsis. She was treated with IV abx (unasyn) based on prior UCx
results (from ___ in which pan-sensitive Enterococcus
and pan-sensitive E. coli both grew. She was treated with PRN
meds for pain and nausea. She responded well to unasyn, with
resolution of fever, downtrending leukocytosis, and resolution
of her nausea/vomiting. UCx from admission did not grow an
organism. She was transitioned to oral Augmentin at the time of
discharge, with plans to complete a total 14 day course of
empiric abx for pyelonephritis (day 1 of antibiotics on ___.
She was also discharged with 6 tabs of Ativan 1 mg PO q8h PRN
nausea for lingering, but overall much improved nausea.
Of note, she also had a significant normocytic anemia on
admission, with nadir at 9, it was stable at the time of
discharge. RDW was wnl. Reticulocyte count was appropriately
elevated. Hemolysis labs were negative. Ferritin was elevated at
157 suggesting this was not iron deficiency. She manifested no
signs or symptoms of overt blood loss. We would expect this to
resolve after her acute illness resolves, but would recommend
repeat CBC in ___ days to follow-up her anemia.
Also of note, EKG on admission had non specific ST-T wave
changes: she had no cardiovascular symptoms and no coronary risk
factors. These were thought to be likely due to tachycardia and
some electrolyte and acid-base abnormalities in the setting of
dehydration/sepsis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 15 mg PO DAILY
2. Minastrin ___ Fe (norethindrone-e.estradiol-iron) 1 mg-20
mcg(24) /75 mg (4) oral qday
3. OxycoDONE (Immediate Release) 5 mg PO Q4-6H:PRN pain
4. Docusate Sodium 100 mg PO BID
5. Senna 8.6 mg PO BID:PRN constipation
6. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Escitalopram Oxalate 15 mg PO DAILY
4. Minastrin ___ Fe (norethindrone-e.estradiol-iron) 1 mg-20
mcg(24) /75 mg (4) oral qday
5. OxycoDONE (Immediate Release) 5 mg PO Q4-6H:PRN pain
6. Senna 8.6 mg PO BID:PRN constipation
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 10 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
every twelve (12) hours Disp #*20 Tablet Refills:*0
8. Lorazepam 1 mg PO Q8H:PRN nausea/vomiting Duration: 2 Days
RX *lorazepam [Ativan] 1 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
pyelonephritis with sepsis
normocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with one crutch, right knee
immobilizer in place
General: well-appearing
Discharge Instructions:
You were admitted for kidney infection and treated with
antibiotics and fluid infusion. You will need to take oral
antibiotics for the next ___ days. You were also found to have a
mild anemia. Please follow up with your primary care physician
___ ___ days to ensure that you are responding well to
antibiotics and to have labs drawn to evaluate for improvement
in your anemia.
Followup Instructions:
___
|
19797022-DS-11
| 19,797,022 | 21,902,336 |
DS
| 11 |
2147-04-13 00:00:00
|
2147-04-15 14:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
HA
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
Mr. ___ is a ___ year old man with a past medical history of
hypertension who presents today on direction from his outpatient
neurologist for evaluation of headache.
He states that a week ago ___ (8 days ago), he had sudden
onset of headache at work for which he took Tylenol and went
home. The next day, he still had a headache and took advil. By
___, still had headache and was supposed to go to ___ so he
went to urgent care in ___. There he was diagnosed with
tension headache, told to take 4 advils instead of 2. He took 4,
and within an hour felt a lot better. So he drove to ___, spent
the day there, went out to dinner, came home and still felt fine
until an hour later when the headache came back. Took some advil
and layed down, the headache didn't go away so stayed in instead
of going out. As he was getting dressed that night, he got hot,
dizzy, leaned against the wall, asked for some water. Was
sweating profusely, then shortly afterwards, eyes rolled back in
his head and he passed out for ___ minutes. He was disoriented
when he came to, and still dizzy. Tingling in hands and feet and
started getting numb likely ___ hyperventilation. EMS arrived,
took to hospital, got NCHCT with ?hemorrhage in cerebellum. He
was then transferred to ___ and got MRI,
EEG,
TTE, EKG for workup of stroke/syncope, which were all
unremarkable (MRI as below, 24 EEG normal, TTE normal, EKG not
available for review). During that time, headache never really
went away. They gave him toradol, and opiates but never got rid
of the headache.
He says that the headache itself is throbbing, varies in
intensity, and improves somewhat but not all the way with meds.
Every now and then gets a very sharp throb of pain. He has had a
low grade fever off and on, but no nausea/vomiting. T 99-101 at
home. The pain is mainly in the front. At night when he is
sleeping, the pain goes to dependent portion of head. He says
the
headache is not any worse at night vs during the day. He denies
any vision changes. He says the headache is worse with coughing,
sneezing, bearing down. +photophobia.
He has never had a headache similar to this before. Has had mild
headaches but not like this. No bug bites. No rashes. Never had
a
blood clot, no swelling in legs.
Blood pressure was 168 at onset of symptoms, currently 140s/90s.
He was seen in neurology clinic today for follow up and sent to
the ED for CTV given high pressure features, and possibly LP to
rule out viral meningitis, or SAH given sudden-onset of
throbbing
headache in a patient with no history of migraines.
On neuro ROS, he denies loss of vision, blurred vision,
diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness. No bowel or
bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, +"low grade fevers." No night
sweats or recent weight loss or gain. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
HTN
Social History:
___
Family History:
- No autoimmune disease
- No history of blood clots
- Mother with migraines
Physical Exam:
Vitals:
T= ___, BP= 142/93, HR= 84, RR= 17, SaO2= 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM. Fundoscopic exam unremarkable but unable to
fully visualize disc margins.
Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. 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. Attentive, able to name ___ backward without
difficulty. Pt. was able to register 3 objects and recall ___
at
5 minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch in all distributions
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick, proprioception
throughout. No extinction to DSS.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Discharge exam unchanged
Pertinent Results:
___ 04:20PM CEREBROSPINAL FLUID (CSF) PROTEIN-67*
GLUCOSE-46
___ 04:20PM CEREBROSPINAL FLUID (CSF) WBC-139 RBC-36*
POLYS-8 ___ MONOS-5 OTHER-3
___ 04:20PM CEREBROSPINAL FLUID (CSF) WBC-168 RBC-305*
POLYS-3 ___ MACROPHAG-1 OTHER-3
___ 10:00AM GLUCOSE-88 UREA N-18 CREAT-1.0 SODIUM-139
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-27 ANION GAP-16
___ 10:00AM estGFR-Using this
___ 10:00AM CALCIUM-9.7 PHOSPHATE-3.9 MAGNESIUM-2.1
___ 10:00AM WBC-4.0 RBC-5.47 HGB-15.8 HCT-45.0 MCV-82
MCH-28.9 MCHC-35.1 RDW-11.9 RDWSD-35.2
___ 10:00AM NEUTS-53.7 ___ MONOS-8.5 EOS-1.2
BASOS-0.5 IM ___ AbsNeut-2.16 AbsLymp-1.43 AbsMono-0.34
AbsEos-0.05 AbsBaso-0.02
___ 10:00AM PLT COUNT-252
___ 10:00AM ___ PTT-32.4 ___
There is a 0.3 cm focus of hypo enhancement in the anterior
pituitary gland,
series 9, image 125 dens 116 to.
There is no evidence of hemorrhage, edema, mass effect, midline
shift or
infarction. The ventricles and sulci are normal in caliber and
configuration. There are few stable scattered subcortical and
periventricular
white matter signal abnormalities. There is no abnormal
enhancement after
contrast administration. A left cerebellar developmental venous
anomaly is
seen. The major vascular flow voids are preserved.
A large retention cyst is seen in the left maxillary sinus. The
orbits and
mastoid air cells are normal. There is a nonenhancing, FLAIR
hyperintense 0.8
cm lesion in the posterior nasopharynx, likely representing a
retention cyst
or Tornwaldt cyst.
IMPRESSION:
1. A 0.3 cm focus of hypo enhancement in the anterior pituitary
gland which may represent a small microadenoma versus a coursing
vessel. Recommend correlation with dedicated MRI of the
pituitary gland for further evaluation.
2. No evidence of abnormal enhancement.
3. Few scattered white matter signal abnormalities which is a
nonspecific
finding and may be secondary to migraines, infection,
inflammation,
demyelination or vasculitis.
RECOMMENDATION(S): A 0.3 cm focus of hypo enhancement in the
anterior
pituitary gland which may represent a small microadenoma versus
a coursing
vessel. Recommend correlation with dedicated MRI of the
pituitary gland for further evaluation.
Brief Hospital Course:
Mr. ___ was admitted to the neurology service for HA presumed
secondary to viral meningitis. LP was performed in the ED
showing lymphocytic pleocytosis and 36 RBCs, tap traumatic.
His headache improved over the course of admission. Neurologic
exam was normal except slight "tightness" in back but no pain
with touching chin to chest, otherwise neck with good ROM.
MRI brain with and without contrast unremarkable. We spoke with
ID, who recommended HIV from serum and supportive treatment. He
was discharged home, and advised that we would call him if any
cultures from CSF returned positive.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Headache
RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours
Disp #*10 Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q6H:PRN headache, fever
3. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Viral meningitis
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 ___ with an ongoing headache. You were
found to have viral meningitis. We sent your spinal fluid for
viral cultures. We spoke with the infectious disease team who
recommended repeating an HIV test. Viral meningitis is treated
with supportive measures, you do not require any antibiotics or
antivirals at this time. Your symptoms should gradually get
better on their own. We are sending you home with naproxen and
oxycodone to take for pain control in the meantime. You should
follow up with your primary care doctor and also with neurology
here.
You should make sure to keep well hydrated at home.
We will call you if any of the viral studies return positive.
Your MRI brain showed an incidental spot in the pituitary gland
which may represent a "microadenoma." This is likely not
significant, and will need to be followed up in 6 months to a
year.
The loss of consciousness event that you had one week ago was
most likely something called "syncope" which happened in the
setting of illness. This was fully worked up at the outside
hospital and does not need any further evaluation at this time.
It was a pleasure taking care of you during this hospital stay.
Followup Instructions:
___
|
19797153-DS-10
| 19,797,153 | 22,240,803 |
DS
| 10 |
2159-05-29 00:00:00
|
2159-05-30 20:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Calcium Channel Blocking
Agents-Dihydropyridines
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o asthma, myasthenia ___, a-fib, ___, and
constrictive pericarditis, who p/w dyspnea and productive cough
x2 weeks and left lateral CP x1 week.
Pt complains of dyspnea and cough that began about two weeks
ago. Notably, patient was hospitalized at ___ ___ for
dyspnea, cough and chest pain. At that time, dyspnea and cough
were thought to be due to viral bronchitis or PNA. He reports
these symptoms being improved upon discharge with a return to
baseline and new SOB/cough for the past two weeks.
Pt's dyspnea is exertional in nature. Reports he used to be able
to walk a block without getting SOB and now cannot. Dyspnea got
progressively worse over last 2 weeks, particularly bad ___ AM
so he decided to come into the ED. Reports still being able to
speak in full sentences. He denies that the dyspnea is worse at
any particular time of day. He has tried using his albuterol
inhaler for relief and today took it more often than his q4hrs
that is prescribed. He reports some improvement with the
albuterol, but not back to his baseline. He reports that prior
to this illness, his inhaler would bring total relief.
+smoking history, quit many years ago
He has also had cough x2 weeks that is productive of yellow
sputum. He denies hemoptysis. Denies the cough being worse at a
particular time of day.
Denies fevers/chills. +Sick contacts at ___
(reports multiple people w/ PNA).
Has associated left sided CP x1 week that he denies is pain or
pressure. Describes it as a funny feeling. Denies ever having
pain like this before. Non-exertional, non-pleuritic,
non-positional. Not worse with palpation or movements. Denies
palpitations.
+2-pillow orthopnea (no change)
+PND - reports that every night this week he has woken up SOB
and needed to go sleep in recliner. Reports that this is similar
to baseline as well.
+Scale is broken, but reports he may have gained weight.
Denies worsening edema.
The morning of admission, patient did not take his Lasix and
pyridostigmine. Denies skipping doses in the past week but
unclear history.
No abd pain, n/v/d/c. No bloody stools. Denies abdominal
distention.
+Occasional dysuria but none recently. Denies hematuria.
In the ED, initial vitals: T 99.0, BP 155/72, HR 84, RR 20, O2
96%RA
- Exam notable for: NIF -20 w/ VC 1.6L
- Labs notable for: Trop 0.04, proBNP 509, WBC 10.4 w/ 84% PMNs
- Imaging notable for: CXR Pulmonary vascular congestion with
mild interstitial pulmonary edema, bibasilar atelectasis.
- Bedside echo done w/ no pericardial effusion.
- Pt given: 1000mg Vancomycin, 750mg levofloxacin, duoneb
- Vitals prior to transfer: T 98.6 , BP 152/74, HR 81, RR 18, O2
96RA
On arrival to the floor, pt reports significant improvement of
his dyspnea since this AM. Continued cough and continued chest
discomfort.
ROS:
No fevers, chills, night sweats, or weight changes.
No changes in vision or hearing.
No nausea or vomiting. No diarrhea or constipation. No
hematochezia, no melena.
No hematuria.
No numbness or weakness.
Past Medical History:
Asthma
Atrial Fibrillation
CKD
Hyperparathyroidism
DM
HLD
ACh R Ab +ve Myasthenia ___
Colonic Polyps
Duodenal angiomas (s/p thermal therapy)
GI bleeding - capsule endoscopy ___ (for guaiac +ve stools)
showed mild, focal gastritis and no active bleeding sites were
found.
Gastritis
HTN
Constrictive pericarditis
Congestive heart failure diastolic
H/o Exudative pleural effusion
P Surgical Hx:
s/p R total hip replacement
S/p appendectomy
Social History:
___
Family History:
Brother with DM, Mother d. ___ of CVA, Father d. ___ CAD
No family history of myasthenia ___
Physical Exam:
Admission Physical Exam:
Vitals: T 98.0, BP 136/80, HR 90, RR 20, O2 98%RA, ___ 180
General: Alert, oriented, visibly tachypneic w/ shallow
breathing, mildly diaphoretic
HEENT: Sclerae anicteric, MMM, oropharynx clear, Significant L
eyelid ptosis (totally closed), EOM limited (either patient not
complying w/ exam or movements limited to 1-2mm in each
direction)
Neck: supple, JVP 7-9cm
Lungs: Rhonchi and mild wheezes at bases bilaterally equal on
both sides with vesicular breath sounds up to mid-lung fields.
Can count up to 10 in one breath.
CV: Irregularly irregular rhythm, not tachycardic. Normal S1/S2.
No m/r/g appreciated
Abdomen: soft, NT/ND bowel sounds present, no rebound tenderness
or guarding. Difficult to assess for hepatomegaly ___ body
habitus.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis. 1+
pitting edema to mid-shins bilaterally. Diminished sensation on
plantar surface of feet bilaterally.
Neuro: A&Ox3, can say days of week backwards
CN: EOM limited as above. V, VII-XII intact bilaterally
Motor: ___ strength in all muscle groups of upper and lower
extremities bilaterally. No pronator drift. Normal muscle
bulk/tone.
Coordination: Finger-nose-finger intact bilaterally. Gait
deferred.
Discharge Physical Exam:
Vitals: T 97.7, BP 116/61, HR 61, RR 18, O2 97RA
pMN 200/500; p24 1285/345
NIF ___, VC 1.64
Wt 84.1 (___)
Exam:
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - Lateral EOM intact but limited up/down movements,
improved ptosis of L eyelid (some sclera visible at rest) able
to open eye when asked, sclerae anicteric, MMM, OP clear
HEART - Irregularly irregular rhythm, not tachycardic, nl S1-S2,
no murmurs/gallops
NECK - JVP 6-7cm
LUNGS - Rhonchi on inspiration/expiration bilaterally on first
few breaths of exam, entirely resolved in all lung fields on
further inspiration. Reproduced on second pulmonary exam 2
minutes later.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c, no edema, 2+ peripheral pulses
NEURO - Awake, A&Ox3
Pertinent Results:
Admission Labs:
___ 11:50AM BLOOD WBC-10.4* RBC-3.95* Hgb-11.3* Hct-35.6*
MCV-90 MCH-28.6 MCHC-31.7* RDW-14.2 RDWSD-46.9* Plt ___
___ 11:50AM BLOOD Neuts-84.0* Lymphs-7.6* Monos-6.7
Eos-0.9* Baso-0.3 Im ___ AbsNeut-8.74* AbsLymp-0.79*
AbsMono-0.70 AbsEos-0.09 AbsBaso-0.03
___ 11:50AM BLOOD Glucose-128* UreaN-18 Creat-1.2 Na-138
K-4.3 Cl-97 HCO3-28 AnGap-17
___ 06:40AM BLOOD ALT-48* AST-37 LD(LDH)-262* AlkPhos-93
TotBili-1.6* DirBili-0.4* IndBili-1.2
___ 11:50AM BLOOD proBNP-509
___ 11:50AM BLOOD cTropnT-0.04*
___ 09:25PM BLOOD CK-MB-6 cTropnT-0.04*
___ 06:40AM BLOOD Albumin-4.8 Calcium-9.9 Phos-3.7 Mg-2.0
Discharge Labs:
___ 06:30AM BLOOD WBC-7.4 RBC-3.72* Hgb-10.7* Hct-33.1*
MCV-89 MCH-28.8 MCHC-32.3 RDW-14.4 RDWSD-46.4* Plt ___
___ 06:30AM BLOOD Glucose-123* UreaN-28* Creat-1.4* Na-137
K-3.9 Cl-97 HCO3-29 AnGap-15
___ 06:49AM BLOOD Calcium-9.7 Phos-4.5 Mg-2.0
Chest xray ___
FINDINGS:
PA and lateral views of the chest provided. Lung volumes are
low limiting
evaluation. There is mild elevation of the right hemidiaphragm
unchanged. No large pleural effusion is seen. Hilar congestion
is noted with mild interstitial pulmonary edema. The heart size
is stable. Mediastinal contour is unchanged. Bony structures
are intact.
IMPRESSION:
Pulmonary vascular congestion with mild interstitial pulmonary
edema,
bibasilar atelectasis.
Chest xray ___
IMPRESSION:
Heart size is top-normal. Mediastinum is unremarkable. Small
bilateral
pleural effusions are present. There is no evidence of
pneumothorax.
Surface ECHO ___:
Conclusions
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild global left ventricular hypokinesis
(LVEF = 50%). There is considerable beat-to-beat variability of
the left ventricular ejection fraction due to an irregular
rhythm/premature beats. The right ventricular cavity is mildly
dilated with mild global free wall hypokinesis. There is
abnormal septal motion/position. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Mild global biventricular systolic dysfunction. Mild
mitral regurgitation. Mild pulmonary hypertension.
Nuclear stress test ___:
INTERPRETATION: This ___ year old IDDM man with a history of
S-CHF,
AF, CKD and shortness of breath was referred to the lab for
evaluation.
The patient was infused with 0.142 mg/kg/min of dipyridamole
over 4
minutes. No arm, neck, back or chest discomfort was reported by
the
patient throughout the study. There were no significant ST
segment
changes during the infusion or recovery. The rhythm was AF with
frequent isolated vpbs and multiple ventricular couplets.
Appropriate
hemodynamic response to the infusion and recovery. The
dipyridamole was
reversed with 125 mg of aminophylline IV.
IMPRESSION: No anginal type symptoms or ST segment changes.
Nuclear
report sent separately.
IMPRESSION:
1. Normal myocardial perfusion.
2. Normal left ventricular cavity size and systolic function.
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
=====================================================
___ y/o male w/ h/o asthma, myasthenia ___, a-fib, dCHF, and
constrictive pericarditis, who p/w dyspnea and productive cough
x2 weeks.
ACTIVE ISSUES:
=====================================================
#Shortness of breath: The patient's dyspnea was thought to be
due to pulmonary edema from CHF w/ exacerbating viral illness. A
rapid flu test was negative and two chest x-rays were done which
did not identify any focal consolidation. Thus, there was low
concern for pneumonia and the vancomycin/levofloxacin given in
the Emergency Department were discontinued. The patient was
diuresed with Lasix with improvement in his shortness of breath
but continuation of his cough. The Lasix was downtitrated from
100mg home dose (to which he diuresed ~3.5L) to 20mg, and then
switched to 5mg torsemide on ___ per the recommendation of
cardiology. He also used nebulizers during admission with
symptomatic improvement. He was also assessed for a myasthenic
component to his shortness of breath. In the ED, NIF -20 w/ VC
1.6L. This improved daily to NIF -60 w/ VC 1.68L on ___. His
shortness of breath remained improved/resolved from the second
day of admission on through discharge.
#Acute decompensation of diastolic heart failure: He had a TTE
done on ___ to assess his cardiac function which showed mild
global biventricular systolic dysfunction w/ an EF of 50%.
Cardiology saw the patient and recommended pharmacologic stress
testing that did not show any areas of reversible ischemia. His
outpatient cardiologist had been called during admission and
reported that the patient had multiple missed appointments and
was likely not compliant with his furosemide regimen. The
outpatient cardiologist recommended an atrius cardiology consult
for assistance with a management plan. It was with this
consultant's recommendations that the patient was switched to
torsemide 5mg as this was thought to be a more amenable
solution. He was thought to be euvolemic on discharge with a
weight of 84.2kg.
#Acute on Chronic Kidney Injury: The patient's admission Cr 1.2
was at baseline on ___. This increased to 1.5 following
diuresis with his home dose of Lasix 100mg. Lasix was initially
held then restarted at 20mg due to clinical fluid overload, and
ultimately switched to torsemide 5mg on ___ per the
recommendation of cardiology. The patient was discharged with a
Cr of 1.5 on torsemide 5mg with a ___ appointment with his
PCP ___ ___ to assess for resolution of the elevated
creatinine. His home losartan was held on discharge, to be
restarted by PCP.
#Myasthenia ___: On admission, the patient had significant
ptosis of the L eyelid as well as a NIF -20 w/ VC 1.6L done in
the Emergency Department. He reported that he had not taken his
pyridostigmine the morning of admission and that he was supposed
to have gone up on the dose of the medication but hadn't as it
was giving him diarrhea. During admission, the patient's ptosis
significantly improved as was his NIF to -60. He did have a few
loose stools during admission but these were inconsistent and
many were formed. This may suggest that the patient does not
take his pyridostigmine regularly at baseline.
#Atrial fibrillation: CHADSVASC score of 5, pt not on
anti-coagulation due to h/o GI bleed. On diltiazem for rate
control. Continued home Diltiazem Extended-Release 240 mg PO
BID.
#DM: last A1C 7.2 on ___, patient not on any Rx at home.
Fingersticks were between 100-180 during admission.
TRANSITIONAL ISSUES:
=====================================================
-Discharged on torsemide 5mg daily(prior to admission was on
furosemide 100mg). Home ___ services were set up to monitor
vital signs and weights. PCP or ___ called if weight
increases by >3 lbs in 3 days. ___ need to titrate torsemide
dose.
-Creatinine on discharge was 1.5. Needs repeat creatinine at PCP
___ (scheduled for ___ to ensure improvement/stability.
-Home losartan (50mg daily) was held on discharge given mildly
elevated creatinine. This should be discussed with PCP at
___ appointment (scheduled for ___.
- Weight on day of discharge was 84.2kg.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Calcitriol 0.25 mcg PO DAILY
3. Furosemide 100 mg PO QAM
4. Losartan Potassium 50 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Pyridostigmine Bromide 60 mg PO BID
7. Vitamin D 5000 UNIT PO DAILY
8. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
9. Diltiazem Extended-Release 240 mg PO BID
10. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Calcitriol 0.25 mcg PO DAILY
3. Diltiazem Extended-Release 240 mg PO BID
4. Omeprazole 20 mg PO BID
5. Potassium Chloride 20 mEq PO DAILY
Hold for K >
6. Pyridostigmine Bromide 60 mg PO BID
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
8. Vitamin D 5000 UNIT PO DAILY
9. Torsemide 5 mg PO DAILY
RX *torsemide 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Shortness of breath
Acute exacerbation of heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized at ___
for shortness of breath. Your shortness of breath was thought to
be due to a viral illness in combination with your heart
failure. You had two chest x-rays done that did not identify a
pneumonia. You were treated with a water pill to remove excess
fluid in your lungs. We switched your water pill (Lasix) to a
related medicine called torsemide. We think this medicine will
be easier for you to take at home. Please stop taking Lasix and
use the torsemide instead.
We also evaluated the functioning of your heart during this
admission, including an echocardiogram (ultrasound of your
heart). You had a stress test on ___ that was normal. Please
follow up with your outpatient cardiologist.
Your breathing improved while you were in the hospital. Please
follow up with your primary care doctor.
It was a pleasure taking care of you.
-___ Team
Followup Instructions:
___
|
19797153-DS-11
| 19,797,153 | 26,170,024 |
DS
| 11 |
2160-03-13 00:00:00
|
2160-03-12 15:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / Calcium Channel Blocking
Agents-Dihydropyridines
Attending: ___.
Chief Complaint:
Left femoral neck fracture
Major Surgical or Invasive Procedure:
___: CRPP L femoral neck fracture
History of Present Illness:
___ male ___ medical comorbidities presents with
left hip pain after a fall. Patient was giving himself a Fleet
enema on the bathroom floor, attempted to stand up, fell
sideways, landing on his left hip. He denies any head strike or
loss of consciousness. Since that time, he has had left groin
pain worse with movement. Denies any paresthesias
Past Medical History:
Asthma
Atrial Fibrillation
CKD
Hyperparathyroidism
DM
HLD
ACh R Ab +ve Myasthenia ___
Colonic Polyps
Duodenal angiomas (s/p thermal therapy)
GI bleeding - capsule endoscopy ___ (for guaiac +ve stools)
showed mild, focal gastritis and no active bleeding sites were
found.
Gastritis
HTN
Constrictive pericarditis
Congestive heart failure diastolic
H/o Exudative pleural effusion
P Surgical Hx:
s/p R total hip replacement
S/p appendectomy
Social History:
___
Family History:
Brother with DM, Mother d. ___ of CVA, Father d. ___ CAD
No family history of myasthenia ___
Physical Exam:
Discharge Exam;
Gen: NAD, AOx3
CV: RRR
Resp: CTAB
Abd: Soft, NT/ND
Extrem:
LLE:
Incision c/d/I, no swelling or erythema
SILT over lfc/f/s/s/sp/dp/t nerve distributions
Fires ___
2+ ___ pulses, foot wwp with good cap refill
Pertinent Results:
___ 02:26AM BLOOD WBC-12.1* RBC-4.17* Hgb-11.1* Hct-36.7*
MCV-88 MCH-26.6 MCHC-30.2* RDW-14.6 RDWSD-47.1* Plt ___
___ 07:40AM BLOOD Glucose-107* UreaN-23* Creat-1.4* Na-137
K-3.7 Cl-96 HCO3-22 AnGap-23*
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 minimally displaced left femoral neck fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for closed reduction
percutaenous pinning of the left femoral neck which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
will be discharged on heparin SC BID for DVT prophylaxis for 12
additional days. The patient will follow up with Dr. ___
___ routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pyridostigmine Bromide 60 mg PO BID:PRN for weakness
2. Polyethylene Glycol 17 g PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Calcitriol 0.25 mcg PO 3X/WEEK (___)
5. Fluocinonide 0.05% Cream 1 Appl TP BID
6. Torsemide 10 mg PO QAM
7. Torsemide 5 mg PO NOON
8. Losartan Potassium 25 mg PO DAILY
9. Naphazoline 0.1% Ophth ___ DROP LEFT EYE Q12H:PRN eye
drooping
10. Betamethasone Dipro 0.05% Augmented Gel 1 Appl TP PRN skin
irritation
11. Omeprazole 40 mg PO DAILY
12. Potassium Chloride 20 mEq PO DAILY
13. Vitamin D 5000 UNIT PO DAILY
14. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing, dyspnea
3. Atorvastatin 10 mg PO QPM
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC BID
7. Multivitamins 1 TAB PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
9. Senna 8.6 mg PO DAILY
10. Betamethasone Dipro 0.05% Augmented Gel 1 Appl TP PRN skin
irritation
11. Calcitriol 0.25 mcg PO 3X/WEEK (___)
12. Diltiazem Extended-Release 240 mg PO DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. Fluocinonide 0.05% Cream 1 Appl TP BID
15. Losartan Potassium 25 mg PO DAILY
16. Naphazoline 0.1% Ophth ___ DROP LEFT EYE Q12H:PRN eye
drooping
17. Omeprazole 40 mg PO DAILY
18. Polyethylene Glycol 17 g PO DAILY
19. Potassium Chloride 20 mEq PO DAILY
Hold for K >
20. Pyridostigmine Bromide 60 mg PO BID:PRN for weakness
21. Torsemide 10 mg PO QAM
22. Torsemide 5 mg PO NOON
23. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left minimally displaced femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take heparin twice daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Physical Therapy:
Weight bearing as tolerated left lower extremity
Treatments Frequency:
Primary dressing has been changed. Dressing may be changed per
nursing discretion, when saturated or wet.
Followup Instructions:
___
|
19797153-DS-12
| 19,797,153 | 29,785,992 |
DS
| 12 |
2160-05-27 00:00:00
|
2160-05-27 16:00:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Calcium Channel Blocking
Agents-Dihydropyridines
Attending: ___.
Chief Complaint:
shortness of breath, cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of HTN,
HLD, asthma, DM2, atrial fibrillation, ___, myasthenia ___,
who presents with dyspnea and cough.
He states that he's been having a productive cough and shortness
of breath for the last week. It has been progressively getting
worse. He is now taking albuterol inhaler every 2 hours without
much help. He has been having orthopnea as well. He endorses
rhinorrhea. Denies any sore throat or myalgias. Denies any chest
pain, nausea, vomiting, diarrhea. Patient states that he has
been taking his torsemide regularly, 10mg qAM and 5mg qPM.
Denies fever or chills.
Of note, admitted ___ for SOB thought due to viral
illness triggering acute CHF.
In the ED initial vitals were:
98.2, HR 60-80, 135/83, RR 17. 100% RA
He subsequently developed A-Fib with RVR with rates sustained
>110
Labs/studies notable for:
- Infleunza A POSITIVE
- Proteinuria on UA
- Lactate 2.1
- WBC 11.5 with 89% N's, Hgb 11.7
Patient was given:
- 30mg IV Lasix
- 10mg + 15mg IV Diltiazem
- 1mg PO Ativan, 1mg IV Ativan
- 1g Tylenol
- 75mg Oseltamivir
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative unless
stated above in HPI.
Past Medical History:
Asthma
Atrial Fibrillation
CKD
Hyperparathyroidism
DM
HLD
ACh R Ab +ve Myasthenia ___
Colonic Polyps
Duodenal angiomas (s/p thermal therapy)
GI bleeding - capsule endoscopy ___ (for guaiac +ve stools)
showed mild, focal gastritis and no active bleeding sites were
found.
Gastritis
HTN
Constrictive pericarditis
Congestive heart failure diastolic
H/o Exudative pleural effusion
P Surgical Hx:
s/p R total hip replacement
S/p appendectomy
Social History:
___
Family History:
Brother with DM, Mother d. ___ of CVA, Father d. ___ CAD
No family history of myasthenia ___
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
VS: Afebrile, HR 90-120's, BP 140's/80's, RR 22, 93% 3LNC
GENERAL: Elderly male coughing frequently
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL.
Oropharynx clear
NECK: Supple. No adenopathy
CARDIAC: Irregular. No murmur. Tachycardic.
LUNGS: No chest wall deformities or tenderness. Respiration rate
low 20's. Diffuse rhonchi on exhalation. Minimal wheezes.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis. Trace
edema at ankles
SKIN: Small lesion on left ankle
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
==========================
Pertinent Results:
ADMISSION PHYSICAL EXAM
===========================
___ 11:20AM BLOOD WBC-11.5* RBC-4.11* Hgb-11.7* Hct-37.2*
MCV-91 MCH-28.5 MCHC-31.5* RDW-14.8 RDWSD-48.8* Plt ___
___ 11:20AM BLOOD Neuts-89.4* Lymphs-2.8* Monos-6.4
Eos-0.8* Baso-0.3 Im ___ AbsNeut-10.26* AbsLymp-0.32*
AbsMono-0.74 AbsEos-0.09 AbsBaso-0.03
___ 11:20AM BLOOD ___ PTT-31.8 ___
___ 11:20AM BLOOD Glucose-155* UreaN-20 Creat-1.2 Na-137
K-3.5 Cl-93* HCO3-30 AnGap-18
___ 11:20AM BLOOD proBNP-1104*
___ 11:20AM BLOOD Calcium-9.2 Phos-2.8 Mg-2.1
___ 11:26AM BLOOD Lactate-2.1*
___ 11:15 Influenza A positive
CXR ___
Possible small pleural effusions with overlying atelectasis.
Mild central pulmonary vascular engorgement without overt
pulmonary edema. Cardiomegaly.
Brief Hospital Course:
___ with a h/o DCHF, constrictive pericarditis, Afib, DM, HTN,
HLD, Asthma, myasthenia ___, who presents with shortness of
breath and cough, found to have Influenza A with exacerbation of
dCHF requiring 3L NC. CXR without evidence of pneumonia, but
with small pleural effusion. In the ED, he had an episode of
afib with RVR that was controlled with IV diltiazem. He finished
a 5 day course of oseltamivir and was diuresed with IV Lasix
until he was euvolemic (lost 3kg from admission) and was weaned
off O2. However, upon ambulating, patient would desat to
mid-80s. Pulmonary was consulted, and suspected hypoxia likely
secondary to influenza effect on patient's chronic pulmonary
conditions. He was discharged with Advair to use temporarily as
he recovers from flu as well as home O2. On day of discharge,
his oxygenation improved and on RA, he only de-satted to 89%. He
was also set up with respiratory therapist to see if he would
benefit from home NIPPV
#Influenza A infection
#Hypoxia: Positive by nasal PCR and likely triggered HFpEF and
afib with RVR. He initially required ___ NC. He was started on
oseltamivir and completed a ___nd was weaned off O2.
However, upon ambulating, patient would desat to mid-80s. VBG
revealed chronic compensated CO2 retention. Pulmonary was
consulted, and suspected hypoxia likely secondary to influenza
effect on patient's chronic pulmonary conditions. He was
discharged with Advair to use temporarily as he recovers from
flu as well as home O2. On day of discharge, his oxygenation
improved and on RA, he only de-satted to 89%. He was also set up
with respiratory therapist to see if he would benefit from home
NIPPV.
# Acute Hypoxic Respiratory failure
# Acute on chronic diastolic CHF: Likely triggered by Influenza
infection. BNP 1104, outpatient values in 400-500's. EF of 50%
as of ___. Pt with chronic RHF iso constrictive
pericarditis. Patient was given 40 IV Lasix for a couple days
and was transitioned back to home torsemide regimen when
euvolemic. Patient had improved
sats after diuresis with IV Lasix with weight ___ pounds down
from previous outpatient weight. He was continued on home
losartan and treated for influenza as above. Discharge weight:
80.7kg (admit wt: 83kg, ___: 83.9kg).
# A-Fib: History of chronic AF, the RVR in EDis likely
triggered by infection. He was given IV diltiazem with control
of rates. He was continued on home diltiazem ER 240mg with HRs
80-90s. Not currently on anticoagulation per outpatient notes
___ recurrent GI hemorrhage.
# Myasthenia ___ - continued home Pyridostigmine BID. Was
concerned if myasthenia ___ was contributing to patient's
hypoxia. Patient had NIF and VC recorded although per
respiratory therapist, patient had poor effort. NIF: ___: -40
(on ___: -32), VC: ___: 1L (on ___. Recommend
outpatient neurology follow up
# HTN - continued home Losartan
# HLD - continued home atorvastatin 10mg
# DM: diet controlled at home. Was on insulin sliding scale
while inpatient
# Supplements: continue home multivitamin, vitamin D, iron
# GERD - continued home Omeprazole
TRANSITIONAL ISSUES:
discharge weight: 80.7kg (admit wt: 83kg, ___: 83.9kg)
[]recommend outpatient PFTs with MIP/MEP, bronchodilator and
sniff study.
[]outpatient sleep study to assess for night time
hypoventilation
[]repeat ambulatory O2 sat as outpatient. Can d/c home O2 if
normal
[]assess albuterol PRN use. modify asthma regimen as indicated
[]recommend neuro follow-up for myasthenia ___. ___ be
contributing to patient's hypoventilation
New medications: Advair 250/50, guaifenesin ER 600mg BID
# CODE STATUS: Full
# CONTACT:
Proxy name: Dr. ___
___: brother Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
2. Calcitriol 0.25 mcg PO 3X/WEEK (___)
3. Pyridostigmine Bromide 60 mg PO BID
4. Atorvastatin 10 mg PO QPM
5. Senna 8.6 mg PO QHS
6. Losartan Potassium 25 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Diltiazem Extended-Release 240 mg PO BID
12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
13. Torsemide 10 mg PO QAM
14. Torsemide 5 mg PO QPM
15. Potassium Chloride 20 mEq PO DAILY
16. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
puff inhaled twice a day Disp #*1 Disk Refills:*0
2. GuaiFENesin ER 600 mg PO Q12H
RX *guaifenesin 600 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
5. Atorvastatin 10 mg PO QPM
6. Calcitriol 0.25 mcg PO 3X/WEEK (___)
7. Diltiazem Extended-Release 240 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Losartan Potassium 25 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Potassium Chloride 20 mEq PO DAILY
14. Pyridostigmine Bromide 60 mg PO BID
15. Senna 8.6 mg PO QHS
16. Torsemide 10 mg PO QAM
17. Torsemide 5 mg PO QPM
18. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Influenza
Acute on chronic diastolic heart failure
Atrial fibrillation with rapid ventricular rate
SECONDARY:
Diabetes
Hypertension
Asthma
Myasthenia ___
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.
Why you were admitted
-You were admitted because you were short of breath and
coughing. We found that you had the flu and had excess fluid in
your body
What we did for you
-You were treated with an anti-flu medication and given IV
medications to help you urinate the excess fluids and you felt
much better
-Your heart rate was also very fast, which we controlled with
medication
-You still had low oxygen while walking, so you were evaluated
by the lung doctors who ___ it was related to the flu
What you should do when you go home
-Please use Advair everyday for the next week even if you do not
feel short of breath
-Use home oxygen 2L if you are ambulating. No need to use it at
rest. Please continue to use it until you see your primary care
doctor
-___ do not need to wear a mask when you go home
-If your weight increases more than 3 pounds, please call your
PCP
-___ take all your medications and go to your follow up
appointment
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19797153-DS-14
| 19,797,153 | 25,621,411 |
DS
| 14 |
2161-05-17 00:00:00
|
2161-05-17 21:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Calcium Channel Blocking
Agents-Dihydropyridines
Attending: ___.
Chief Complaint:
Shortness of breath, orthopnea, cough, leg swelling
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Mr. ___ is a ___ yo M w history of HFpEF, Afib on Dilt
not on anticoag, myasthenia ___ not on steroids, CKD, HTN,
NIDDM, HLD, and asthma on home O2 (2L) presenting with 1 week of
cough, dyspnea and orthopnea, and chronic ___ swelling.
Cough has worsened over the past couple days. Cough productive
with yellow sputum. Reporting difficulty breathing, DOE that has
worsened over the past week, as well as orthopnea. Endorses sick
contacts at ___, says the flu. He has chronic
___ swelling and he reports ___ erythema for the past year. He
also reports occasional chest pain that lasts for a few seconds
that seems to also be a chronic issue.
Per Atrius records, patient has been on 40mg torsemide daily,
360 mg Dilt daily and 25mg losartan daily.
Denies fever/chills. Denies n/v and abdominal pain. No changes
___ medications, takes them all himself. Reporting some urinary
frequency, but denies burning. Poor appetite since last night.
Having otherwise normal bowel movements.
___ the ED, patient's exam was notable for decreased lung sounds
at bases, more on R, some crackles and rhonchi, elevated JVP, 1+
pitting edema to shins with erythema bilaterally. Afebrile.
Tachy. Breathing 100% on RA, BP 160/95. EKG done showed AF @114
bpm, frequent PVCs, TWI V1-4 seen on prior.
Past Medical History:
Asthma
Atrial Fibrillation
CKD
Hyperparathyroidism
DM
HLD
ACh R Ab +ve Myasthenia ___
Colonic Polyps
Duodenal angiomas (s/p thermal therapy)
GI bleeding - capsule endoscopy ___ (for guaiac +ve stools)
showed mild, focal gastritis and no active bleeding sites were
found.
Gastritis
HTN
Constrictive pericarditis
Congestive heart failure diastolic
H/o Exudative pleural effusion
P Surgical Hx:
s/p R total hip replacement
S/p appendectomy
Social History:
___
Family History:
Brother with DM, Mother d. ___ of CVA, Father d. ___ CAD
No family history of myasthenia ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
=============================
Vitals: 98.4 146/76 92 20 98% on 3L
General: alert, oriented, no acute distress, coughing
Eyes: Sclera anicteric, L eye droop (chronic)
HEENT: MMM, oropharynx clear
Neck: notably elevated JVP, + hepatojugular reflex
Resp: decreased lung sounds at bases R>L, crackles and rhonchi
throughout
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
MSK: 2+ pulses, 2+ pitting edema (L>R), with erythematous scaly
overlying skin
Neuro: CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
=========================
General: alert, oriented, no acute distress, coughing
Eyes: Sclera anicteric, L eye droop (chronic)
HEENT: MMM, oropharynx clear
Neck: JVP about 9cm at 45 degrees
Resp: breath sounds heard at R base, some expiratory wheezes, no
crackles
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops
GI: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
Extrem: palpable pulses, no edema, w erythematous scaly
overlying skin
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 05:50PM CK-MB-6 cTropnT-0.10*
___ 04:35PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 04:35PM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 04:35PM URINE MUCOUS-RARE*
___ 09:50AM ___ PO2-29* PCO2-53* PH-7.39 TOTAL
CO2-33* BASE XS-4
___ 09:50AM LACTATE-1.7
___ 09:40AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 09:30AM GLUCOSE-114* UREA N-23* CREAT-1.5* SODIUM-146
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-28 ANION GAP-17
___ 09:30AM CK(CPK)-177
___ 09:30AM cTropnT-0.10*
___ 09:30AM CK-MB-6 proBNP-1046*
___ 09:30AM MAGNESIUM-2.2
___ 09:30AM WBC-8.7 RBC-3.60* HGB-9.5* HCT-31.2* MCV-87
MCH-26.4 MCHC-30.4* RDW-16.6* RDWSD-51.8*
___ 09:30AM NEUTS-80.9* LYMPHS-6.5* MONOS-9.9 EOS-1.7
BASOS-0.5 IM ___ AbsNeut-7.07* AbsLymp-0.57* AbsMono-0.86*
AbsEos-0.15 AbsBaso-0.04
___ 09:30AM PLT COUNT-307
___ 4:36 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
___ 05:50PM BLOOD CK-MB-6 cTropnT-0.10*
___ 07:05AM BLOOD CK-MB-7 cTropnT-0.09*
CXR ___
IMPRESSION: Moderate right and small left pleural effusion with
adjacent atelectasis.
TTE ___ compared to ___: LVEF= 50% Mildly reduced
biventricular systolic function. Mildly dilated aortic root and
ascending aorta. Mild MR and TR. At least moderate pHTN.
Compared with the prior study (images reviewed) of ___,
the pulmonary pressure has increased (previously 36 mmHg+RAP).
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, if not previously known or
a change, a f/u echo is suggested ___ ___ year; if previously known
and stable, a f/u echocardiogram is suggested ___ ___ years. A
left pleural effusion is present.
CXR ___
No significant interval change from prior day's radiograph, with
stable appearance of moderate right pleural effusion and
subjacent atelectasis.
DISCHARGE LABS
___ 05:55AM BLOOD Glucose-103* UreaN-28* Creat-1.6* Na-142
K-3.4 Cl-94* HCO3-34* AnGap-14
Brief Hospital Course:
Mr. ___ is a ___ yo M w history of HFpEF, Afib on Dilt
not on anticoag, myasthenia ___ not on steroids, CKD, HTN,
NIDDM, HLD, and asthma on home O2 (2L) presenting with 1 week of
dyspnea and orthopnea, cough, and chronic ___ swelling.
#Dyspnea
#Community acquired pneumonia
#Acute on Chronic HFpEF
#Asthma
Likely CHF exacerbation ___ setting of possible pneumonia. Exam
notable for elevated JVP, rhonchi and crackles with decreased
lung sounds at b/l bases, pitting edema ___ b/l ___. CXR ___ the ED
showing bilateral pleural effusion, R >L. BNP was elevated at
1046. Initially required 2L O2 (on O2 at home for asthma). TTE
with EF 50%. Diuresed with IV Lasix with improvement ___ his
respiratory status. Prior to discharge O2 95% on RA at rest,
with desaturations to 85% on RA with ambulation. Also treated
for CAP with CTX/Azithromycin with 5 day course (___). Also
given duo nebs/albuterol nebs ___ setting of asthma.
#Loose stools
Infectious etiology vs side effect of Lasix. C. Diff negative.
Had resolved on discharge.
#AF
Presented ___ Afib with elevated HR 114. Not on anticoagulation
given recurrent GI bleed and AVM. Continued home diltiazem
fractionated to 90mg Q6h, and transitioned back to 360 mg daily
by discharge.
#Troponinemia
Likely d/t demand ischemia (Type 2 NSTEMI) iso respiratory
distress. Not having any chest pain. EKG reassuring without
ischemic changes. Trop 0.1 -> 0.1 -> 0.09. TTE also reassuring
against acute myocardial damage.
CHRONIC ISSUES
==============
#CKD
Patient with CKD, baseline Cr ___.
#Anemia
Patient with recent admission for GI bleed (___). Underwent
EGD, capsule study and colonoscopy with e/o distal duodenal and
colonic AVM's. Given clinical stability on iron supplements,
aggressive intervention not pursued. Continued home omeprazole
and ferrous sulfate.
#HTN
- Held home losartan during admission as patient was
normotensive.
#MG:
- Home pyridostigmine continued.
#DM2:
- Held ___ glimepiride during admission; insulin sliding scale
while ___ house.
#OSA
- CPAP which patient uses at home was continued.
# Emergency contact: ___ (___) ___ ___
___
# Code: Full (confirmed)
Transitional Issues:
=====================
- The patient has a mildly dilated ascending aorta. Based on
___ ACCF/AHA Thoracic Aortic Guidelines, if not previously
known or a change, a follow-up echocardiogram is suggested ___ ___
year; if previously known and stable, a follow-up echocardiogram
is suggested ___ ___ years. This was noted on his TTE from ___
at ___.
- Patient discharged on Torsemide 50mg (previously 40mg). Please
monitor electrolytes and titrate dosage. Inform PCP if weight
change >3 lb. Dc weight = 78.2 kg (172.4 lb).
- Holding home Losartan. Please monitor BP and resume if
hypertensive.
- Continued on home potassium (20 mEq daily) on discharge.
Please obtain chem7 on ___ to monitor K.
-# Emergency contact: ___) ___ ___
___
# Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
2. glimepiride 2 mg oral BREAKFAST
3. Losartan Potassium 25 mg PO DAILY
4. Torsemide 40 mg PO QAM
5. Atorvastatin 10 mg PO QPM
6. Calcitriol 0.25 mcg PO M, W, F
7. Diltiazem Extended-Release 360 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Omeprazole 40 mg PO DAILY
11. Pyridostigmine Bromide 60 mg PO BID
12. Vitamin D 5000 UNIT PO DAILY
13. Fluocinonide 0.05% Cream 1 Appl TP BID
14. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. Torsemide 50 mg PO DAILY
RX *torsemide [Demadex] 10 mg 5 tablet(s) by mouth daily Disp
#*180 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB
3. Atorvastatin 10 mg PO QPM
4. Calcitriol 0.25 mcg PO M, W, F
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluocinonide 0.05% Cream 1 Appl TP BID
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. glimepiride 2 mg oral BREAKFAST
10. Omeprazole 40 mg PO DAILY
11. Potassium Chloride 20 mEq PO DAILY
12. Pyridostigmine Bromide 60 mg PO BID
13. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: CHF exacerbation iso respiratory infection
Secondary: Tropininemia, Afib, Anemia, Myasthenia ___, DM2
Discharge Condition:
Mental Status: Clear and coherent. Hard of hearing.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
WHY YOU WERE HERE?
You came to the hospital because you had shortness of breath,
difficulty breathing lying flat, and swelling ___ your legs for
the past week. You also had a cough for several days.
WHAT WE DID WHILE YOU WERE HERE?
- We gave you the water pills via IV to make sure you got rid of
extra fluid ___ your lungs. You lost 10 kg!
- We took a picture of your heart which showed not many changes
from ___. Your heart had been stressed by your heart failure
and fluid ___ the lungs so we monitored your heart with ekgs and
labs that showed improvement over time.
- We gave you antibiotics to treat you for what could be
pneumonia. Your sputum culture did not grow harmful bacteria.
WHAT YOU SHOULD DO WHEN YOU GO HOME?
- Please follow up with your GI doctor at ___.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Please take your medications. We changed your Torsemide to
50mg.
Your ___ Team
Followup Instructions:
___
|
19797153-DS-16
| 19,797,153 | 20,224,954 |
DS
| 16 |
2163-03-18 00:00:00
|
2163-03-20 13:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Calcium Channel Blocking
Agents-Dihydropyridines / aspirin / nifedipine
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
================
___ 08:13PM CK(CPK)-135
___ 08:13PM cTropnT-0.16*
___ 08:13PM CK-MB-4
___ 05:15PM URINE HOURS-RANDOM
___ 05:15PM URINE UHOLD-HOLD
___ 05:15PM URINE COLOR-Straw APPEAR-CLEAR SP ___
___ 05:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-20*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NORMAL PH-6.5
LEUK-NEG
___ 05:15PM URINE RBC-<1 WBC-2 BACTERIA-NONE YEAST-NONE
EPI-0
___ 05:15PM URINE MUCOUS-RARE*
___ 04:57PM ___ PO2-68* PCO2-58* PH-7.38 TOTAL
CO2-36* BASE XS-6 COMMENTS-GREEN TOP
___ 04:57PM LACTATE-1.7
___ 04:50PM GLUCOSE-211* UREA N-36* CREAT-1.8* SODIUM-142
POTASSIUM-4.7 CHLORIDE-95* TOTAL CO2-31 ANION GAP-16
___ 04:50PM estGFR-Using this
___ 04:50PM ALT(SGPT)-12 AST(SGOT)-31 ALK PHOS-104 TOT
BILI-0.7
___ 04:50PM LIPASE-40
___ 04:50PM CK-MB-4 cTropnT-0.17*
___ 04:50PM ALBUMIN-4.4 CALCIUM-8.9 PHOSPHATE-3.5
MAGNESIUM-2.6
___ 04:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 04:50PM WBC-11.4* RBC-3.68* HGB-9.9* HCT-32.9* MCV-89
MCH-26.9 MCHC-30.1* RDW-14.3 RDWSD-46.3
___ 04:50PM NEUTS-89.2* LYMPHS-4.0* MONOS-5.7 EOS-0.5*
BASOS-0.3 IM ___ AbsNeut-10.16* AbsLymp-0.46* AbsMono-0.65
AbsEos-0.06 AbsBaso-0.03
___ 04:50PM PLT COUNT-292
___ 04:50PM ___ PTT-33.8 ___
___ 03:30PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
DISCHARGE LABS:
===============
___ 06:50AM BLOOD WBC-6.6 RBC-3.27* Hgb-8.8* Hct-30.1*
MCV-92 MCH-26.9 MCHC-29.2* RDW-14.3 RDWSD-48.2* Plt ___
___ 06:50AM BLOOD Glucose-130* UreaN-34* Creat-1.8* Na-142
K-3.9 Cl-95* HCO3-32 AnGap-15
___ 06:50AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.3
MICROBIOLOGY:
===============
___ 5:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
__________________________________________________________
___ 4:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
IMAGING:
==========
- ___ Knee XR: No acute fracture or dislocation.
- ___ Hip XR: No acute fracture.
- ___ CXR: Stable small right pleural effusion with
associated right basilar atelectasis. Mild pulmonary vascular
congestion. No definite focal consolidation.
- ___ Video Swallow
Rare trace penetration with thin liquids. No evidence of
aspiration. The
patient was able to swallow a 13 mm barium tablet.
Please note that a detailed description of dynamic swallowing as
well as a
summative assessment and recommendations are reported separately
in a
standalone note by the Speech-Language Pathologist (OMR, Notes,
Rehabilitation Services).
Brief Hospital Course:
Mr. ___ is an ___ with a history of myasthenia ___,
?chronic hypoxemic respiratory failure (on 2L home O2), HFpEF
c/b recurrent pleural effusion, and atrial fibrillation (not on
AC due to prior GIB), who presented with a near fall on the bus,
found to have mild HFpEF exacerbation that resolved with IV
Lasix 120mg x1.
ACUTE ISSUES:
=============
# Acute on chronic diastolic heart failure exacerbation
Presented with mild volume overload on admission of unclear
trigger. ECG without dynamic changes, but troponin mildly
elevated (see below). No evidence of infection. Received IV
Lasix 120mg x1 on ___ and subsequently transitioned back to
home torsemide 60mg BID on ___. Continued home diltiazem
(fractioned while inpatient) and maintained on low sodium diet
with 2L fluid restriction.
# Type II NSTEMI
Secondary to mild HF exacerbation, as above. Trops peaked at
0.17 with no dynamic changes on ECG. Home atorvastatin increased
from 10mg to 20mg daily. Is not on home aspirin for unclear
reasons; held off on starting this admission given history of
prior GIB requiring discontinuation of AC for atrial
fibrillation, but should be discussed further with outpatient
providers.
# ?Chronic Hypoxemic Respiratory Failure (on 2L home O2)
Has history of both asthma and COPD documented in chart and
reports requiring 2L home O2 that was prescribed 'many years
ago'. During admission, supplemental O2 was quickly weaned and
patient maintained SaO2 > 92% on room air. Reports history of
chronic productive cough, suspicious for chronic bronchitis. Had
been taking albuterol 2x/day at home as he was unable to afford
his prescribed Advair inhaler. Advair inhaler re-started during
admission and patient discharged with Advair inhaler in hand.
Spoke with pharmacy who reported copay of $30, so Rx sent to
pharmacy. Also started on Flonase for possible post-nasal drip.
# Near fall
Presented after witness near fall on the bus. No head strike,
loss of consciousness, or preceding symptoms to suggest syncope.
Etiology felt to be mechanical in nature. Patient was evaluated
by ___ who recommended discharge home.
CHRONIC ISSUES:
===============
# Myasthenia ___
Evaluated by neurology in ED who felt symptoms were at baseline
and there was no evidence of active flare. Continued home
pyridostigmine 60 mg BID.
# Atrial fibrillation: Remained rate controlled with HR <110
throughout admission. Continued home diltiazem (fractioned
during admission). Not on AC due to prior history of GIB.
# Stasis Dermatitis: Followed by dermatology. Initially with
some concern for cellulitis in the ED, prompting 1x dose of
cefazolin; however, upon further evaluation, felt to be
consistent with known stasis dermatitis and antibiotics
discontinued.
# Chronic normocytic anemia: Recent baseline Hgb 8.8-11.2 mg/dL,
with most recent tsat 17%. Hgb trended daily and remained stable
during admission.
# CKD: Baseline Cr 1.7-2. Remained at baseline throughout
admission.
# Type II diabetes: Home glipizide held during admission and
re-started on discharge. Received Humalog insulin sliding scale
during admission.
TRANSITIONAL ISSUES:
======================
[] Prescribed rolling walker on discharge (Rx sent ___ in OMR)
[] Ensure outpatient follow-up with pulmonology for chronic
productive cough, asthma, COPD
[] Consider outpatient PFTs
[] Uptitrate statin as tolerated given Type II NSTEMI
[] Consider initiation of ASA given Type II NSTEMI (history of
prior GIB, causing discontinuation of AC for atrial
fibrillation)
[] Reported 2L O2 requirement on admission, but SaO2 > 92% on
room air throughout admission. Please re-evaluated need for home
O2
[] Please re-check chem 7 in ___ days and replete K+ as needed;
if persistently low, consider increasing daily KCl
#CODE: Full, presumed
#CONTACT: Dr. ___
___: brother
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Calcitriol 0.25 mcg PO EVERY OTHER DAY
3. Diltiazem Extended-Release 360 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Potassium Chloride 20 mEq PO DAILY
6. Pyridostigmine Bromide 60 mg PO BID
7. Vitamin D 1000 UNIT PO DAILY
8. Torsemide 60 mg PO BID
9. GlipiZIDE XL 10 mg PO DAILY
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
11. triamcinolone acetonide 0.5 % topical DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 1 SPRY NU BID
RX *fluticasone propionate 50 mcg/actuation 1 spray IN twice a
day Disp #*1 Spray Refills:*0
2. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 tablet(s) by mouth qpm Disp #*30 Tablet
Refills:*0
3. Albuterol Inhaler 2 PUFF ___ Q4H:PRN dyspnea
4. Calcitriol 0.25 mcg PO EVERY OTHER DAY
5. Diltiazem Extended-Release 360 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. GlipiZIDE XL 10 mg PO DAILY
8. Potassium Chloride 20 mEq PO DAILY
9. Pyridostigmine Bromide 60 mg PO BID
10. Torsemide 60 mg PO BID
11. triamcinolone acetonide 0.5 % topical DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Diastolic heart failure exacerbation
Type II NSTEMI
SECONDARY DIAGNOSIS:
======================
Myasthenia ___
Chronic hypoxemic respiratory failure
Atrial fibrillation
Chronic kidney disease
Type II diabetes mellitus
Obstructive sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
======================================
You were admitted to the hospital after almost falling on the
bus.
WHAT HAPPENED TO YOU IN THE HOSPITAL?
=======================================
In the hospital, you were feeling a little more short of breath
than usual. We felt your breathing troubles were due to having
extra fluid in your body, so you received a medication called
Lasix to help remove the extra fluid. Your breathing felt better
after receiving this medication.
You were also seen by the speech and swallow experts, who
evaluated your swallowing and did not find any problems with it.
You were re-started on your home inhalers to help your
breathing.
You were seen by the neurology doctors, who felt that your
myasthenia ___ was at baseline.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
=================================================
- When you leave the hospital, please continue taking all your
medications as prescribed and follow-up with your doctors
___ information below).
- It is very important that you call the Pulmonary doctors and
make ___ appointment with them.
- After close monitoring in the hospital, it was determined that
you no longer need to wear oxygen at home. You should discuss
this further with the pulmonary doctors.
- Please weigh yourself every morning, and call your doctor if
your weight increases by more than 3 pounds.
It was a privilege caring for you, and we wish you well.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19797687-DS-14
| 19,797,687 | 28,730,072 |
DS
| 14 |
2162-02-08 00:00:00
|
2162-02-08 23:31:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Mustard / Levaquin / Ceftriaxone / Benadryl /
cefepime
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is an ___ year old female with a history of multiple
myeloma initiated recently on pomalidomide presenting with
worsening shortness of breath over the past week, akin to her
prior episodes of COPD. Her COPD is managed by her
pulmonologist. She was started on azithromycin and 60 mg
prednisone 5 days prior to admission with no improvement in her
symptoms. In fact, she feels her shortness of breath has
slightly worsened over the past day. She also endorses a
persistent, mildly productive cough with no hemoptysis. Ms
___ states she's had slightly worsened edema in her ankles
bilaterally. She denies a history of heart failure or
pulmonary edema, although she never sleeps flat and uses ___
pillows while sleeping. She had a normal echo in ___.
She otherwise denies fevers, chills, rigors, chest pain, chest
pressure, nausea, vomiting, diarrhea, abdominal pain. At home,
she desaturated to the low ___ with near normal oxygen
saturations at rest. Despite PO prednisone and azithromycin she
continues to experience shortness of breath and hypoxemia. A
chest ___ in the ED was obtained which did not show any
infiltrates or edema. She was admitted for further management
of her COPD.
Past Medical History:
- ___: began developing pain in distal medial right leg.
Did not go away as would with typical MSK pain from dancing.
- ___: Xray which showed a 2.3 cm R tibial lesion
- ___: CT guided bone biopsy significant for plasmacytoma.
After this diagnosis she was seen by Dr. ___ and
referred to us.
- ___: Bone marrow biopsy with 30% monoclonal plasma cells
- ___ - ___: Radiation 35 Gy in 14 fractions to right
distal tibia.
- ___: Dexamethasone 20mg with rapid taper over 7
days.
- On DF/HCC ___ Elotuzumab + 4 cycles of Revlimid and
Decadron.
- ___ Revlimid/Dex therapy. Revlimid discontinued on ___
and Dexamethasone discontinued on ___.
- ___: started therapy on clinical trial Protocol ___: A
Phase 3, Multicenter, Randomized, ___ Study to Compare
the
Efficacy and Safety of Pomalidomide (POM), Bortezomib (BTZ) and
___ Dexamethasone (___) versus Bortezomib and ___
Dexamethasone in Subjects with Relapsed or Refractory Multiple
Myeloma (MM).
- patient was randomized to the Velcade/Dex arm
- ___: Cycle 1 Velcade/Dex
- ___: Cycle 2 Velcade/Dex
PAST MEDICAL/SURGICAL HISTORY:
- asthma - dx'ed ___
- COPD - dx'ed in ___
- GERD - ___
- HLD - ___
- anemia - dx'ed ___, resolved ___
- right rotator cuff tear -___
- chronic low back pain - ___
- s/p R meniscus repair - ___
- s/p L meniscus repair - ___
- L forearm abrasion ___ tx'ed with Clindamycin x 7 days
- Arthritis x ___ years
Social History:
___
Family History:
siblings: brother with mental health problems
children: 1 son, healthy
No family history of malignancy or blood disorders besides a
cousin with breast cancer.
Physical Exam:
ADMISSION ___
.
VS: temp 98.3, 142/70, 80, 20, 97% RA
Gen: Caucasian female, sitting up in bed, cheerful, but pausing
in between words for breaths
HEENT: Anicteric
Neck: no lymphadenopathy
Cardiac: Nl s1/s2 RRR wheezes appreciable even in anterior lung
fields, no JVP evident
Pulm: prolonged expiratory phase, wheezes appreciable throughout
both lung fields apically and at bases, no rales appreciable
Abd: soft NT ND + BS
Ext: 1+ edema bilaterally at ankles
.
DISCHARGE ___
.
Vitals: afebrile overnight, 140/80, 73, 20, 99 on 2 L and 97
without O2 while sitting and 92 while ambulating without O2
GENERAL: NAD
SKIN: warm and well perfused, lipodermatosclerosis b/l and trace
to +1 edema in lower extrem to calves, surgical scar on area
above anterior right shin but no erythema noted.
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no MRG
LUNG: ronchi about the same as previous two days, moving air at
same level which is an improvement since admission, was off O2
while examining, no coughing spells
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact, strength ___ in all 4 ext, sensation
grossly intact
Pertinent Results:
ADMISSION LABS
.
___ 04:50PM ___
___ 04:50PM UREA ___
___ TOTAL ___ ANION ___
___ 04:50PM ___ this
___ 04:50PM ALT(SGPT)-41* AST(SGOT)-25 ALK ___ TOT
___
___ 04:50PM TOT ___
___
___ 04:50PM ___
___ 04:50PM ___
___
___ 04:50PM ___
___
___ 04:50PM PLT ___
___ 04:50PM BLOOD ___
.
DISCHARGE LABS
.
___ 06:10AM BLOOD ___
___ Plt ___
___ 06:10AM BLOOD Plt ___
___ 06:10AM BLOOD ___
___
___ 06:10AM BLOOD ___ LD(LDH)-142 ___
___
___ 06:10AM BLOOD ___
.
IMAGING
.
CXR ___
No evidence PNA.
.
CTA ___
No PE, no PNA, COPD flare is best option, 6 mm ground glass opac
RUL since ___ and small granuloma in LLL since
___, need nonurgent thyroid ultrasound for nodule.
.
Right ankle 3 view Xray ___
.
The patient has had prior curettage and cement packing in the
distal tibia
with plate and screw fixation laterally. The appearances are
unchanged when
compared to the prior study. There is some periosteal new bone
formation
adjacent to the middle 2 of the fixating screws however this is
also unchanged
when compared to the prior study and is nonaggressive in
appearance. No change
in the degree of lucency surrounding the hardware. The ankle
mortise is
congruent, and mild degenerative changes in the subtalar joint.
.
No convincing radiographic evidence of osteomyelitis or
osteonecrosis.
.
MICRO
.
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
Brief Hospital Course:
___ ___ woman with multiple myeloma presenting with
worsening shortness of breath.
.
She was hypoxemic on ambulation at home with subjective dyspnea,
cough, and wheezing akin to prior episodes of COPD. Chest ___
does not reveal any infiltrate or pulmonary edema. Normal echo
and absence of pulmonary edema on imaging makes cardiac
etiologies less likely. CTA chest did not reveal a pulmonary
embolism or pneumonia but just several incidental findings.
Refractoriness to prednisone suggests severe flare or other
etiology. No recent history of unilateral leg swelling or
prior history of blood clots. She was continued on steroids
during hospitalization with a planned taper as she made
improvement in breathing while inpatient. She was placed on a
seven day course of cefpodoxime. She received nebulizer
treatments every four hours along with instruction on how to use
her acapella device. Her O2 saturation improved to 93%
ambulating without oxygen. ___ antitrypsin level that was
drawn outpatient was within normal limits.
.
Her right shin began to hurt over the site of a remote
orthopedic bone fixation. while she was an inpatient. There was
no erythema or swelling. A 3 view right ankle Xray was ordered
and did not show any concerning interval changes to the ankle.
No further scans were warranted inpatient per Dr. ___
orthopedics.
.
Her multiple myeolma was diagnosed in ___. She was on clinical
trial
protocol ___ randomized to Velcade/Dexamethasome arm. She is
currently on pomalidomide/dexamethasone. We continued her home
acyclovir and Bactrim.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Lorazepam ___ mg PO Q4H:PRN anxiety
6. Multivitamins 1 TAB PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Ranitidine 75 mg PO BID
9. Senna 8.6 mg PO DAILY:PRN constipation
10. Simvastatin 30 mg PO DAILY
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. Symbicort ___ mcg/actuation
INHALATION 2 PUFFS
13. TraZODone 50 mg PO HS:PRN insomnia
14. Vitamin D 400 UNIT PO DAILY
15. ___
___ mg oral daily
16. B Complete (B complex vitamins) 1 cap oral daily
17. Tiotropium Bromide 1 CAP IH DAILY
18. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
19. PredniSONE 40 mg PO DAILY
Tapered dose - DOWN
20. Guaifenesin ___ mL PO Q4H:PRN cough/wheeze
21. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN wheeze/cough
22. Ipratropium Bromide Neb 1 NEB IH Q8H:PRN dyspnea/wheeze
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Guaifenesin ___ mL PO Q4H:PRN cough/wheeze
6. Lorazepam ___ mg PO Q4H:PRN anxiety
7. Multivitamins 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Ranitidine 75 mg PO BID
10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H wheeze/cough
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 Neb IH every four
(4) hours Disp #*30 Vial Refills:*0
11. Ipratropium Bromide Neb 1 NEB IH Q4H dyspnea/wheeze
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb IH every four
(4) hours Disp #*30 Vial Refills:*0
12. PredniSONE 30 mg PO DAILY
Take 30mg for 2 days, then 20mg for 3 days, then 10mg for 3
days, then stop
Tapered dose - DOWN
RX *prednisone 10 mg 3 tablet(s) by mouth daily Disp #*18 Tablet
Refills:*0
13. Senna 8.6 mg PO DAILY:PRN constipation
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
16. TraZODone 50 mg PO HS:PRN insomnia
17. Vitamin D 400 UNIT PO DAILY
18. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 2 Days
RX *cefpodoxime 200 mg 2 tablet(s) by mouth q12 hours Disp #*4
Tablet Refills:*0
19. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
20. B Complete (B complex vitamins) 1 cap oral daily
21. ___
___ mg oral daily
22. Simvastatin 30 mg PO DAILY
23. Symbicort ___ mcg/actuation
INHALATION 2 PUFFS
24. oxygen therapy
Titrate to 2L as needed when ambulating.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
-Chronic obstructive pulmonary disease exacerbation
Secondary
-Multiple myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for during your time at ___. Based on
your presentation you most likely had a worsening of your
obstructive lung disease (COPD). This flare could have been
caused in a number of different ways including certain viruses
or bacteria. You were treated with antibiotics and steroids
while inpatient and your ability to walk and breath improved
while here.
Do NOT take pomalidomide until you have seen your pulmonologist
and attended your heme/onc appointment at which point dosing of
medication for your multiple myeloma can be addressed.
You also noted right leg shin pain while inpatient over the site
of an orthopedic surgery. It was not red or swollen. You got an
Xray of the ankle that did not show concerning findings. After a
discussion with your orthopedic surgeon, it was determined that
no further investigation should be done inpatient. If you
continue to have leg pain please ___ with Dr. ___.
Based on your CT scan of the chest that showed a small spot near
the thyroid, you should get a ___ thyroid scan as an
outpatient. Please discuss the matter further with your primary
care provider.
The following medications were started:
START cefpodoxime 400mg twice daily for the next 3 days
START prednisone (please refer to your prescription for dosage
and taper)
Followup Instructions:
___
|
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