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19797687-DS-18
| 19,797,687 | 25,776,542 |
DS
| 18 |
2162-11-26 00:00:00
|
2162-11-26 21:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Mustard / Levaquin / Ceftriaxone / Benadryl /
cefepime
Attending: ___.
Chief Complaint:
cc: dyspnea
Major ___ or Invasive Procedure:
None
History of Present Illness:
___ yo F with MM, asthma/copd, GERD who presents with subacute
dyspnea and wheezing not resolving despite multiple steroid
bursts over the past month. Pt with multiple myeloma, recently
started on pomalidomide until she developed a flare of COPD. Pt
with transient improvement on steroids but persistent symptoms
that have led to at least 3 steroid tapers over the past month.
Pt hospitalized on ___ and has had multiple visits with her
oncologist and pulmonologist for this issue. Initially
attributed to side effect of her pomalidomide which has been
held, but pt not improving. Alternate diagnoses pursued with
multiple negative d-dimers, normal TTE, and normal BNP. No
advanced imaging of chest done yet.
Pt reports dry cough which is unusual for her asthma/copd. No
fevers or chills. No sick contacts. No change to housing. On
bactrim and acyclovir ppx. Dyspnea is significant with short
ambulation whereas she can ususually tolerate significant
exertion (works as ___). Pt seen in ___ clinic
today and sent in for inpatient workup.
In the ED, pt given multiple rounds of nebulizer treatments for
diffuse wheezing as well as 125 of solumedrol and admitted for
furhter care.
ROS: negative except as above
Past Medical History:
PAST ONCOLOGIC 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/___ ___ 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, Open-label Study to Compare
the
Efficacy and Safety of Pomalidomide (POM), Bortezomib (BTZ) and
Low-Dose Dexamethasone (LD-DEX) versus Bortezomib and Low-Dose
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 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:
Vitals: 97.7 98 110/54 23 97%3L
Gen: NAD, able to speak in complete sentences
HEENT: no cervical lad, no thrush
CV: rrr, no r/m/g
Pulm: poor air movement, diffuse wheeze
Abd: soft, nt/nd, +bs
Ext: no edema
Neuro: alert and oriented x 3
Exam on discharge:
97.8 130/55 93 20 95%RA
Sitting in bed in NAD, Able to speak in full sentences
HEENT: MMM, no lesions
LUNGS: Clear B/L at bases, +expiratory wheeze on forced
expiration
___: RRR S1 S2 present
ABD: Soft, slightly distended, non-tender
Ext: No edema, chronic skin changes on anterior shins
NEURO: AAOx3, pleasant and cooperative
Pertinent Results:
___ 06:48PM WBC-12.4*# RBC-3.55* HGB-12.5 HCT-37.4
MCV-105* MCH-35.1* MCHC-33.3 RDW-15.9*
___ 06:48PM PLT COUNT-315#
___ 06:48PM ___ PTT-28.8 ___
___ 06:48PM GLUCOSE-84 UREA N-21* CREAT-0.9 SODIUM-137
POTASSIUM-4.6 CHLORIDE-99 TOTAL CO2-29 ANION GAP-14
___ 06:48PM proBNP-180
___ 06:48PM cTropnT-<0.01
CXR:
1. Hyperinflated lungs compatible with chronic obstructive
pulmonary disease,
but no focal consolidation.
2. Persistent left upper lobe opacity may represent a
parenchymal nodule and
further evaluation via non-urgent Chest CT may be indicated.
CT chest:
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism.
2. 5 mm right upper lobe nodule, not clearly seen on prior
studies. Followup
with dedicated chest CT is recommended in 6 months. Additional
pulmonary
nodules are stable since at least ___.
3. Small focal right lower lobe aspiration. No consolidation.
4. Panlobular emphysema with lower lobe predominance, typically
seen in alpha
1 antitrypsin deficiency, but per the medical record, there is
no history of
this.
5. Moderate to severe stenosis at the origin of the celiac axis.
Brief Hospital Course:
___ yo F with asthma/copd, multiple myeloma here with subacute
dyspnea and wheezing not responding to increasing doses of
steroids as outpatient.
# Asthma/COPD -
#Pneumonia, bacterial
The patient presented with significant dyspnea on exertion in
addition to increased cough with sputum production concerning
for COPD exacerbation. She was seen by her pulmonologist, Dr.
___ recommended high dose steroids. She also underwent a
CT chest which ruled out PE but raised concern for a RLL
infiltrate. Additionally, the pulmonary team suggested checking
ANCA and IgE which were negative. Aspergillus specific
antibodies is pending on discharge. Given failure to improve on
steroids, the patent was started on Meropenem with some
improvement in her symptoms. Given her immunocompromised state,
significant underlying lung disease the decision was made to
continue IV Ertapenem for a total of 7 days. The patent was
discharged on a steroid taper (80mg decrease by 10mg every 4
days) with close follow up with both her oncologist and
pulmonologist. As an outpatient can consider allergic work up
and work up for tracheobronchomalacia. The patent was continued
on her home Spiriva, Advair and nebulizers on discharge.
#Multiple Myeloma
Currently off treatment given COPD exacerbations. Continued
Bactrim and acyclovir ppx
#Pulmonary nodule
Not seen on previous images- repeat CT in 6months, patient
aware, letter sent to PCP
___ issues:
- Continue Ertapenem until ___
- repeat CT in 6months to asses pumonary nodule
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO BID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN dyspnea
3. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze
4. Azithromycin 250 mg PO Q24H
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Lorazepam 0.5 mg PO QHS:PRN insomnia
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Aspirin 81 mg PO DAILY
10. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO BID
2. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN dyspnea
3. Aspirin 81 mg PO DAILY
4. Azithromycin 250 mg PO Q24H
5. Docusate Sodium 100 mg PO DAILY
6. Lorazepam 0.5 mg PO QHS:PRN insomnia
7. PredniSONE 80 mg PO DAILY Duration: 1 Dose
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
RX *prednisone 10 mg 8 tablet(s) by mouth daily Disp #*104
Tablet Refills:*0
8. PredniSONE 70 mg PO DAILY Duration: 4 Doses
Start: After 80 mg DAILY tapered dose
9. PredniSONE 60 mg PO DAILY Duration: 4 Doses
Start: After 70 mg DAILY tapered dose
10. PredniSONE 50 mg PO DAILY Duration: 4 Doses
Start: After 60 mg DAILY tapered dose
11. PredniSONE 40 mg PO DAILY Duration: 4 Doses
Start: After 50 mg DAILY tapered dose
12. PredniSONE 30 mg PO DAILY Duration: 4 Doses
Start: After 40 mg DAILY tapered dose
13. PredniSONE 20 mg PO DAILY Duration: 4 Doses
Start: After 30 mg DAILY tapered dose
14. PredniSONE 10 mg PO DAILY Duration: 4 Doses
Start: After 20 mg DAILY tapered dose
15. Psyllium 1 PKT PO DAILY
16. Ranitidine 150 mg PO QAM
17. Ranitidine 75 mg PO QHS
18. Senna 8.6 mg PO DAILY:PRN constipation
19. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
20. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheeze
21. Artificial Tears ___ DROP BOTH EYES QAM
22. Ascorbic Acid ___ mg PO DAILY
23. Benefiber (guar gum) (guar gum) 0 . ORAL DAILY
24. Flovent HFA (fluticasone) 220 mcg/actuation inhalation Other
25. Glucosamine Sulf-Chondroitin (glucosamine ___ 2KCl-chondroit)
500-400 mg oral DAILY
26. Guaifenesin ___ mL PO Q4H:PRN cough
27. Guaifenesin-Dextromethorphan 5 mL PO Q4H:PRN cough
28. Multivitamins 1 TAB PO DAILY
29. Tiotropium Bromide 1 CAP IH DAILY
30. Vitamin B Complex 1 CAP PO DAILY
31. carboxymethylcellulose 0 . MISCELLANEOUS QHS
32. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
33. Ertapenem Sodium 1 g IV DAILY Duration: 5 Doses
RX *ertapenem [Invanz] 1 gram 1 gm IV daily Disp #*5 Vial
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
COPD exacerbation
Pneumonia
Multiple myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with difficulty breathing.
You had a CT of your chest which showed a possible infection.
With the help of your pulmonologist, a decision was made to
start you on antibiotics for pneumonia. You had a PICC line
placed and you will continue on Ertapenem to complete a 7 day
course.
You were also given high dose steriods. You will be discharged
on 80mg daily and you should reduce your dose by 10mg every four
days.
Please follow up with your oncologist and with your
pulmonologist as scheduled.
Followup Instructions:
___
|
19797687-DS-21
| 19,797,687 | 28,866,675 |
DS
| 21 |
2164-04-26 00:00:00
|
2164-04-26 18:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Mustard / Levaquin / Ceftriaxone / Benadryl /
cefepime
Attending: ___.
Chief Complaint:
Shortness of breath, confusion, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yoF followed by Dr. ___ with hx of multiple myeloma
(___) tx with radiation to right distal tibia, Elotuzumab +
4 cycles of Revlimid and Decadron, ___ Revlimid/Dex therapy.
___: started therapy on clinical trial Protocol ___:
patient was randomized to the Velcade/Dex arm, completed 2
cycles of velcade/dex. Course has been complicated by mixed
asthma, copd, multiple admissions for exacerbations I/s/o
infection and chemotherapy induced dyspnea often requiring
prolonged steroid tapers. Pt has been on azithromycin since
___. Most recently pt was admitted in ___ with pan
sensitive pseudomonas PNA and possibly aspergillus ___
(oropharyngeal contamination invalidated results). She was
treated with 14d meropenem. Multiple myeloma tx was held at this
time I/s/o infection and decreased stability. After pt was
started on Carfilzomib which was interrupted by SOB. ECHO which
did not show evidence of HF. There was some concern that that
she could be having some immune inf response for Carfilomib so
tx was held. Ninlaro 4mg 3 weeks + dexamethasone 20mg once
weekly was started on ___.
Last night she p/w fever, hypotension, tachycardia, AMS and CXR
showing Multifocal pneumonia with a small left pleural effusion.
The patient was found at her home by her son to be very
confused so he brought her to the ED. She is alert and oriented
on admission but is unsure of some details over the last few
days. The son thinks she has probably been ill for about 3 days.
She has chronic shortness of breath and cough and is unsure if
this has worsened at all. She is not aware of any fevers at
home. She has not been eating or drinking much for the last few
days or taking care of herself. Her son noted diarrhea near her
when he found her. She thinks this may have been going on for
two days. She denies any nausea or dysuria.
In the ED she was noted to be hypotensive to 89/66, febrile to
102.6 tachycardic to 107 and hypoxic. She was also noted to have
a leukocytosis and ___. A CXR showed a pneumonia and she was
given vanc and meropenum.
Past Medical History:
(per chart, confirmed with pt and updated):
PAST ONCOLOGIC 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, Open-label Study to Compare
the
Efficacy and Safety of Pomalidomide (POM), Bortezomib (BTZ) and
Low-Dose Dexamethasone (LD-DEX) versus Bortezomib and Low-Dose
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
- currently on carfilzomib
PAST MEDICAL HISTORY:
- asthma - dx'ed ___
- COPD - dx'ed in ___, no smoking hx, thought to be due to
second hand smoke as husband was smoker
- GERD - ___
- HLD - ___, not on treatment
- anemia - dx'ed ___, resolved ___
- right rotator cuff tear -___
- chronic low back pain - ___
- s/p R meniscus repair - ___
- s/p L meniscus repair - ___
- Arthritis x ___ years
Social History:
___
Family History:
siblings: brother with mental health problems
children: 1 son, healthy
Father with chronic bronchitis
Physical Exam:
PHYSICAL EXAM ON ADMISSION
==========================
General: NAD
VITAL SIGNS: 98.3
PO 90 / 52 94 20 93 2.0LNC --> 100/50
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: Decreased breath at lower bases with inspiratory and
expiratory wheezing, +rhonchi with shifts when cough
ABD: Soft, ND, no masses or hepatosplenomegaly, mild tenderness
in LUQ
LIMBS: No edema, clubbing, tremors, or asterixis. + for
bruising
around ankles and darkened skin on anterior leg. Significant
bruise left ankle
NEURO: Alert and oriented x3. Unable to lift arms past elbow
joint, cannot elevate elbow.
Proximal upper extremity ___
Distal upper extremity ___
Proximal lower extremity ___
distal lower extremity ___
PHYSICAL EXAM ON DISCHARGE
=============================
VITAL SIGNS:
___ 98.4 PO 114 / 62 72 18 98 3L
1136 98.3 PO 102 / 64 75 18 98 3L NC
General: NAD, sleeping comfortably in bed with sleep mask over
eyes and shawl around shoulders
HEENT: MMM, no OP lesions
CV: RRR, NL S1S2
PULM: Decreased breath at lower bases bilaterally (R worse than
L), poor inspiratory effort; seems unchanged from prior
ABDOMEN: soft NT ND; small area of ecchymosis LLQ from
injections.
LIMBS: 1+ edema ___ bilaterally, trace edema LUE forearm
persists
Skin: large band of ecchymosis L abdomen/pannus, stretching from
hip toward pubis continues to improve.
NEURO: Alert and responding to questions appropriately; moving
all extremities. EOMI grossly, full ROM in upper extremities
bilaterally; ___ ___ bilaterally. Speech fluent.
Lines: R arm midline placed, no bleeding or surrounding erythema
noted after procedure.
Pertinent Results:
Admission
___ 11:37PM BLOOD WBC-12.4*# RBC-3.75* Hgb-12.6 Hct-40.7
MCV-109* MCH-33.6* MCHC-31.0* RDW-14.3 RDWSD-57.5* Plt ___
___ 11:37PM BLOOD Neuts-62 Bands-33* ___ Monos-3*
Eos-0 Baso-0 ___ Metas-1* Myelos-1* NRBC-1* AbsNeut-11.78*
AbsLymp-0.00* AbsMono-0.37 AbsEos-0.00* AbsBaso-0.00*
___ 11:37PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-3+ Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
___ 11:37PM BLOOD ___ PTT-35.2 ___
___ 09:30AM BLOOD ___
___ 11:37PM BLOOD Glucose-193* UreaN-38* Creat-1.6* Na-136
K-4.3 Cl-97 HCO3-20* AnGap-23*
___ 11:37PM BLOOD ALT-31 AST-53* AlkPhos-80 TotBili-0.4
DirBili-<0.2 IndBili-0.4
___ 11:37PM BLOOD cTropnT-<0.01
___ 11:37PM BLOOD Albumin-3.0* Calcium-8.5 Mg-2.1
___ 09:30AM BLOOD Free T4-1.2
___ 09:30AM BLOOD PEP-PND FreeKap-PND FreeLam-PND
b2micro-4.4* IgG-1187 IgA-<5* IgM-<5*
___ 11:37PM BLOOD
___ 11:50PM BLOOD Lactate-2.2*
RELEVANT IMAGING
=================
Modified Barium Swallow ___
IMPRESSION:
1. No significant spontaneous gastroesophageal reflux was seen
during this examination will while the patient was in supine
position or turning either towards the right or towards the
left.
2. No gross aspiration is seen during this examination.
3. There is notable dysmotility, with incomplete emptying of
the esophagus and residua seen within the esophagus after each
swallow, despite attempts to clear using subsequent dry
swallows.
CXR ___
IMPRESSION:
Multifocal pneumonia with a small left pleural effusion.
CT Chest w/o Contrast ___
IMPRESSION:
Borderline sized mediastinal lymph nodes. New multifocal
pneumonia.
Subsequent areas of consolidations and opacities in the middle
lobe, the
lingular and the left and right lower lobe. Accompanying
moderate pleural
effusions. Moderate coronary and aortic wall calcifications.
U/S UE ___
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
U/S ___ ___
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity veins.
2. Left ___ cyst, stable from ___.
U/S UE ___
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
RELEVANT MICROBIOLOGY
=====================
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
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 and/or Influenza PCR
(results
listed under "OTHER" tab) for further information.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
___ 12:00 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. RARE GROWTH.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
MRSA SCREEN (Final ___: No MRSA isolated.
PERTINENT LABS AND LABS ON DISCHARGE
=======================================
___ 06:35AM BLOOD WBC-5.7 RBC-2.97* Hgb-9.9* Hct-31.0*
MCV-104* MCH-33.3* MCHC-31.9* RDW-14.2 RDWSD-54.0* Plt ___
___ 06:20AM BLOOD WBC-5.1 RBC-2.89* Hgb-9.9* Hct-30.5*
MCV-106* MCH-34.3* MCHC-32.5 RDW-14.4 RDWSD-56.2* Plt ___
___ 07:50AM BLOOD WBC-7.0 RBC-3.02* Hgb-10.2* Hct-32.1*
MCV-106* MCH-33.8* MCHC-31.8* RDW-14.5 RDWSD-56.8* Plt ___
___ 05:32AM BLOOD WBC-7.0 RBC-3.00* Hgb-10.0* Hct-31.7*
MCV-106* MCH-33.3* MCHC-31.5* RDW-14.4 RDWSD-56.1* Plt ___
___ 06:10AM BLOOD WBC-8.7 RBC-3.19* Hgb-10.6* Hct-34.3
MCV-108* MCH-33.2* MCHC-30.9* RDW-14.4 RDWSD-56.9* Plt ___
___ 06:05AM BLOOD WBC-6.9 RBC-2.96* Hgb-9.7* Hct-31.5*
MCV-106* MCH-32.8* MCHC-30.8* RDW-14.6 RDWSD-56.2* Plt ___
___ 06:05AM BLOOD WBC-6.1 RBC-2.78* Hgb-9.3* Hct-30.1*
MCV-108* MCH-33.5* MCHC-30.9* RDW-14.5 RDWSD-57.6* Plt ___
___ 06:15AM BLOOD WBC-7.3 RBC-2.91* Hgb-9.6* Hct-31.5*
MCV-108* MCH-33.0* MCHC-30.5* RDW-14.3 RDWSD-57.1* Plt ___
___ 07:50AM BLOOD Neuts-80* Bands-3 Lymphs-7* Monos-10
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-5.81 AbsLymp-0.49*
AbsMono-0.70 AbsEos-0.00* AbsBaso-0.00*
___ 05:32AM BLOOD Neuts-88* Bands-2 Lymphs-3* Monos-3*
Eos-0 Baso-0 ___ Metas-4* Myelos-0 AbsNeut-6.30*
AbsLymp-0.21* AbsMono-0.21 AbsEos-0.00* AbsBaso-0.00*
___ 06:10AM BLOOD Neuts-72* Bands-3 Lymphs-12* Monos-3*
Eos-3 Baso-0 ___ Metas-5* Myelos-2* AbsNeut-6.53*
AbsLymp-1.04* AbsMono-0.26 AbsEos-0.26 AbsBaso-0.00*
___ 06:05AM BLOOD Neuts-87* Bands-0 Lymphs-4* Monos-7 Eos-1
Baso-0 ___ Myelos-1* AbsNeut-6.00 AbsLymp-0.28*
AbsMono-0.48 AbsEos-0.07 AbsBaso-0.00*
___ 06:05AM BLOOD Neuts-86* Bands-0 Lymphs-10* Monos-3*
Eos-1 Baso-0 ___ Myelos-0 AbsNeut-5.25 AbsLymp-0.61*
AbsMono-0.18* AbsEos-0.06 AbsBaso-0.00*
___ 06:15AM BLOOD Neuts-79.4* Lymphs-8.5* Monos-9.0 Eos-1.2
Baso-0.1 Im ___ AbsNeut-5.76 AbsLymp-0.62* AbsMono-0.65
AbsEos-0.09 AbsBaso-0.01
___ 06:05AM BLOOD ___ PTT-30.0 ___
___ 06:05AM BLOOD ___ PTT-30.0 ___
___ 06:15AM BLOOD ___ PTT-31.0 ___
___ 06:20AM BLOOD ___
___ 06:35AM BLOOD ___
___ 06:05AM BLOOD ___
___ 06:15AM BLOOD ___ 06:20AM BLOOD Glucose-153* UreaN-28* Creat-1.0 Na-144
K-3.5 Cl-108 HCO3-29 AnGap-11
___ 07:50AM BLOOD Glucose-156* UreaN-28* Creat-0.9 Na-145
K-3.8 Cl-108 HCO3-30 AnGap-11
___ 05:32AM BLOOD Glucose-87 UreaN-25* Creat-0.9 Na-141
K-3.5 Cl-104 HCO3-29 AnGap-12
___ 06:10AM BLOOD Glucose-93 UreaN-25* Creat-0.9 Na-142
K-4.4 Cl-101 HCO3-33* AnGap-12
___ 06:05AM BLOOD Glucose-88 UreaN-23* Creat-1.0 Na-142
K-4.2 Cl-101 HCO3-36* AnGap-9
___ 06:05AM BLOOD Glucose-85 UreaN-22* Creat-1.0 Na-141
K-4.2 Cl-100 HCO3-38* AnGap-7*
___ 06:15AM BLOOD Glucose-83 UreaN-19 Creat-0.9 Na-142
K-4.2 Cl-101 HCO3-36* AnGap-9
___ 07:50AM BLOOD Albumin-2.3* Calcium-8.4 Phos-3.6 Mg-2.0
___ 05:32AM BLOOD Albumin-2.2* Calcium-8.6 Phos-3.4 Mg-1.8
___ 06:10AM BLOOD Albumin-2.4* Calcium-8.8 Phos-3.7 Mg-1.9
___ 06:05AM BLOOD Calcium-8.5 Phos-3.0
___ 06:05AM BLOOD Albumin-2.2* Calcium-8.5 Phos-3.1 Mg-2.2
___ 06:15AM BLOOD Albumin-2.6* Calcium-8.6 Phos-2.8 Mg-2.3
___ 09:30AM BLOOD PEP-ABNORMAL B b2micro-4.4* IgG-1187
IgA-<5* IgM-<5*
___ 11:37PM BLOOD ___ FreeLam-2.7* Fr K/L-5.59*
Brief Hospital Course:
___ w/ IgG kappa MM recently started on ninlaro/dex
___, has finished 2 cycles, ___ cycle ___, w/ hx
chronic obstructive asthma and COPD (never smoker; FEV1 51%;
supposed to be on home O2 but does not use), multiple prior
pulmonary infections p/w confusion, hypotension, bandemia, and
found to have multifocal PNA.
#PNA: Multiple prior PNAs, most recently ___ w/ Pseudomonas
and Aspergillus ___ on sputum sample ___ of unclear
significance at the time (galactomannan negative, ultimately not
treated). Psuedomonas tx in the past with 14d meropenem. On
admission, pt was AOx3 with diffuse weakness, cough. Physical
exam notable for rhonchi and mild inspiratory and expiratory
wheezing with a wet weak cough with O2 requirement of 2LNC. Pt
was started on meropenem and had a total of 2 doses of vanc and
immediately improved with all her symptoms. CT scan on ___
notable for borderline sized mediastinal lymph nodes. New
multifocal pneumonia. Subsequent areas of consolidations and
opacities in the middle lobe, the lingular and the left and
right lower lobe. Accompanying moderate pleural effusions.
Vancomycin was discontinued as its levels were found to be
sub-theraputic with significant improvement overnight. Pulmonary
consulted and recommended no bronchoscopy. ID consulted and
agreed with keeping her on meropenem for three weeks, end date
___. Work up for fungal infection/ sputumm cultures, viral
cultures pertinent for pseudomonas growth with pan
susceptibility. Azithromycin continued as prescribed in
outpatient. On day of discharge, patient's respiratory status
remained stable; still requiring 3L NC with sats in high ___.
Per ___ evaluation, Shows signs of improving mobility as pt is
able to ambulate 350' with S and SC and steady gait; however, pt
continuous to require O2 at rest, increased with mobility
secondary to desaturation. Pt is functionally appropriate for
d/c to home with A and home ___ services when pt is medically
stable. Recommend continued physical therapy and conditioning at
rehab facility to prevent further deconditioning as outpatient.
#Diarrhea
Pt was found unkept in her home with diarrhea. Patient states
she has never had diarrhea. BM normal during hospital course
with some constipation. W/u with C. difficile DNA amplification
assay; Cryptosporidium/Giardia (DFA); Cyclospora; Stool culture;
Microsporidium; Stool culture - E.coli 0157:H7; Stool culture -
Yersinia; Ova and Parasites; Viral culture all negative. Please
see full results section.
#MM: Recently started ixazomib/dex after rise in M protein on
carfilzomib/dex. Last BMBx ___ cycle of ninlaro and dex
due for ___ which was held. Pt was changed from 7.5mg prednisone
to Hydrocortisone Na Succ. 50 mg IV Q6H for stress dosing and
was tapered off and back to her home dose on ___. Now on
prednisone 7.5 mg daily. PPX were continued with Acyclovir 400
mg PO/NG Q12H, Aspirin 81 mg PO/NG DAILY.
# Cough
___ to infection or GERD, chronic since ___, worse at night
when laying at 45 degree angle to sleep. Added mucomyst and
omeprazole, d/c zantac on ___. Will follow with pulm/Id as
outpatient to consider IH tobra therapy.
#Macrocytic anemia
No B12 or folate deficiency.
#Coagulopathy; elevated INR ___ on 1.7; Vit K 5mg PO x3 days
(___). Now stable.
#Diffuse weakness, decreased strength
___ to infection or medication induced with ninlaro/dex. Ft4
normal. Strength improved with treatment of pneumonia. Patient
still with deconditioning during hospitalization
___
___ to poor PO intake in setting of confusion from infection.
Resolved after fluids.
# Asthma/COPD
Continued home advair, Spiriva, azithromycin, albuterol, and
combivent.
# GERD: Home zantac changed to omeprazole as per above.
BOWEL REGIMEN:
-Held home senna, magnesium, Metamucil, Colace, and benefiber
given diarrhea initially. Continued when constipated.
====================
Transitional issues
___ with GI for possible promotility agent to prevent
aspiration
___ with repeat CXR prior to ID visit ___ with Dr. ___ third cycle of ninlaro and dex
___ with ID as outpatient for possible inhaled tobramycin
therapy
5. Per discussion with ID no need for lab draw for monitoring
from their perspective; further evaluation per Heme/Onc
recommendations.
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. Azithromycin 250 mg PO Q24H
5. Magnesium Oxide 250 mg PO DAILY
6. PredniSONE 7.5 mg PO DAILY
7. Psyllium Powder 1 PKT PO DAILY
8. Senna 8.6 mg PO DAILY:PRN constipation
9. Vitamin B Complex 1 CAP PO DAILY
10. ipratropium-albuterol ___ mcg/actuation inhalation
Q6H:PRN dyspnea/wheeze
11. Multivitamins 1 TAB PO DAILY
12. GenTeal Mild to Moderate (artificial tears(hypromellose))
0.3 % ophthalmic ___ gtt QAM
13. Dexamethasone 20 mg PO 1X/WEEK (TH)
14. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
15. Ninlaro (ixazomib) 4 mg oral DAILY
16. Benefiber Clear SF (dextrin) (wheat dextrin) Dose is Unknown
oral DAILY
17. Lactobacillus acidophilus Dose is Unknown oral DAILY
18. Ranitidine 150 mg PO DAILY
19. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing
20. LORazepam 0.5 mg PO QHS:PRN Anxiety
21. Docusate Sodium 100 mg PO DAILY:PRN Constipation
22. Tiotropium Bromide 1 CAP IH DAILY
23. GuaiFENesin ER 600 mg PO Q12H:PRN Cough
24. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Medications:
1. Benzonatate 100 mg PO TID cough
You may stop taking this medication when your cough gets better.
2. Calcium Carbonate 500 mg PO QID:PRN upset stomach
3. Caphosol 30 mL ORAL QID:PRN dry mouth
4. Enoxaparin Sodium 30 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
5. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
6. Meropenem 500 mg IV Q8H
Please continue this medication until ___.
7. Milk of Magnesia 30 mL PO Q8H:PRN constipation
8. Omeprazole 40 mg PO DAILY
9. Acyclovir 400 mg PO Q12H
10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing
11. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing
12. Ascorbic Acid ___ mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Azithromycin 250 mg PO Q24H
15. Benefiber Clear SF (dextrin) (wheat dextrin) Dose is
Unknown ORAL DAILY
16. Docusate Sodium 100 mg PO DAILY:PRN Constipation
17. Flovent HFA (fluticasone) 220 mcg/actuation inhalation BID
18. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
19. GenTeal Mild to Moderate (artificial tears(hypromellose))
0.3 % ophthalmic ___ gtt QAM
20. GuaiFENesin ER 600 mg PO Q12H:PRN Cough
21. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
22. ipratropium-albuterol ___ mcg/actuation inhalation
Q6H:PRN dyspnea/wheeze
23. Lactobacillus acidophilus Dose is Unknown ORAL DAILY
24. LORazepam 0.5 mg PO QHS:PRN Anxiety
25. Multivitamins 1 TAB PO DAILY
26. PredniSONE 7.5 mg PO DAILY
27. Psyllium Powder 1 PKT PO DAILY
28. Senna 8.6 mg PO DAILY:PRN constipation
29. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
30. Tiotropium Bromide 1 CAP IH DAILY
31. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Multifocal pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You came in with
shortness of breath, confusion and fever. An image of your lungs
showed you had pneumonia and you were treated on antibiotics.
Your shortness of breath improved as well as your confusion.
Please continue taking the antibiotics through the ___ line at
the rehab facility (they will end on ___
You will have close follow up with Dr. ___ continuation
of your multiple myeloma meds, as well as our Infectious Disease
doctors (___) and your pulmonolgist (Dr. ___ for repeat
imaging of your lungs.
We are wishing you all the best and good luck on your next
performance!
Sincerely,
Your ___ team
Followup Instructions:
___
|
19797687-DS-23
| 19,797,687 | 27,682,568 |
DS
| 23 |
2164-06-14 00:00:00
|
2164-06-14 22:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Mustard / Levaquin / Ceftriaxone / Benadryl /
cefepime
Attending: ___.
Chief Complaint:
Difficulty with antibiotic infusions at home
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with a history of COPD and multiple myeloma,
recently treated at ___ for a pulmonary abscess with MDR
pseudomonas, discharged on ceftazidime/avibactam who is admitted
due to logistical issues with PICC and infusion company which
resulted ___ 3 missed antibiotic doses as an outpatient.
Patient was recently hospitalized from ___ for a
complicated hospital course most notably for a pulmonary
abscess. Given the complexity of her situation, she was
eventually discharged home to complete 4 weeks of
ceftazidime/avibactam therapy with ___ administration at 1200
and patient self administrating at 2400. Over the past few days,
Mrs ___ has had increasing difficulty getting her PICC line
to flush with medication. She contacted her PCP for help,
although there were significant issues with communication
between Pt/PCP and infusion company/PNA. This resulted ___
patient missing 3 doses total. Given the difficulty managing her
as an outpatient, her difficult infection, and logistical
challenges, she was referred ___ to the hospital for admission ___
order to get missed medication doses and set up secure home
services. Per patient, she had no problem with the PICC line,
but rather with the regulator of the antibiotic infuser.
___ regards to her infection, Mrs ___ has been doing well.
Her pulmonary symptoms have been improving. Although she still
requires oxygen, her cough may have somewhat improved. No fevers
or chills.
REVIEW OF SYSTEMS: Positive as per HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___: began developing pain ___ 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 ___.
- ___: Bone marrow biopsy with 30% monoclonal plasma cells
- ___ - ___: Radiation 35 Gy ___ 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, Open-label Study to Compare
the Efficacy and Safety of Pomalidomide (POM), Bortezomib (BTZ)
and
Low-Dose Dexamethasone (LD-DEX) versus Bortezomib and Low-Dose
Dexamethasone ___ Subjects with Relapsed or Refractory Multiple
Myeloma (MM).
- patient was randomized to the Velcade/Dex arm
- ___: Cycle 1 Velcade/Dex
- ___: Cycle 2 Velcade/Dex
- currently on carfilzomib
- Started ninlaro and dexamethasone on ___.
PAST MEDICAL HISTORY
- asthma - dx'ed ___
- COPD - dx'ed ___ ___, no smoking hx, thought to be due to
second hand smoke as husband was smoker
- GERD - ___
- HLD - ___, not on treatment
- anemia - dx'ed ___, resolved ___
- right rotator cuff tear -___
- chronic low back pain - ___
- s/p R meniscus repair - ___
- s/p L meniscus repair - ___
- Arthritis x ___ years
Social History:
___
Family History:
Siblings: brother with mental health problems
Children: 1 son, healthy
Father with chronic bronchitis
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VITALS: 98.2 110 / 52 100 18 98 1.5L
GEN: Thin woman lying ___ bed with nasal cannula on, not ___
apparent respiratory distress, appears comfortable.
HEENT: Oropharynx without erythema, exudate, or erosion, mucus
membranes appear moist. Sclera anicteric. Neck supple.
CV: RRR, normal S1S2 without audible murmurs
CHEST: Exam limited secondary to coughing; poor air entry ___ the
lower fields, marked diffuse rhonchi
ABD: Soft, non-tender, non-distended
LIMBS: No edema, clubbing, tremors, or asterixis. Purple
ecchymoses on the upper and lower extremities. Chronic venous
stasis changes ___ the lower extremities bilaterally.
SKIN: No rashes, bruises and venous stasis changes as noted
above
NEURO: Alert and oriented, no focal deficits.
PHYSICAL EXAM ON DISCHARGE:
===========================
GEN: Thin woman lying ___ bed with nasal cannula on at 1.5 L and
eye mask, not ___ apparent respiratory distress, appears
comfortable.
HEENT: Oropharynx without erythema, exudate, or erosion, mucus
membranes appear moist. Sclera anicteric. Neck supple.
CV: RRR, normal S1S2 without audible murmurs
CHEST: Poor air entry ___ the lower fields, marked diffuse
rhonchi
ABD: Soft, non-tender, non-distended
LIMBS: No edema, clubbing, tremors, or asterixis. Purple
ecchymoses on the upper and lower extremities. Chronic venous
stasis changes ___ the lower extremities bilaterally. L 1.5 cm
tibial wound on anterior aspect of leg, no purulent drainage or
erythema.
SKIN: No rashes, bruises and venous stasis changes as noted
above
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 12:40PM BLOOD WBC-7.8 RBC-2.50* Hgb-8.5* Hct-27.0*
MCV-108* MCH-34.0* MCHC-31.5* RDW-13.9 RDWSD-55.3* Plt ___
___ 12:40PM BLOOD Neuts-85.3* Lymphs-4.0* Monos-7.5 Eos-2.0
Baso-0.4 Im ___ AbsNeut-6.68* AbsLymp-0.31* AbsMono-0.59
AbsEos-0.16 AbsBaso-0.03
___ 05:04PM BLOOD ___ PTT-35.3 ___
___ 12:40PM BLOOD Glucose-103* UreaN-21* Creat-1.4* Na-135
K-4.1 Cl-97 HCO3-28 AnGap-14
___ 05:04PM BLOOD ALT-27 AST-33 LD(LDH)-228 AlkPhos-60
TotBili-<0.2
___ 12:40PM BLOOD Calcium-9.0 Mg-2.0
PERTINENT INTERVAL LABS:
========================
___ 07:00AM BLOOD IgG-3174* IgA-22* IgM-9*
___ 12:40PM BLOOD ___ Fr K/L-2.1*
LAB RESULTS ON DISCHARGE:
=========================
___ 07:00AM BLOOD WBC-4.1 RBC-2.35* Hgb-7.9* Hct-25.3*
MCV-108* MCH-33.6* MCHC-31.2* RDW-13.8 RDWSD-54.2* Plt ___
___ 07:00AM BLOOD Neuts-63.4 Lymphs-12.0* Monos-18.8*
Eos-5.1 Baso-0.2 Im ___ AbsNeut-2.59 AbsLymp-0.49*
AbsMono-0.77 AbsEos-0.21 AbsBaso-0.01
___ 07:00AM BLOOD ___ PTT-32.0 ___
___ 07:00AM BLOOD Glucose-88 UreaN-22* Creat-1.2* Na-142
K-4.2 Cl-106 HCO3-29 AnGap-11
___ 07:00AM BLOOD ALT-21 AST-18 LD(LDH)-202 AlkPhos-46
TotBili-<0.2
___ 07:00AM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.4 Mg-2.1
MICROBIOLOGY:
=============
___ 12:17 pm SPUTUM Source: Expectorated.
ACID-FAST SMEAR & CULTURE ADDED ON ___ PER FAX.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
WORK-UP REQUEST BY ___ ___ ___ .
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
ZERBAXA AND CEFTAZIDIME/AVIBACTAM Sensitivity testing
per ___
___ ___. CEFTAZIDIME /AVIBACTAM = ___ MCG/ML =
SUSCEPTIBLE.
CEFTAZIDIME /AVIBACTAM SUSCEPTIBILITY PERFORMED BY THE
ALLERGAN
REFERENCE LAB.
PLEASE REFER TO ___ FOR CEFTOLOZANE/TAZOBACTAM
SUSCEPTIBILITY.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 8 R
PIPERACILLIN/TAZO----- I
TOBRAMYCIN------------ <=1 S
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
Time Taken Not Noted ___ Date/Time: ___ 4:54 pm
TRACHEAL ASPIRATE Site: TRACHEA
TRACHEAL ASPIRATE, SPECIMEN TYPE CONFIRMED PER ___
___
19:25.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SECOND TYPE.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
CEFTOLOZANE/TAZOBACTAM Sensitivity testing per ___
___ ___.
SENT FOR CEFTOLOZANE/ TAZOBACTAM TESTING AT LAB
___, ___
___. CEFTOLOZANE/ TAZOBACTAM MIC OF ___ MCG/ML =
RESISTANT.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 16 I 32 R
CEFTAZIDIME----------- 16 I 8 S
CIPROFLOXACIN--------- 1 S =>4 R
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM------------- 1 S 8 R
PIPERACILLIN/TAZO----- 8 S R
TOBRAMYCIN------------ <=1 S <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
IMAGING:
========
CXR ___
Persistent right basilar opacity although improved since ___. This is likely due to known underlying pulmonary
abscess/consolidation. Suspected residual small effusion on the
right as well as left lower lobe atelectasis.
Left PICC tip projects over the upper right atrium.
RENAL ULTRASOUND ___
1. Unremarkable renal ultrasound.
2. Patient reports voiding 15 min before the exam, but bladder
appears
moderately distended. Finding is suggestive of moderate-large
postvoid
residual bladder volume.
Brief Hospital Course:
Mrs ___ is an ___ woman with a history of COPD
and multiple myeloma, recently on Ninlaro therapy and recently
hospitalized with a MDR pseudomonas pulmonary abscess who was
re-admitted with difficulties with her infusion pump at home,
resulting ___ multiple missed antibiotic doses.
# Pulmonary abscess: From a clinical standpoint, patient did not
have any worse respiratory or infectious symptoms. No fevers. O2
requirements remained stable. Pulmonary imaging without
significant interval change. Patient expressed difficulty with
working the infusion pump. After discussion with case
management, it was decided that patient would return home with
daily ___ services for her 1200 dose. Mrs. ___
agreed to pay for private nursing to come ___ the evening and run
her infusion for the first several scheduled 2400 doses. Her son
would accompany her and both would receive daily teaching
regarding use of the infuser. Thereafter, patient's son would
help with her 2400 doses until antibiotic course completion. If
she had any difficulty with infusion, they could call ___ hour
on-call infusion nurse, available at ___ for
infusion-related difficulties. She will resume her regularly
scheduled OPAT follow-up.
# Multiple Myeloma: Ninlaro currently on hold secondary to
recurrent lung infections. Acyclovir, Bactrim, Ativan, and
vitamin B were continued.
# Acute kidney injury: Admission Cr 1.4 from recent baseline of
1.1. She has had documented exposure to tobramycin for 10 days
which could theoretically lead to direct tubular damage and
interstitial nephritis though the latter is less likely as she
doesn't have a perhiperhal eosinophilia or WBC ___ the urine.
Renal ultrasound had question of elevated PVR, but when actually
measuring PVR was < 50, hence obstructive cause unlikely. We
note that she has Albumin/Creatinine radio of 144.4. Free K/L
was 2.1. ___ had initially improved with increased PO fluid
intake back to recent baseline of 1.1, however increased
slightly to 1.2 on day of discharge, and she will require close
follow up of renal function.
# COPD/Asthma: Albuterol, adviar, guafenesin, prednisone,
tiotropium, bensonatate, and ipratropium were continued.
Azithromycin was discontinued at the recommendation of
infectious diseases consult during prior hospitalization.
# L shin wound: Patient has very fragile, thin skin from chronic
steroid use. Wound care nurse was concerned about L shin wound
appearance and thought it may require debridement. Per vascular
surgery, wound appears to be consistent with skin hematoma that
is healing and beginning to detach from wound base. Does not
appear infected. Does not appear to require debridement. Wound
care as follows: cover with xeroform then gauze; wrap with kling
and secure with medipore tape; change daily.
TRANSITIONAL ISSUES
====================
PULMONARY ABSCESS:
# Patient will require Q12H dosed at 1200 and 2400 x 4 weeks.
1200 dose to be performed by ___ services, while 2400 dose to be
administered by patient ___ conjunction with her son and a
private-pay nurse.
# OPAT Labs: WEEKLY: CBC/DIFF, BUN, Cr, AST, ALT, ALK PHOS,
TBILI
# OPAT CONTACT: **ATTN: ___ CLINIC - FAX: ___
# Infectious Disease Dept. will contact pt as needed for any
follow-up appointments
# Pt to be seen with pulmonary follow-up (Dr ___
# Pt to wear 1.5L supplemental O2 at all times with portable O2
concentrator
# Pt to have follow up CT at ___ ___
# Please draw CMP at next PCP appointment, follow creatinine
# A 24 hour on-call infusion nurse is available at
___ should patient have difficulty with her infusion
pump.
___
# Discharge Cr 1.2; she requires close follow up of renal
function
# Patient will require labs to be drawn ___ and faxed to
___ ATTN: ___. Labs: CBC/DIFF BUN, Cr, AST,
ALT, ALK PHOS, TBILI.
MULTIPLE MYELOMA
# Patient's myeloma treatments were placed on hold during this
hospitalization given her frequent lung infections.
# Patient to follow-up with Dr ___ as listed above for
ongoing treatment.
# Prophylactic mediations were continued.
COPD:
# Continue outpatient pred taper as dictated by pulmonary and
heme/onc.
# Contact: ___ (Son/HCP) ___
# Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Avycaz (ceftazidime-avibactam) 2.5 gram injection Q12H
2. Acyclovir 400 mg PO Q12H
3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing
5. Ascorbic Acid ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Benzonatate 100 mg PO TID cough
8. Calcium Carbonate 500 mg PO QID:PRN upset stomach
9. Caphosol 30 mL ORAL QID:PRN dry mouth
10. Docusate Sodium 100 mg PO DAILY:PRN Constipation
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
12. GuaiFENesin ER 600 mg PO Q12H:PRN Cough
13. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
14. LORazepam 0.5 mg PO QHS:PRN Anxiety
15. Milk of Magnesia 30 mL PO Q8H:PRN constipation
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 40 mg PO DAILY
18. PredniSONE 7.5 mg PO DAILY
19. Psyllium Powder 1 PKT PO DAILY
20. Senna 8.6 mg PO DAILY:PRN constipation
21. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
22. Tiotropium Bromide 1 CAP IH DAILY
23. Vitamin B Complex 1 CAP PO DAILY
24. GenTeal Mild to Moderate (artificial tears(hypromellose))
0.3 % ophthalmic ___ gtt QAM
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB, wheezing
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN Wheezing
4. Ascorbic Acid ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Avycaz (ceftazidime-avibactam) 2.5 gram injection Q12H
RX *ceftazidime-avibactam [Avycaz] 2.5 gram 2.5 G IV every
twelve (12) hours Disp #*32 Vial Refills:*0
7. Benzonatate 100 mg PO TID cough
8. Calcium Carbonate 500 mg PO QID:PRN upset stomach
9. Caphosol 30 mL ORAL QID:PRN dry mouth
10. Docusate Sodium 100 mg PO DAILY:PRN Constipation
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
12. GenTeal Mild to Moderate (artificial tears(hypromellose))
0.3 % ophthalmic ___ gtt QAM
13. GuaiFENesin ER 600 mg PO Q12H:PRN Cough
14. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
15. LORazepam 0.5 mg PO QHS:PRN Anxiety
16. Milk of Magnesia 30 mL PO Q8H:PRN constipation
17. Multivitamins 1 TAB PO DAILY
18. Omeprazole 40 mg PO DAILY
19. PredniSONE 7.5 mg PO DAILY
20. Psyllium Powder 1 PKT PO DAILY
21. Senna 8.6 mg PO DAILY:PRN constipation
22. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
23. Tiotropium Bromide 1 CAP IH DAILY
24. Vitamin B Complex 1 CAP PO DAILY
25.Outpatient Lab Work
Draw on ___
Labs: CBC/DIFF BUN, Cr, AST, ALT, ALK PHOS, TBILI
ICD 10: ___
FAX RESULTS TO: ___ ATTN: ___ CLINIC
26.Outpatient Lab Work
Draw on ___
Labs: CBC/DIFF BUN, Cr, AST, ALT, ALK PHOS, TBILI
ICD 10: ___
FAX RESULTS TO: ___ ATTN: ___ CLINIC
27.Outpatient Lab Work
Draw on ___
Labs: CBC/DIFF BUN, Cr, AST, ALT, ALK PHOS, TBILI
ICD 10: ___
FAX RESULTS TO: ___ ATTN: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Pulmonary Abscess
Multiple Myeloma
Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital because ___ were having
difficulty with your infusion pump at home and ___ had missed
some antibiotic dosing. While ___ were hospitalized,
***** Should ___ have any difficulty with the infusion pump
while at home, a 24 hour on-call infusion nurse is available at
___. Please call at any time with any questions.
*****
Please take all medications as prescribed and keep all scheduled
appointments.
It was a pleasure taking care of ___!
Your ___ Care Team
Followup Instructions:
___
|
19797687-DS-33
| 19,797,687 | 24,221,054 |
DS
| 33 |
2167-01-09 00:00:00
|
2167-01-09 13:01:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Mustard / Levaquin / Ceftriaxone / cefepime
Attending: ___.
Chief Complaint:
right intertrochanteric hip fracture
Major Surgical or Invasive Procedure:
right long TFN
History of Present Illness:
___ female with a history of MM (dx ___, not
eligible for auto-HSCT, most recently on
Pomalidomide/Carfilzomib/Dex therapy), chronic obstructive
asthma, osteoporosis on monthly zoledronic acid, recurrent
pneumonias on monthly IVIG, severe persistent asthma, and COPD
with eosinophilia (s/p treatment with mepolizumab) on home O2
2L,
who presents with right intertrochanteric/basicervical FNF after
trip and fall. She reports that she was walking this morning
and
tripped over her oxygen tubing. She fell around 11 AM. Her son
ended up finding her this evening around 9 ___. She reports that
although she was on the ground for that extended period of time
she was able to scoot around on her behind and was not in any
one
position too long. Any time she felt uncomfortable she was able
to move around. However she does report that she is in
excruciating pain and that the morphine that they have given her
does seem to help somewhat. She denies any numbness or
tingling,
head strike, loss of consciousness, chest pain, any new or
worsening dyspnea other than her baseline need for oxygen,
fevers, sweats, or chills.
Of note she does have some baseline bilateral shoulder and arm
pain. She does also have bilateral anterior tibia pain, as well
as "sensitive skin". She is not on any anticoagulation.
Past Medical History:
PAST ONCOLOGIC 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 ___.
-___: 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/___ ___ 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, Open-label Study to Compare
the Efficacy and Safety of Pomalidomide (POM), Bortezomib (BTZ)
and Low-Dose Dexamethasone (LD-DEX) versus Bortezomib and
Low-Dose 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
-currently on carfilzomib
-Started ninlaro and dexamethasone on ___.
-___: Initiated Pom + ___ (cycle 1 50% dose reduction)\
-___: Daratumumab (full dose) Plus Pomalyst 2mg daily ___
days
___- Present: Increase Pomalyst to 3mg,continue Daratumumab
DARATUMUMAB TREATMENT HISOTRY
=========================================
___ Dose 1: 50% dose reduction + Pom 2mg ___ days
___: Dose 2: Full dose - delay due to infection + Pom
___: Dose 3: Full dose given + Pom 3mg daily ___ days
___: Dose 4: Full dose given + Pom 3mg daily ___ days
___: Dose 5: Full dose given - Delay due to COPD + Pom 3mg
___: Dose 6: Full dose given + Pom 3mg daily ___ days
___: Dose 7: Full dose given + Pom 3mg daily ___ days
___: Dose 8: Full dose given + Pom 3mg daily ___ days
___: Dose 9: Full dose given + Pom 3mg daily ___ days
___: Dose 10: Full dose given + Pom 3mg daily ___ days
___: Dose 11: Full dose given + Pom 3mg daily ___ days
___: Dose 12: Full dose given + Pom 3mg daily ___ days
___: Dose 13: Full dose given + Pom 3mg daily ___ days
___: Dose 14: Full dose given + Pom 3mg daily ___ days
___: Dose 15: Full dose given + Pom 3mg daily ___ days
___: Dose 16: Full dose given + Pom 3mg daily ___ days
___: Dose 17: Full dose given + Pom 3mg daily ___ days
___: Dose 18: Full dose given + Pom 3mg daily ___ days
___- Dose 19 Full Dose given + Pom 2mg.
___- Dose 20 Full Dose given + Pom 2mg.
___- Dose 21 Full Dose given + Pom 2mg.
___- Dose 22 Full Dose ___, Pom 2mg daily ___ days
___ Dose 23 Full Dose ___, Pom 2mg daily for ___
days
___ Dose 24 Full Dose ___, Pom 2mg daily for ___
days
___ Dose 25 Full Dose ___, Pom 2mg daily for ___
days
___: Admit for new sternal fractures, pain control and
radiation therapy.
___: Dose 26. Full dose ___ Hold Pom after recent
completion of RT.
___: ___, ___ - Restart POM
___: Daratumumab every other week/Pom 2mg daily
___ days. Monthly IVIG. Monthly Zometa
___: Daratumumab monthly/Pom 2mg daily ___ days.
Monthly IVIG, Monthly Zometa
___: Continue Daratumumab maintenance. Pomalyst placed on
hold given ongoing functional decline in the setting of disease
stability.
PAST MEDICAL HISTORY
================================
-asthma - dx'ed ___
-COPD - dx'ed in ___, no smoking hx, thought to be due to
second hand smoke as husband was smoker
-GERD - ___
-HLD - ___, not on treatment
-anemia - dx'ed ___, resolved ___
-right rotator cuff tear -___
-chronic low back pain - ___
-s/p R meniscus repair - ___
-s/p L meniscus repair - ___
-Arthritis x ___ years
Social History:
___
Family History:
Siblings: brother with mental health problems
Children: 1 son, healthy
Father with chronic bronchitis
Physical Exam:
right lower extremity
-dressings intact
-fires ___
-silt s/s/sp/dp/t nerve distributions
-foot wwp
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right intertrochanteric hip fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for a right long TFN, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. 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
___ partial weight bearing in the right lower extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
3. Aspirin 81 mg PO DAILY
4. Azithromycin 250 mg PO Q24H
5. Bisacodyl 5 mg PO DAILY:PRN Constipation - Third Line
6. Fentanyl Patch 75 mcg/h TD Q72H
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. Furosemide 20 mg PO DAILY:PRN edema
9. GuaiFENesin ER 600 mg PO Q12H
10. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of
breath
11. LORazepam 0.5 mg PO QHS:PRN insomnia
12. Morphine Sulfate ___ 15 mg PO Q4H:PRN Pain - Moderate
13. Omeprazole 40 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. PredniSONE 5 mg PO DAILY
16. Psyllium Powder 1 PKT PO DAILY
17. Senna 8.6 mg PO BID:PRN Constipation - Third Line
18. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
19. Nucala (mepolizumab) 100 mg subcutaneous ASDIR
20. Magnesium Oxide 400 mg PO DAILY
21. Klor-Con 10 (potassium chloride) 10 mEq oral DAILY
22. guar gum 1 packet oral DAILY
23. Tiotropium Bromide 2 CAP IH DAILY
24. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
25. Pomalyst (pomalidomide) 2 mg oral DAILY
26. Dexamethasone 12 mg PO 1X/WEEK (FR) ASDIR
27. Docusate Sodium 200-300 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Enoxaparin Sodium 30 mg SC QHS
RX *enoxaparin 30 mg/0.3 mL ___t bedtime Disp #*28
Syringe Refills:*0
3. Acyclovir 400 mg PO Q12H
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
5. Aspirin 81 mg PO DAILY
6. Azithromycin 250 mg PO Q24H
7. Bisacodyl 5 mg PO DAILY:PRN Constipation - Third Line
8. Dexamethasone 12 mg PO 1X/WEEK (FR) ASDIR
9. Docusate Sodium 200-300 mg PO DAILY
10. Fentanyl Patch 75 mcg/h TD Q72H
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
12. Furosemide 20 mg PO DAILY:PRN edema
13. GuaiFENesin ER 600 mg PO Q12H
14. guar gum 1 packet oral DAILY
15. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of
breath
16. Klor-Con 10 (potassium chloride) 10 mEq oral DAILY
17. LORazepam 0.5 mg PO QHS:PRN insomnia
18. Magnesium Oxide 400 mg PO DAILY
19. Morphine Sulfate ___ 15 mg PO Q4H:PRN Pain - Moderate
20. Nucala (mepolizumab) 100 mg subcutaneous ASDIR
21. Omeprazole 40 mg PO DAILY
22. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
23. Polyethylene Glycol 17 g PO DAILY
24. Pomalyst (pomalidomide) 2 mg oral DAILY
25. PredniSONE 5 mg PO DAILY
26. Psyllium Powder 1 PKT PO DAILY
27. Senna 8.6 mg PO BID:PRN Constipation - Third Line
28. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
29. Tiotropium Bromide 2 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
right hip 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:
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:
- 50% partial weight bearing right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add *** as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___.
You will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
Physical Therapy:
see last ___ note
Treatments Frequency:
staples to be removed at two week postop appointment
Followup Instructions:
___
|
19797689-DS-24
| 19,797,689 | 22,027,509 |
DS
| 24 |
2187-07-06 00:00:00
|
2187-07-06 16:18:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F dCHF, afib (on coumadin) presents after fall from toilet
to carpeted floor. She does not recall events immediately
surrounding the fall, however denies any head strike or loss of
consciousness. Believes it happened as she was getting up from
commode and not during any straining for urination. Fell
backwards and developed large left gluteal hematoma. Heard
calling for help immediately after event by sister and brought
to ED.
In ___ had a fall forward with head strike. At that
time had bruising of face. Pt lives in assisted living facility
and is quite independent at baseline. Since previous fall has
had 24 hour supervision. Uses walker and has good mobility at
baseline with it. Sister lives in ___ but has been with pt
for for last 3 months. Has chronic lower back pain with unclear
diagnosis but has been getting LESI ___ years or so with the most
recent being 2 weeks ago. Per pt back pain did not contribute to
fall.
Of note patient has recurrent UTIs. Was on Cefuroxime in late
___ for UTI which was discontinued due to diarrhea. No
diarrhea currently. In mid ___ she also had a left ankle
cellulitis with ulceration that was successfully treated with
Keflex. Went to PCP yesterday and was prescribed Cipro 500mg BID
for treatment of symptomatic UTI (dysuria and frequency). Pt is
on torsemide 40mg BID and spironolactone 12.5mg BID but has not
had these medications adjusted in some time.
In the ED, initial vital signs were 97.3 100 90/59 18 100%.
Patient was given 1L NS. Found to have INR 1.9 (on coumadin) and
creatinine 2.8 and BUN 128 over baseline ranging from 2.1 to 2.5
and ___, respectively. No pelvic, vertebral or femoral fracture
on Xray.
Past Medical History:
- Hypertension
- dCHF
- Atrial fibrillation on warfarin
- Chronic kidney disease (baseline creatinine 2.5 mg/dL)
- Hypothyroidism
- Gout
- Osteoarthritis
Social History:
___
Family History:
Two brothers died in their ___ of heart failure. Also notable
for HTN, esophageal cancer. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION
Vitals- 97.4 ___ 18 97RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP at clavicle, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Soft heart sounds, Irregular 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, 6cm diameter left gluteal hematoma with smaller 2cm
diameter hematoma superiorly. Non-tender. Mildly indurated.
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE
Vitals- 98.4 102/70 95 18 97RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP at clavicle, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Soft heart sounds, Irregular 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, 6cm diameter left gluteal hematoma with smaller 2cm
diameter hematoma superiorly. Non-tender. Mildly indurated.
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION
___ 05:21AM BLOOD WBC-12.6*# RBC-4.78 Hgb-14.7 Hct-46.1
MCV-96 MCH-30.7 MCHC-31.8 RDW-16.7* Plt ___
___ 05:21AM BLOOD ___ PTT-33.7 ___
___ 05:21AM BLOOD Glucose-211* UreaN-128* Creat-2.8* Na-137
K-4.3 Cl-96 HCO3-28 AnGap-17
IMAGING ___
Xray Lumbosacral spine: No fracture
Xray Pelvis/Femur: No fracture.
DISCHARGE
___ 06:20AM BLOOD WBC-10.3 RBC-4.09* Hgb-12.5 Hct-39.4
MCV-96 MCH-30.6 MCHC-31.7 RDW-16.7* Plt ___
___ 06:20AM BLOOD ___ PTT-30.8 ___
___ 06:20AM BLOOD Glucose-147* UreaN-89* Creat-2.0* Na-145
K-3.9 Cl-106 HCO3-27 AnGap-16
___ 06:20AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.8*
Brief Hospital Course:
BRIEF HOSPITAL COURSE
___ F dCHF, afib (on coumadin) presents after fall from toilet
to carpeted floor. On admission found to be 5lbs under baseline
weight of 170 and with florid orthostatic hypotension. Home
torsemide/spironolactone held and pt given 2L fluid. Home
metoprolol transiently dose reduced to 50mg BID from 75mgBID.
Orthostasis improved. ___ evaluated and recommended rehab but
patient adamantly refused--has 24 hour home supervision with ___
and sister is always present. When pt fell she stuck buttocks
and developed L gluteal hematoma. Hct dropped 6 points on day of
admission but this was likely due to volume expansion. Stable
thereafter. Hematoma did not markedly increase in size. Should
be assessed for stability by PCP shortly after discharge.
Warfarin was continued for Afib. While patient was here was
continued on Cipro for treatment of symptomatic UTI to finish a
___CTIVE ISSUES
# FALL: Differential includes vagal event due to setting,
arrhythmia, orthostatic hypotension (baseline BP ___ with
standing in context of diuresis. Positive orthostatics. Bolused
2L total over course of stay. Monitored on tele which just
showed baseline Afib. ___ evaluated and recommended rehab but
patient adamantly refused--has 24 hour home supervision with ___
and sister is always present.
# HEMATOMA: INR subtherapeutic on admission to 1.9. Also given
renal failure with significant uremia may have element of
platelet dysfunction. Initial fall in Hct from 46 to 40
attributed to volume expansion. Subsequently Hct stabilized
around 40. Hematoma did not markedly increase in size. Should be
assessed for stability by PCP shortly after discharge. Warfarin
was continued for Afib given low suspicion of active bleeding.
# UTI: Pt had been placed on Cipro 500mg BID day prior to
admission for symptoms of dysuria and urgency. Leukocytosis on
admission to 12.6 resolved. Pt told to continue to finish a 3
day course of treatment.
# AOCKD: Likely hypertensive and diabetic nephropathy as
baseline chronic CKD. More recently may be overdiuresed on
torsemide and spironolactone. Creatinine improved with 2L
fluids. Diuretics continued to be held on discharge. Has
followup with PCP ___.
# AFIB: CHADS2= 3 (heart failure, age, HTN). INR subtherapeutic
on admission but with hematoma. Currently no signs of continued
bleeding into the hematoma. INR currently subtherapeutic at 1.9.
Although pt has had 2 falls recently, with a CHADs this high,
still worthwhile to anticoagulate. Metoprolol transiently
reduced to 50mg BID given fall, but then home dose restarted on
day of discharge. Warfarin continued as above.
# dCHF: Last stress echo showed LVEF 43% in ___. Currently
does not appear volume overloaded. If anything appears somewhat
dry. On an aggressive home diuretic regimen of spironolactone
12.5mg and torsemide 40mg BID. Diuresis was held as above.
INACTIVE ISSUES
# IMPAIRED OGT: Historically had DM but per discussion with PCP
has had better control recently with most recent A1c down to
6.5%. Possible this number has gone up again and poor control is
contributing to her frequent recent infections. Not on any
current pharmacologic therapy.
# HoThyroidism: stable. Continued levothyroxine 50mcg
# Gout: Crystal-proven gout. Colchicine had been discontinued in
___. Per rheum notes she has been doing well with only one
possible attack since then. Continued allopurinol ___ daily
TRANSITIONAL ISSUES
# Assess volume status, consider restarting diuretics. Discharge
wt 75.2kg.
# Assess L gluteal hematoma and stability of hematocrit given
that patient is anticoagulated
# Anticoagulation for Afib
# consider outpatient rehab for deconditioning
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO Q12H
Day 1 = ___
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Metoprolol Tartrate 75 mg PO BID
HOld for SBP < 100 or HR < 60
5. Simvastatin 20 mg PO DAILY
6. Spironolactone 12.5 mg PO DAILY
7. Torsemide 40 mg PO BID
8. Warfarin 2 mg PO DAILY16
9. Aspirin 81 mg PO DAILY
10. Cyanocobalamin 50 mcg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 50 mcg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Metoprolol Tartrate 75 mg PO BID
6. Simvastatin 20 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Warfarin 2 mg PO DAILY16
9. Ciprofloxacin HCl 500 mg PO Q12H
Please continue this through ___ to complete 3 day treatment
for UTI.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Orthostatic Hypotension likely from overdiuresis
Left gluteal hematoma
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. ___,
Thank you for choosing us for your care. You were admitted after
a fall that we think was related to you being dehydrated. Your
labs showed some worsening of your kidney function. We held you
diuretic medicines and gave you some fluids and your blood
pressures and kidney function recovered. Please discuss with Dr.
___ when to start these diuretic medicines (torsemide and
spironolactone) again.
When you fell, you developed a large hematoma on your left
buttocks. We monitored this for any signs of active bleeding.
You blood counts remained stable.
You were evaluated by our physical therapists who thought that
you would benefit from a stay at a rehabilitation facility to
help get you stronger. However, you clearly stated that you did
not want to go.
At discharge, you weigh 75.2kg or 166 lbs. (Weigh yourself every
morning, call MD if weight goes up more than 3 lbs)
We have made the following changes to your medications:
Followup Instructions:
___
|
19797689-DS-26
| 19,797,689 | 26,541,624 |
DS
| 26 |
2188-01-10 00:00:00
|
2188-01-22 21:38:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors
Attending: ___.
Chief Complaint:
SOB, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old woman with a history of CHF, HTN, afib on warfarin
and CKD, presents with SOB and abdominal pain since yesterday.
The patient states that for the past 2 days, she has felt
malaise. Yesterday, she began to experience shortness of breath.
She denies associated cough, fevers, chills. She also had mild
abdominal pain and decreased appetite. Last night, she
experienced loose stool and a "large" amount of BRBPR (unable to
quantify, enough to scare her). Following this, she experienced
pain in her rectum. She has subsequently had 1 bloody bowel
movement today. No back pain. No nausea, vomiting.
In the ED, initial VS: 92 BP 96/66 99%RA RR 15. The patient
underwent EKG that showed no ischemic change. Exam was notable
for diffusely tender abdomen to palpation, guiac positive with
light red stool. Labs were notable for Cr. 2.0, Hct 40.1, BNP
8895. CXR with mild effusions bilaterally. The patient was
written for 40 mg IV lasix. She was admitted for diuresis,
serial Hct for GI bleed. VS prior to transfer: 98.0 92 ___
95% RA.
On the floor, the patient endorses ongoing rectal pain and
dyspnea.
Review of Systems:
(+) HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, nausea, vomiting,
constipation, dysuria, hematuria.
Past Medical History:
Hypertension
- ___
- Atrial fibrillation on warfarin
- Chronic kidney disease (baseline creatinine 2.5 mg/dL)
- Hypothyroidism
- Gout
- Osteoarthritis
- Recurrent UTIs
Social History:
___
Family History:
Two brothers died in their ___ of heart failure. Also notable
for HTN, esophageal cancer. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION:
Vitals- 97.9 ___ 22 98%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP elevated angle of jaw, no LAD
Lungs- bibasilar crackles, no wheezes or rhonchi
CV- Irregularly irregular S1, S2, no murmurs, rubs, gallops
Abdomen- soft, mildly tender in lower quadrants bilaterally,
non-distended, bowel sounds present; patient refused repeat
rectal exam
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE:
Vitals- T97.4 BP 100/70 HR 94 18 97% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP elevated bilaterally
Lungs- soft crackles, but good air movement
CV- Irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen- obese, (+) BS, soft, mild diffuse tenderness,
non-distended, bowel sounds present, no rebound tenderness or
guarding, aly
Rectal- small external hemorrhoids, no fluctance around the
perianal area, Tenderness on exam no masses felt, no BRBPR, no
melena
GU- no foley
Ext- warm, well perfused, 2+ pulses,
Neuro- , motor function grossly normal
Pertinent Results:
ADMISSION:
___ 05:30PM NEUTS-64.9 ___ MONOS-5.3 EOS-3.0
BASOS-0.6
___ 05:30PM WBC-7.8 RBC-4.41 HGB-12.9 HCT-40.1 MCV-91
MCH-29.2 MCHC-32.1 RDW-17.8*
___ 05:30PM ALBUMIN-3.9 CALCIUM-8.8 PHOSPHATE-4.0
MAGNESIUM-2.6
___ 05:30PM proBNP-8895*
___ 05:30PM cTropnT-0.03*
___ 05:30PM LIPASE-108*
___ 05:30PM ALT(SGPT)-22 AST(SGOT)-27 ALK PHOS-105 TOT
BILI-0.4
___ 05:30PM GLUCOSE-162* UREA N-76* CREAT-2.0* SODIUM-142
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-24 ANION GAP-17
___ 06:25PM LACTATE-1.8
DISCHARGE:
___ 06:00AM BLOOD WBC-8.7 RBC-4.05* Hgb-11.7* Hct-37.0
MCV-91 MCH-28.9 MCHC-31.6 RDW-17.7* Plt ___
___ 04:05PM BLOOD Hct-36.0
___ 11:34PM BLOOD Hct-37.6
___ 11:34PM BLOOD ___
___ 06:00AM BLOOD Glucose-115* UreaN-73* Creat-2.0* Na-143
K-3.9 Cl-107 HCO3-29 AnGap-11
___ 06:00AM BLOOD CK-MB-3 cTropnT-0.03*
___ 05:30PM BLOOD cTropnT-0.03*
Brief Hospital Course:
___ year old woman with a history of CHF, HTN, afib on warfarin
and CKD, presents with SOB and bright red blood per rectum.
# Acute on Chronic Diastolic Heart Failure: Patient presented
with several day history of SOB, orthopnea, and Dyspnea on
exertion. Symptoms were attributed to ___ axacerbation given
mild elevation in JVD and bibasilar crackles/effusions on CXR
with a BNP elevated to 8800. She was diuresed with lasix and
symptomatically improved.
# Anal Fissures: Patient had 1 episode of rectal bleeding that
was described as bright red blood on toilet paper after a bowel
movement. Patient also described rectal pain. Rectal exam showed
good rectal tone with no evidence of hemorrhoids or gross blood.
The exam was painful supporting the diagnosis of anal fissures.
Her hematocrit was stable during the admission. She declined
lidocaine jelly or steroid suppository for symptomatic
treatment.
#Dysuria- Patient intermittently complained of burning with
urination, and increased frequency. Unfortunately Ms ___
declined giving a urine sample.
# Atrial fibrillation: Rate controlled on metoprolol and
anticoagulated on coumadin.
Admission INR was supratherapeutic so coumadin was initially
held in the context of the possible bleed. she was restarted on
her home dose on discharge.
CHRONIC ISSUES:
# Gout: Chronic.
- continued allopurinol and colchicine
# Hypothyroidism: Chronic.
- continued levothyroxine
# Hypercholesterolemia: Chronic.
- continued simvastatin
# CAD: Chronic.
- continued plavix, atorvastatin, metorprolol
****Transitional issues***
Patient briefly complained of dysuria, but would not give urine
sample. Please reasses.
If her rectal pain does not improve, consider anoscopy for
further workup.
Please re-assess the dosage of her diuretic
Please recheck her inr and assess the appropriateness of the
current dose
Her allopurinol may need to be renally dosed given her CKD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Colchicine 0.6 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Metoprolol Tartrate 75 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Spironolactone 12.5 mg PO DAILY
7. Torsemide 40 mg PO DAILY
8. Warfarin 2 mg PO DAILY16
9. Aspirin 81 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Acetaminophen 650 mg PO Q6H:PRN pain
12. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Colchicine 0.6 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Simvastatin 20 mg PO DAILY
7. Torsemide 40 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Allopurinol ___ mg PO DAILY
10. Metoprolol Tartrate 75 mg PO BID
11. Spironolactone 12.5 mg PO DAILY
12. Warfarin 2 mg PO DAILY16
13. Senna 1 TAB PO BID
Stop if you are having diarrhea.
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Acute on chronic diastolic heart failure,
Anal Fissure
SECONDARY DIAGNOSIS: Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You came to the hospital due to increasing shortness of breath
and were found to have an exacerbation of your diastolic heart
failure. We gave you extra medicine to diurese you (make you
urinate out extra fluid) and your breathing improved. You
should weigh yourself every morning, and call your cardiologist
if your weight goes up more than 3 lbs.
You also came after you found red blood on the toilet paper
after a bowel movement. This was likely due to a anal fissure.
Your blood level was stable during your stay and you had no more
episodes of the bleeding. We held your coumadin during your stay
because it was above the goal level. We gave you some medicine
to help with the pain. You can take ___ baths at home to help
with the pain (Please see attached handout.) We also recommend
you take medicine to help keep your stools soft.
You should follow up with your primary care doctor and your
cardiologist at the appointments below.
Followup Instructions:
___
|
19797689-DS-27
| 19,797,689 | 28,992,963 |
DS
| 27 |
2188-02-24 00:00:00
|
2188-02-26 11:50:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of ___, CKD, A.Fib on coumadin presenting with
SOB since this morning and questionable right sided, constant,
sharp, nonradiating chest pain since last night. History
limited by patient's mental status (gives inconsistent answers,
AO X 1). Pt initially stated that she is not having any chest
pain and 2 minutes later said that she has had constant chest
pain for the past day that has not gone away. History partially
provided by pt's health aide and sister. Per health aide, pt
had SOB this AM, worse with exertion. Health aide states pt was
not complaining of chest pain, just SOB. ___ home RN noticed rales
on pulmonary exam on ___ and her torsemide dose was
increased from 40mg to 80mg daily. Pt also complaining of
dysuria since ___, was evaluated by PCP who started her on Abx
for presumed UTI. Health aide denies fevers, chills, cough,
nausea, vomiting, ___ swelling, orthopnea, hematuria, diarrhea.
Took torsemide 80mg ~10AM. Did not take her clopidogrel today.
Took aspirin 81 and warfarin.
In the ED initial vital signs were: 98.7 96 119/93 20 95% ra.
Labs were significant for Na 141, K 5, Cl 98, HCO3 27, BUN 62,
Cr 2.0, glucose 172, Ca 9.1, Mg 2.5, P 3.6, WBC 10.1 (N:86.5
L:7.3 M:3.7 E:2.1 Bas:0.4), H/H 12.8/42.2, plt 213, ___ 24.9, PTT
33.9, INR 2.3, proBNP 7731, CK 76, MB 2 and Trop-T 0.02. UA was
largely unremarkable. CXR showed vascular congestion and b/l
pleural effusions. She recevied furosemide 80 mg IV and
albuterol/ipratropium nebs.
Transfer vital signs were: 98.2 98 116/83 17 95% RA. On arrival
to the floor pt, complains of suprapubic discomfort, denies
chest pain, denies SOB. Pt intermittently tearful, but states
she is not sure why.
Past Medical History:
Hypertension
- ___
- Atrial fibrillation on warfarin
- Chronic kidney disease (baseline creatinine 2.5 mg/dL)
- Hypothyroidism
- Gout
- Osteoarthritis
- Recurrent UTIs
Social History:
___
Family History:
Two brothers died in their ___ of heart failure. Also notable
for HTN, esophageal cancer. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION:
VS: 98.4 122/84 100 22 92% RA
GENERAL: Frail, NAD. Alternates between smiling and being
tearful.
HEENT: NCAT. PERRL.
NECK: Supple with JVP to tragus.
CARDIAC: Tachycardic. Irregular rhythm. Nl S1, S2. No m/r/g
LUNGS: Rales halfway up posterior lung fields.
ABDOMEN: Soft, NTND. Nl BS. No rebound or guarding.
EXTREMITIES: 1+ pitting edema bilateral ___ to mid calf. wwp.
NEURO: AO to self and to BI. Does not know city or year. Unable
to say days of week backwards (could not go back one day).
SKIN: Erythematous, warm patch posteromedial LLE just above the
ankle w/o fluctuance or induration. Hyperpigmentation of
bilateral ___ (venous stasis).
.
DISCHARGE:
O: VS Temp 98.5 BP 81-92/59-69 HR 98-108 RR 20 O2 sat 98% on RA
AM I/O: incontinent
24 hr I/O: incontinent
Wgt: 75.2 kg (74.9 on ___
General: frail, NAD
HEENT: sclera anicteric, conjunctiva clear, MMM
Neck: supple, JVP 1 cm above clavicle with patient sitting at 45
degrees
Cardiac: irregularly irregular, normal S1 and S2, no murmurs,
rubs, or gallops
Lungs: mild bibasilar crackles(L>R)
Abdomen: NABS, soft, nontender, nondistended
Extremities: 1+ b/l ___ edema to mid-shin level
Skin: bilateral hyperpigmentation of lower extremities
Pertinent Results:
ADMISSION LABS:
___ 01:20PM BLOOD WBC-10.1 RBC-4.72 Hgb-12.8 Hct-42.2
MCV-89 MCH-27.0 MCHC-30.2* RDW-17.5* Plt ___
___ 01:20PM BLOOD Neuts-86.5* Lymphs-7.3* Monos-3.7 Eos-2.1
Baso-0.4
___ 01:20PM BLOOD ___ PTT-33.9 ___
___ 01:20PM BLOOD Glucose-173* UreaN-62* Creat-2.0* Na-141
K-5.0 Cl-98 HCO3-27 AnGap-21*
___ 01:20PM BLOOD CK(CPK)-76
___ 01:20PM BLOOD CK-MB-2 cTropnT-0.02* proBNP-7731*
___ 01:20PM BLOOD Calcium-9.1 Phos-3.6 Mg-2.5
___ 01:38PM BLOOD Lactate-2.7*
___ U/A NEGATIVE
.
IMAGING:
CXR ___: 1. Left retrocardiac opacity could represent
atelectasis, infection or aspiration. 2. The left
costophrenic angle is blunted. A small left pleural effusion is
not excluded.
.
ECHO ___: Suboptimal image quality. Within the technical
limitations of the exam, overall LV function appears moderately
depressed, with estimated LVEF 35-40% with beat-to-beat
variability. Mildly dilated RV with mildly depressed function.
Biatrial enlargement. Moderate tricuspid regurgitation. Mild
pulmonary artery systolic hypertension.
Image quality on the current exam limits comparison with the
prior study (images reviewed) of ___. Overall LV
ventricular function appears worse.
.
DISCHARGE LABS:
___ 05:40AM BLOOD WBC-8.4 RBC-4.63 Hgb-12.7 Hct-41.6 MCV-90
MCH-27.4 MCHC-30.5* RDW-18.2* Plt ___
___ 05:40AM BLOOD ___
___ 05:40AM BLOOD Glucose-100 UreaN-100* Creat-2.3* Na-138
K-3.6 Cl-92* HCO3-33* AnGap-17
___ 05:40AM BLOOD Calcium-9.1 Phos-4.9* Mg-2.7*
Brief Hospital Course:
___ y/o F with PMHx of dCHF, afib on coumadin, presents with
progressive SOB X 3 days c/w CHF exacerbation, as well as
dysuria with negative U/A.
.
# Acute on chronic diastolic and systolic CHF: Last ECHO ___
with LVEF 55%. Dry weight unknown. Echo performed on ___
revealed decreased systolic function (LVEF 35-40%) and biatrial
enlargement concerning for infarction. The decision was made
with Ms. ___ HCP, PCP, and outpatient cardiologist to defer
cardiac cath and continue medical management. Started lasix 80mg
IV BID ___. Began furosemide drip ___ at 12/hr with goal
net negative 1.5L per day. Administered metolazone 2.5mg X 1 on
___. Discontinued lasix gtt ___ ___uvolemic with dry
weight 74.6 kg. Held home spironolactone and torsemide in
setting of lasix diuresis. Started torsemide 60mg daily on
___.
.
# Atrial fibrillation: CHADS2= 3 (heart failure, age, HTN). On
coumadin with INR 2.3 on admission. Pt with HR to ___.
Changed home metoprolol 75 mg BID to 50 mg Q6 hr for better
control of HR/optimization of cardiac output with resulting
decrease in HR to ___.
.
# Coronary artery disease: Last cath in ___ showing multivessel
disease in D1, LCx, and RCA. No history of PCI. Ms ___ was
confused and oriented x1 during this hospitalization and gave
inconsistent reports of chest pain. EKGs negative for ischemic
changes, and troponins showed no uptrending. Echo performed on
___ revealed decreased systolic function (LVEF 35-40%) and
biatrial enlargement concerning for infarction. The decision was
made with Ms. ___ HCP, PCP, and outpatient cardiologist to
defer cardiac cath and continue medical management. Continued
home ASA, simvastatin. Adjusted metoprolol as above.
.
# HTN: Held home spironolactone and torsemide in setting of
lasix diuresis and adjusted home metoprolol as above. Restarted
torsemide 60mg daily on ___.
.
# LLE cellulitis: Pt received cefazolin 1g q12h X 3 days, then
keflex ___ q8h X 4 days. Completed abx course ___ with
complete resolution of cellulitis.
.
# suprapubic pain/dysuria: No ttp on exam. U/A negative.
Etiology of pain unclear. Pt AO X 1 and gives inconsistent
reporting of symptoms.
.
# Gout: No evidence of acute flare. Decreased home colchicine
from 0.6mg to 0.3mg daily on ___ in setting of CKD. Continued
home allopurinol.
.
# CKD with baseline Cr 2: Creatinine increased to 2.6 this
admission and trended down to 2.3, which likely represents new
baseline in setting of systolic CHF with EF 35-40%
.
# Hypothyroidism: Continued home levothyroxine
.
## transitional issues:
--changed metoprolol from 75 mg BID --> metoprolol succinate
50mg daily
--changed torsemide from 40 mg BID --> to 40mg daily
--changed colchicine from 0.6 mg daily --> 0.3 mg daily, given
poor renal function
--Cr 2.3 on ___, please re-check on ___
--INR 2.5, please re-check on ___
--would consider adding ACE-I to ___ regimen once blood
pressure and renal function stabalize
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Colchicine 0.6 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Torsemide 40 mg PO BID
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Allopurinol ___ mg PO DAILY
9. Metoprolol Tartrate 75 mg PO BID
10. Spironolactone 12.5 mg PO DAILY
11. Warfarin 2 mg PO DAILY16
12. Senna 1 TAB PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Colchicine 0.3 mg PO DAILY
RX *colchicine [Colcrys] 0.6 mg 0.5 (One half) tablet(s) by
mouth once daily Disp #*15 Tablet Refills:*1
5. Docusate Sodium 100 mg PO BID
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Senna 1 TAB PO BID
8. Simvastatin 20 mg PO DAILY
9. Torsemide 40 mg PO DAILY
10. Warfarin 2 mg PO DAILY16
11. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: acute on chronic congestive heart failure, cellulitis
Secondary: atrial fibrillation, hypertension, gout, chronic
kidney disease, hypothyroidism
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 ___,
___ was a pleasure to take care of you at ___. You were
admitted for evaluation of shortness of breath and were found to
have an exacerbation of your congestive heart failure. We gave
you medication to help remove the excess fluid from your lungs
and your breathing improved. Please weigh yourself every
morning, and call your PCP if weight goes up more than 3 lbs.
You were also found to have an infection of the skin on your
left lower leg. You were treated successfully with a course of
antibiotics. You had some pain with urination when you came to
the hospital. We did some tests on your urine and did not find
any signs of infection.
Followup Instructions:
___
|
19797689-DS-29
| 19,797,689 | 24,527,421 |
DS
| 29 |
2189-02-26 00:00:00
|
2189-02-26 14:43:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ace Inhibitors
Attending: ___.
Chief Complaint:
Urinary Tract Infection / Hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs ___ is an ___ year old woman with a past medical history of
afib on warfarin, CKD, dsCHF, and recurrent UTIs who presents
with questionable vaginal bleeding in the setting of acute
kidney injury.
Mrs ___ was in her normal state of health until the evening of
___ when she noticed that there was a large amount of blood
with her in the toilet after she urinated. This was also
associated with suprapubic pain. Endorses urinary urgency and
frequency, but not dysuria. Describes her abdominal pain as
"like her old periods."
Has a history of vaginal bleeding by pessary that was left
unattended for years. Most recent pessary was placed by OBGYN
(___ some months ago and has not been problematic.
After continuing to have abdominal pain and hematuria, she
called her PCP who directed her to go to the ED.
No fevers, chills, nausea, vomiting, changes in bowel habits,
CP, SOB. Baseline walks minimally before becoming short of
breath.
In the ED, initial vital signs were: 5 97.2 58 115/63 18 95%
Exam notable for absence of blood seen on speculum exam
Labs were notable for
10.3 > 11.5 / 36.6 < 203 N: 67 L: 24 Band: 0 Eo: ___ M: 4
136 / 103 / 84
---------------< 138 ___: 21.6 PTT: 30.2 INR: 2.0
5.5 / ___ / 3.6
Lactate 3.5 to 2.0 on repeat
UA: pink/cloudy 1.101 ph 6.0 large leuk, lerge blood, trace
protein
RBC > 182 WBC > 182 Epi <1
Blood and Urine Cultures taken
Patient was given 1g ceftriaxone
Past Medical History:
- Systolic + diastolic CHF (EF 40%)
- CAD
- Atrial fibrillation on warfarin
- Chronic kidney disease (baseline creatinine 2.5 mg/dL)
- Hypothyroidism
- Gout
- Osteoarthritis
- Recurrent UTIs
Social History:
___
Family History:
Two brothers died in their ___ of heart failure. Also notable
for HTN, esophageal cancer. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.9 114/83 56 18 99/RA Wt 183.6
General: awake, alert, NAD
HEENT: PERRL EOMI MMM grossly normal oropharynx
Lymph: no lymphadenopathy cervical or
CV: RRR S1+S2 no g/r/m peripheral pulses intact.
Lungs: bibasilar rales with fair movement b/l
GU: foley draining light pink urine
Abdomen: obese, soft, ? large ventral hernia normoactive BS, no
organomegally felt
Ext: 1+ peripheral edema to shin, dry, WWP
Neuro: orianted to self and place, not time. no focal defects
Skin: no rashes, lesions, excoriations
DISCHARGE PHYSICAL EXAM:
Vitals: 98.1 126/63 63 18 95/RA
General: awake, alert, NAD
HEENT: EMOI MMM grossly normal oropharynx
CV: RRR S1+S2 no g/r/m peripheral pulses intact.
Lungs: bibasilar rales with fair movement b/l
Abdomen: obese, soft, nt/nd no r/g
Ext: 1+ peripheral edema to shin, dry, WWP. No CVA tenderness
Neuro: orianted to self and place, not time. no focal defects
Skin: no rashes, lesions, excoriations
Pertinent Results:
ADMISSION LABS:
___ 10:40AM BLOOD WBC-10.3 RBC-3.91* Hgb-11.5* Hct-36.6
MCV-94 MCH-29.4# MCHC-31.4 RDW-15.3 Plt ___
___ 10:40AM BLOOD Neuts-67 Bands-0 ___ Monos-4 Eos-2
Baso-1 ___ Myelos-2*
___ 10:40AM BLOOD ___ PTT-30.2 ___
___ 10:40AM BLOOD Glucose-138* UreaN-84* Creat-3.6*# Na-136
K-5.5* Cl-103 HCO3-19* AnGap-20
___ 06:55AM BLOOD Calcium-8.8 Phos-4.5 Mg-2.3
___ 02:13PM BLOOD Lactate-3.5*
___ 02:33PM BLOOD Lactate-2.0
___ 05:27AM URINE Color-DKAMB Appear-Cloudy Sp ___
___ 01:00PM URINE Color-Pink Appear-Cloudy Sp ___
___ 05:27AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 01:00PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 01:00PM URINE RBC->182* WBC->182* Bacteri-MOD
Yeast-NONE Epi-<1
___ 01:00PM URINE AmorphX-FEW
___ 01:00PM URINE WBC Clm-FEW
___ 01:00PM URINE Hours-RANDOM UreaN-237 Creat-21 Na-111
K-16 Cl-113
NOTABLE LABS:
___ 07:13AM BLOOD Plt ___
___ 07:13AM BLOOD ___ PTT-32.0 ___
___ 05:15PM BLOOD Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD ___ PTT-29.3 ___
___ 06:55AM BLOOD ___ PTT-29.7 ___
___ 10:40AM BLOOD Plt Smr-NORMAL Plt ___
___ 10:40AM BLOOD ___ PTT-30.2 ___
MICROBIOLOGY:
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
RENAL U.S. ___
COMPARISON: CT abdomen and pelvis ___. Renal
ultrasound ___ FINDINGS: The right kidney measures 8.7
cm. The left kidney measures 9.6 cm. There is no hydronephrosis,
stones, or masses bilaterally. In the lower pole of the right
kidney a simple cyst measures 1.7 x 1.7 cm. In the interpolar
region of the right kidney a lesion that is isoechoic to renal
cortex measures 1.2 x 1.4 cm and likely corresponds to the prior
hemorrhagic cyst seen on the CT abdomen of ___.
Normal cortical echogenicity and corticomedullary
differentiation are seen bilaterally. The bladder is
decompressed by a Foley catheter. IMPRESSION: No hydronephrosis.
In comparison to the prior CT findings, the lesion in the
interpolar region of the right kidney most likely represents a
hemorrhagic cyst that is stable in size since ___.
DISCHARGE LABS:
___ 07:13AM BLOOD WBC-8.8 RBC-3.50* Hgb-10.1* Hct-33.3*
MCV-95 MCH-28.9 MCHC-30.4* RDW-14.9 Plt ___
___ 07:13AM BLOOD Plt ___
___ 07:13AM BLOOD ___ PTT-32.0 ___
___ 07:13AM BLOOD Glucose-131* UreaN-78* Creat-3.0* Na-139
K-5.4* Cl-106 HCO3-24 AnGap-14
___ 07:13AM BLOOD Calcium-8.5 Phos-4.8* Mg-2.5
Brief Hospital Course:
PATIENT:
Mrs ___ is an ___ year old woman with a past medical history of
afib on warfarin, CKD, dsCHF, and recurrent UTIs who presented
with a hemorrhagic UTI and ___ on CKD.
ACUTE ISSUES:
# Urinary Tract Infection/Acute cystitis:
Patient originally presented to the ED with concern of vaginal
bleeding. Speculum exam was without blood and later Foley
samples confirmed presence of hematuria and a urinary tract
infection once admitted to the hospital floor. Blood and urine
cultures drawn and started empirically on ceftriaxone (given she
had previous UTIs with resistance to ciprofloxacin and
ampicillin.) There were no systemic signs to Microscopic
urinalysis revealed isomorphic RBCs and WBCs without casts or
acanthocytes. Urine culture eventually speciated as
pan-sensitive E. coli. Patient switched to cefpodoxime and
completed a total 5 day course of antibiotics. At time of
discharge, patient had no more dysuria or suprapubic pain,
however, she continued to have pink-tinged hematuria.
# Gross Hematuria: No signs of clots or obstruction. Likely
related to her acute cystitis in the setting of warfarin
therapy. Foley was placed which subsequently was discontinued
by patient. She did not want it replaced. Her renal function
improved with IVF and holding her diuretics. Her hematuria
improved slightly in house, though continued at discharge. We
felt it reasonable to continue to monitor. Urology referral is
recommended given possibility of other underlying processes.
# ___ on CKD: Patient with unclear baseline creatinine which
appeared to be between around 2.3, but PCP communicated that her
creatinine was 2.9 in ___ and more recently. Admitted value
was 3.6. Patient appeared clinically volume overloaded on
admission and a trial of diuresis resulted in a creatinine bump.
She was subsequently volume replete and her creatinine corrected
to near baseline. Medications were renally dosed as needed.
CHRONIC ISSUES:
# Atrial fibrillation: Patient's warfarin was continued while
inpatient given minor nature of bleed, hemodynamic stability,
and stable hematocrit, and high risk of embolic stroke given
CHAD2S2-Vasc. INR initially at 1.9, downtrended to 1.6 before
rebounding. Rate control with metoprolol and amiodarone were
continued. Please monitor INR closely
# Chronic Systolic & Diastolic CHF: Patient appeared clinically
volume overloaded, but responded to fluid repletion. Torsemide
and spironolactone where held as detailed above.
# CAD: History of multivessel disease in D1, LCx, and RCA.
There does not appear to be active ischemia or angina on
admission
# Hypothyroidism: Home levothyroxine was coninuted
# Gout: Home allopurinol was held at admission and restarted at
discharge.
TRANSITIONAL ISSUES:
- Patient continues to have red-tinged hematuria at time of
discharge. If patient stops producig urine, suspicion for
clotting and bring to emergency room. If passing large clots,
consider holding warfarin for ___ days.
- Torsemide held during hospitalization and at time of discharge
(replaced with Lasix 20mg PO daily). It appeared that patient's
___ was a result of hypovolemia from overdiuresis.
- Spironolactone held during hospitalization and at time of
discharge for hyperkalemia
- Please address patient's need for diuretic use in the future.
- Please obtain UA at next PCP ___, and if there is persistent
hematuria please consider a referral to urology
- Warfarin continued through hospitalization and at time of
discharge given minor bleed, and stable vitals/hematocrit.
Please assess the risk/benefit of ongoing anticoagulation.
- Please consider placing patient on a high-intensity statin
given her history of CAD
INSTRUCTIONS FOR HOME CARE TEAM
- PLEASE OBTAIN ___ Q ___ Instructions and please fax
results to Dr. ___ at ___
- PLEASE OBTAIN ___ and fax results to Dr. ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Torsemide 20 mg PO DAILY
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest Pain
5. Dexamethasone Ophthalmic Soln 0.1% 1 DROP BOTH EYES HS
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Warfarin 2 mg PO DAILY16
9. Spironolactone 12.5 mg PO DAILY
10. Allopurinol ___ mg PO DAILY
11. Docusate Sodium 100 mg PO TID
12. Colcrys (colchicine) 0.3 mg oral DAILY
13. Omeprazole 20 mg PO DAILY
14. Simvastatin 20 mg PO DAILY
15. Cyanocobalamin 1000 mcg PO DAILY
16. Amiodarone 200 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amiodarone 200 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Dexamethasone Ophthalmic Soln 0.1% 1 DROP BOTH EYES HS
5. Docusate Sodium 100 mg PO TID
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Metoprolol Tartrate 50 mg PO BID
8. Warfarin 2 mg PO DAILY16
9. Vitamin D 1000 UNIT PO DAILY
10. Simvastatin 20 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest Pain
13. Cefpodoxime Proxetil 100 mg PO Q24H
RX *cefpodoxime 100 mg 1 tablet(s) by mouth ONCE Disp #*1 Tablet
Refills:*0
14. Colcrys (colchicine) 0.3 mg ORAL DAILY
15. Aspirin 81 mg PO DAILY
16. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Urinary Tract Infection
Secondary Diagnoses:
Hematuria
Hypovolemia
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 ___,
___ were seen in the emergency department for bleeding in your
urine. ___ were admitted to the hospital where ___ were
diagnosed with a urinary tract infection (UTI). ___ were treated
with antibiotics. ___ were also found to have an injury to your
kidneys. An ultrasound of your kidneys demonstrated no
structural damage. ___ were given intravneous fluids and your
kidney function improved. Because we thought your diuretics had
caused ___ too lose too much water, swe stopped those
medications, and changed to a less potent diuretic at discharge.
Your symptoms improved and ___ will be discharged home. Please
weigh yourself every morning, and call MD if weight goes up more
than 3 lbs.
Please take all medications as prescribed and keep all scheduled
appointments.
It was a pleasure taking care of ___!
Your ___ Care Team
Followup Instructions:
___
|
19797807-DS-11
| 19,797,807 | 25,184,584 |
DS
| 11 |
2164-06-24 00:00:00
|
2164-07-05 16:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / codeine / amitriptyline
Attending: ___.
Chief Complaint:
Fall, R flank hematoma.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ resident of assisted living home w/ PMH of HTN, NIDDM2, PMR,
history of falls presents after awakening with right flank pain
during the course of last night (___). She experienced a
novel sharp pain in her right flank, non pleuiritc, or radiating
in nature and was immobilized by the severity for a few minutes.
Upon attempt to reach the emergency cord/button near her bed,
she
fell backwards from the bed to the floor landing on her
buttocks.
She did not strike her head or loose consciousness. She was down
no more than 5 minutes. Shortly after signaling the alarm help
and subsequently EMS arrived and brought her to ___.
She was hypotensive to SBP ___ then ___ but maintained her
mental
status and her BP was responsive to fluid resuscitation
(approximately 2.5L given at OSH). Her Hct was 31 which is on
par
with our previous recorded baseline. Otherwise, she had an
elevated lactate of 4.0. Her troponin was negative and an EKG
showed T wave inversions (previous EKGs with similar tracings).
NCHCT and CT spine were negative for acute injuries. A CT Torso
showed a large left sub muscular hematoma in the setting of old
rib fractures with no associated hemo or pneumothorax.
On evaluation in the ED, the patient is alert and oriented and
provides a detailed recent history. She has experienced recent
lightheadedness with ambulation, particularly when not using her
walker. She has had a recent admission to ___ ___ with
resultant right sided rib fractures and R clavicular fracture.
Previous left wrist fracture braced. However, the tenderness and
soft enlarged thoracic/flank mass is new and developed after
today's fall. She is intermittently in SVT to 120s but
otherwise
normal HR in 60-70 during evaluation with normotension. Repeat
HCT is 27 despite 1u PRBC. Lactate down to 1.8.
On exam, she is comfortable, noting pain in the right
flank/thoracic back without overlying ecchymosis. No
respiratory
distress. She does not know her full medications but endorses
aspirin use. She states that her daughter prepares her
medications for her.
Past Medical History:
HTN
DM2
HLD
atrial flutter
persistent orthostatic hypotension
h/o falls
GERD (oesophageal ulcer)
Polymyalgia rheumatica
lumbar radiculopathy
thalamic hemorrhage, likely traumatic
PSH:
spine surgery
appendectomy early in life
bowel obstruction s/p ex-lap
Social History:
___
Family History:
Not relevant to current admission
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ 68 143/69 16 96% RA
Gen: awake, AAOx3, affable and conversant
HEENT: no hemotympanum, no evidence of trauma to head or face,
trachea midline, no facial tenderness, no cervical ttp, neck
full
range of motion w/o pain
Neuro: AAOx3, CN ___ intact, EOMI, PERRL, equal strength b/l UE
and ___, sensate, no pronator drift
CV: sinus regular, no murmur or gallops
Pulm: CTAB, diminished on posterior due to mass
Thorax: no spinal tenderness except for paraspinal ttp near
large
flank mass which is tender to exam, no overlying ecchymosis or
skin changes, no CVA tenderness
Abd: midline scar well healed no fascial defect, no ttp on exam
no guarding no rebound
DRE: good tone, no gross blood
GU: Foley in place, no perineal injury
___: warm well perfused, left wrist braced, removed w/p evidence
of underlying skin changes, distal pulses palable UE and ___
radial, ___, pop and femoral b/l, ___ no evidence of injury,
nttp
=
=
=
=
=
=
=
=
=
=
================================================================
DISCHARGE PHYSICAL EXAM:
Vital Signs: T98, BP ___, orthostatic BP negative,
HR ___, RR 98% RA.
General: AAOx3, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
R Flank hematoma measuring 12 inches x 8 inches, stable, mildly
tender.
GU: No foley
___: L radial wrist with echymosis. Healing fracture. Warm, well
perfused, 2+ pulses, no clubbing, cyanosis or edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
Pertinent Results:
Labs on Admission:
___ 05:09AM BLOOD WBC-9.9# RBC-2.74* Hgb-8.4* Hct-27.2*
MCV-99*# MCH-30.7 MCHC-30.9* RDW-13.9 RDWSD-50.7* Plt ___
___ 05:09AM BLOOD Neuts-73.4* ___ Monos-6.0
Eos-0.6* Baso-0.3 Im ___ AbsNeut-7.28*# AbsLymp-1.89
AbsMono-0.59 AbsEos-0.06 AbsBaso-0.03
___ 05:09AM BLOOD ___ PTT-26.1 ___
___ 05:09AM BLOOD Plt ___
___ 11:30AM BLOOD Plt ___
___ 05:09AM BLOOD Glucose-135* UreaN-17 Creat-0.6 Na-139
K-3.9 Cl-106 HCO3-24 AnGap-13
___ 05:32AM BLOOD Lactate-1.8
=
=
=
=
=
=
=
================================================================
Labs on Discharge:
___ 04:10AM BLOOD WBC-7.2 RBC-2.42* Hgb-7.6* Hct-24.3*
MCV-100* MCH-31.4 MCHC-31.3* RDW-14.6 RDWSD-52.5* Plt ___
___ 04:10AM BLOOD Plt ___
___ 04:10AM BLOOD Glucose-105* UreaN-14 Creat-0.6 Na-140
K-3.9 Cl-106 HCO3-25 AnGap-13
___ 04:10AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9
___ 09:00AM BLOOD Cortsol-15.0
___ 04:10AM BLOOD Cortsol-1.1*
=
=
=
=
=
=
=
================================================================
Studies/Radiographic Imaging:
___: L Wrist Xray
IMPRESSION:
Comparison to ___. Status post fracture of the left
radius. The
transverse fracture is still visible extending into the
articular surface but the margins of the fracture show calus
formation. A new lucent line, not extending into the articular
surface, is visualized along the radial component of the distal
bone, perpendicular to the old fracture. This hyperlucent line,
not visualized on the previous image, could represent an new
fracture. A pre-existing fracture of the styloid is no longer
clearly visualized.
___: R clavicle Xray
IMPRESSION:
Comparison to ___. The known rib fractures on the right
as well as the complete an dislocated right clavicular fracture
are not substantially
changed. The degree of displacement and dislocation is stable
as compared to the previous image.
___: CXR
IMPRESSION:
Moderate cardiomegaly is a stable. The aorta is tortuous.
There is no
evident pneumothorax. Right rib fractures are again noted.
There are
bibasilar atelectasis increasing from prior study .
___: CTA Abd/Pelvis
IMPRESSION:
1. No evidence of IV contrast extravasation. No significant
interval change in the extent of the right posterolateral chest
wall hematoma measuring up to 24 cm in craniocaudal dimension.
2. Extensive diverticulosis.
3. Multiple fractures of varying ages, as described in detail
above.
4. Increased distraction of the right clavicular fracture,
compared to the
prior exam, concerning for an acute on subacute component and
underlying
ligamentous injury.
___: CT CSpine
IMPRESSION:
1. There is no evidence of acute cervical spine fracture or
traumatic
malalignment.
2. Degenerative changes of the cervical spine, as above.
___: CT Head
IMPRESSION:
1. Interval evolution/resolution of the previously described
small left
posterior inferior thalamic hemorrhage. No new acute
intracranial hemorrhage.
2. Previously described fractures of the right zygomatic process
and right superolateral orbital wall are again seen. No new
fracture detected.
Brief Hospital Course:
___ y/o female with a past medical history of Aflutter,
orthostatic hypotension currently on midodrine, h/o falls, DMII,
PMR on prednisone who presented s/p fall and was found to have a
right flank hematoma, transferred for medicine for management of
fall, orthostatic hypotension and acute blood loss anemia.
#Fall, orthostatic hypotension: Patient has a history of
orthostatic hypotension, numerous falls, and suffered a fall on
___ at her living facility. She described losing her step
upon getting out of bed, and had symptoms of lightheadedness at
the time. She denied any loss of consciousness. For her
orthostatic hypotension, patient at baseline is on midodrine. It
is possible that ___ midodrine in combination with her
beta blocker and lisinopril is contributing to her orthostatic
hypotension. Patient is on chronic pred 5mg for PMR and there
was initially a concern for possible adrenal insufficiency but
this was ruled out (see below for more information). Patient
also has peripheral neuropathy, and poor ambulatory function at
baseline, both of which causes her gait to be unsteady as well.
Patient denied any prior history of sudden LOC to suggest
cardiac etiology. She also denied any palpitations or chest
symptoms. She was monitored on tele without any notable cardiac
events. Patient has a history of AF but remained in SR while she
was hospitalized. There was no physical exam findings to suggest
aortic stenosis. Hence, overall there is a low suspicion for
structural heart disease. She denied any prior seizure history
and was not post-ictal after her fall. ___ BP was in
120s-140s/60s-70s prior to discharge and she was not
orthostatic. All together, we believe patient suffered a fall in
the setting of being on midodrine, and antihypertensives
(lisinopril, metoprolol), in combination with poor
balance/peripheral neuropathy at baseline. Patient was continued
on home midodrine on discharge, and after a discussion with her
PCP, ___ lisinopril was discontinued and metoprolol
decreased to 25mg XL daily. Patient will follow-up with PCP to
determine whether she should have any other adjustments to her
medication doses.
#R/o adrenal insufficiency: Patient is on chronic pred 5mg for
PMR, and in the process of working up for her fall, an AM
cortisol returned at 1.1. This was likely artifact. We obtained
a repeat cortisol, which returned as 15 and is more consistent
with prior cortisol levels in our system. This repeat cortisol
level was also drawn at a more appropriate time of the day.
Given that patient did not have any orthostasis, without sodium
or glucose abnormalities, and absence of other adrenal
insufficiency symptoms, this level is likely a laboratory error.
Patient was able to ambulate without any dizziness or other
symptoms. This questionable cortisol result was communicated
with outpatient PCP via phone call, who agreed that it is likely
a non-issue. We continued patient back on home prednisone for
her PMR upon discharge.
#Acute blood loss anemia: Patient developed acute blood loss
anemia in the setting of her fall and developing a large R flank
hematoma. Hgb on discharge was 7.6 (baseline ___. She did
not have any active evidence of bleeding on discharge, and her
CT did not show any active extravasation. Patient will follow-up
with her PCP, and should have her CBC repeated as an outpatient.
#R flank/extrathoracic hematoma: Patient suffered a fall and
developed a large R flank hematoma. A CT scan showed the
flank/extrathoracic hematoma was 18 x 12 x 4.3cm without any
evidence of active extravasation. This was progressively
resolving and improved at the time discharge.
#L radial fracture, R midshaft clavicle fracture: Patient with
fractures from prior fall in ___ and is s/p by ortho. Per
ortho, ___ fractures are healing well and is best managed
non-operatively. Per ortho, patient can be WBAT for LUE and RUE.
She will follow-up in outpatient orthopedics clinic.
#PMR: ___ PMR was stable during this inpatient
hospitalization. We continued ___ home prednisone on
discharge.
#DMII: Patient was treated with ISS while inpatient with sugar
levels remaining largely at goal. She was resumed on her
outpatient DM regimen upon discharge.
#GERD: We continued patient on home omeprazole.
===============================================================
Transitional Issues:
1. Please follow-up on ___ orthostatic hypotension. After
discussing with her primary care physician, ___
discontinued her lisinopril, decreased her metoprolol to 25mg XL
daily and continued her home midodrine.
2. Please follow-up on her acute blood loss anemia and repeat
CBC during primary care appointment. Hgb on discharge was 7.6.
3. Please follow-up regarding her ACTH level (pending on
discharge). Note that this was sent due to low cortisol (1.1),
but the 1.1 was likely a lab error as the repeat cortisol level
was 15.
4. Please follow-up regarding the healing of her L radial and R
clavicle fractures.
# CODE: Full Code
# CONTACT: Daughter, ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Midodrine 5 mg PO TID
3. Lisinopril 20 mg PO DAILY
4. Metoprolol Tartrate 12.5 mg PO Q6H
5. MetFORMIN (Glucophage) 500 mg PO DAILY
6. Alendronate Sodium 70 mg PO QMON
7. Atorvastatin 10 mg PO QPM
8. Omeprazole 20 mg PO DAILY
9. Calcium Carbonate 500 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Citalopram 20 mg PO DAILY
12. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Midodrine 5 mg PO TID
3. Omeprazole 20 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. Alendronate Sodium 70 mg PO QMON
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Calcium Carbonate 500 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. PredniSONE 5 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
hold for BP<100/50, HR<60
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary Diagnoses:
1. Fall
2. Right flank hematoma
3. Orthostatic hypotension
4. Acute blood loss anemia
Secondary Diagnoses:
1. L radial fracture
2. R clavicle fracture
3. PMR
4. DMII
5. AFib
6. GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital after you suffered a fall at
home. We evaluated you in the hospital and found that you had a
big bruise on your right side. We believe this was likely due to
your blood pressure being too low when you stand up. We stopped
your lisinopril to help keep your blood pressure up, and it was
in a good range while you were here. We also decreased your
metoprolol from 50mg to 25 mg. We also called your primary care
physician, ___ to let him know about these changes, and
___ agreed that it was a good plan. You were able to work with
the physical therapists who recommended that you receive more
physical therapy sessions at home. You should follow-up with
your primary care physician and the orthopedic doctors in the
outpatient setting. Please take all your medications as
instructed. It was a pleasure to care for you during this
hospitalization.
We wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19797807-DS-9
| 19,797,807 | 25,158,847 |
DS
| 9 |
2164-03-13 00:00:00
|
2164-03-14 09:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / codeine / amitriptyline
Attending: ___
Chief Complaint:
Trauma: fall:
lat/ant walls R maxillary sinus fracture
right zygomatic arch fracture
sphenoid
right orbital fracture
right rib fractures ___
displaced Right clavicle fracture
right scapula fracture
sternal fracture
Compression def T12,indeterminate age
left distal radius fracture
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female, s/p fall down 5 steps with head strike and
unclear LOC
for unknown amount of time. Unable to recall why she fell. Per
report, she woke up in a pool of congealed blood at the bottom
of
her steps and activated her Life Alert. She was brought to ___ where she was GCS ___, had a CT head revealing a SAH/IPH,
CT max/face demonstrated multiple facial fractures: nondisplaced
R inferior orbital and maxillary sinus fx w/o evidence of
entrapment or intraorbital hemorrhage. She was given clindamycin
and keppra at ___ and transferred to ___ for further
evaluation
Past Medical History:
Lumbar Radiculopathy, NIDDM2, GERD, Polymyalgia rheumatica
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam: ___: upon admission
Vitals: 98.2 102 ST 145/41 19 98%RA
GEN: A&O, NAD, GCS 15
HEENT: No scleral icterus, mucus membranes moist, bilateral
periorbital ecchymosis, no head lacerations, PERRL, EOMI, small
R
subconjunctival hemorrhage
CV: rhythm sounds somewhat irregular ? frequent PACs vs. PVCs,
no
rubs, normal S1/S2
PULM: Clear to auscultation b/l, No W/R/R, tenderness to
palpation over right chest wall and clavicle, no skin tenting,
ecchymosis over right chest wall
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses, mini laparotomy
scar
BACK: Nontender on exam, no stepoff deformities, however, while
examining back, patient was distracted by her right flank pain
Ext: UE: ecchymosis and pain with palpation of right elbow,
edema
and ecchymosis L wrist, with notable reluctance to give thumbs
up
with L thumb ___ to pain. ___ atraumatic, no significant edema,
warm and well perfused
CV: 2+ palpable radial and pedal pulses bilaterally
Physical examination upon discharge: ___
vital signs: 98.1, 140/62, 72, 18, o2 sat 99%
General: ___ ecchymosis bil
CV: irreg, ns1, s2
LUNGS: crackles bases bil
ABDOMEN: soft, non-tender
EXT: no calf tenderness bil., + radial right, splint left
NEURO: Scleral injection right eye, pupils pinpoint, alert and
oriented x 3, speech clear
SKIN; Ecchymosis left fore-arm, right shoulder/clavicle
Pertinent Results:
___ 03:48AM BLOOD WBC-9.8 RBC-3.08* Hgb-10.7* Hct-31.4*
MCV-102* MCH-34.7* MCHC-34.1 RDW-12.9 RDWSD-47.9* Plt ___
___ 04:15PM BLOOD Neuts-75.2* Lymphs-12.3* Monos-11.7
Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.17* AbsLymp-1.17*
AbsMono-1.12* AbsEos-0.00* AbsBaso-0.02
___ 03:48AM BLOOD ___ PTT-25.3 ___
___ 09:10AM BLOOD Glucose-169* UreaN-9 Creat-0.5 Na-136
K-4.1 Cl-104 HCO3-23 AnGap-13
___ 03:48AM BLOOD Glucose-158* UreaN-10 Creat-0.5 Na-136
K-4.1 Cl-99 HCO3-21* AnGap-20
___ 03:48AM BLOOD CK(CPK)-645*
___ 03:48AM BLOOD CK-MB-5 cTropnT-<0.01
___ 11:47PM BLOOD CK-MB-6 cTropnT-<0.01
___ 09:10AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.3
___: right shoulder:
There is a displaced fracture of the mid right clavicle with 1
shaft width of inferior displacement of the distal portion and
with bony overriding of
approximately 4.3 cm. There also be appears irregularity with
concern for
fracture at the base of the acromion, seen on the external
rotation view, but not substantiated on the other views. The
right acromio-clavicular joint is not widened. Multiple
right-sided rib fractures are seen, including at least the
posterior lateral right third, lateral fourth, fifth and likely
sixth ribs.
___: CTA head/neck:
1. Unchanged posterior-lateral left thalamic parenchymal
hemorrhage without
evidence of underlying vascular malformation.
2. Small amount of new right sylvian fissure subarachnoid and
layering
occipital horn left lateral ventricular hemorrhage.
3. Patent intracranial and neck vasculature without occlusion or
dissection.
4. 4 mm superiorly projecting thrombosed and calcified left
supra clinoid
segment internal carotid artery aneurysm.
5. 60-70% stenosis of the left carotid bulb by NASCET criteria.
6. Fracture of the right orbit with intracranial extension and
small foci of pneumo-cephalus, as described. Additional
fracture of the right zygoma and right maxillary sinus walls.
The facial fractures are better characterized on dedicated CT of
the face.
7. Enlarging right scalp hematoma.
8. Fractures involving the right mid clavicle, and the right
lateral third, fourth, and fifth ribs, better characterized on
dedicated CT of the chest.
9. Partially visualized large right gleno-humeral joint effusion
extending into sub-acromial space with internal heterogeneous
hyper-density and scattered calcifications. Findings may be
related to chronic degeneration versus an acute process.
Recommend clinical correlation.
___: ct of chest, abd. pelvis:
1. Acute fractures of the third, fourth, fifth, and sixth right
ribs
posteriorly and laterally. Fractures of the right clavicle and
right scapula.
2. Compression fracture of T12 vertebral body, of indeterminate
age. Overall appears subacute, but cannot exclude an acute
component.
3. No evidence of large hemorrhage.
4. Bladder is very distended, correlate with ability to
voluntarily urinate.
___: right elbow x-ray:
Degenerative changes without definite acute fracture.
___: left hand x-ray:
. Oblique nondisplaced distal radial fracture with
intra-articular extension is likely acute/subacute in age.
Clinical correlation for focal tenderness.
2. Mild soft tissue swelling of wrist.
3. Moderate to severe osteoarthritis involving the DIP joints,
first CMC and triscaphe joint.
4. Diffuse osteopenia.
___: left wrist x-ray :
Unchanged alignment of a left distal radius fracture.
___: MR cervical spine:
. Multilevel degenerative changes of the lumbar spine, as
described, without MR evidence of ligamentous or soft tissue
injury. Please refer to dedicated CT of the cervical spine for
the evaluation of osseous fractures.
2. Multilevel neural foraminal stenosis greatest at left C3-C4,
left C4-C5, and bilateral C5-C6, where there is severe neural
foraminal stenosis.
3. No evidence of cord compression or contusion.
___: MRI head:
1. Parenchymal hemorrhage at the posterior inferior left
thalamus without
evidence of underlying enhancing mass. Small amount of blood
layering in the bilateral occipital horns and within the fourth
ventricle. Small amount of right convexity subdural blood. Small
right convexity subdural hematoma.
These findings are relatively unchanged.
2. Punctate focus of slow diffusion at the mid superior left
thalamus without corresponding blood products which may
represent an acute infarct.
3. Background sequela chronic microangiopathy and small right
frontal remote microbleeds.
4. Facial fractures are not well seen on MRI and are better
characterized on prior dedicated CT.
Brief Hospital Course:
___ year old female who sustained a fall down 5 steps with head
strike and unclear LOC
for unknown amount of time. She was unable to recall why she
fell. She activated her Life alert. She was brought to an OSH
where she was GCS ___. She underwent a CT of the head which
revealed a SAH/IPH. Cat scan imaging of the maxillary/face
demonstrated multiple facial fractures: non-displaced right
inferior orbital and maxillary sinus fracture without evidence
of entrapment or intraorbital hemorrhage. She was given
clindamycin and keppra at ___ and transferred to ___ for
further
evaluation.
Upon arrival to the hospital, the patient was admitted to the
Trauma Intensive care unit for monitoring. She was alert and
oriented x 3. She was having ectopy with multiple runs of NSVT
which improved with electrolytes repletion. Troponins were sent
to rule out a cardiac contusion. She was given additional
intravenous fluids for a decreased urine output. On review of
the imaging the patient was reported to have right sided ___ rib
fractures, a right displaced clavicle fracture, a right scapula
fracture and a sternal fracture. Her pain was controlled with
oral analgesia. The patient was encouraged to use the incentive
spirometer.
The patient was transferred to the surgical floor on ___.
Because of her multiple injuries, the Orthopedic, Neurosurgery,
and Plastic surgery service were consulted. No surgical
intervention was indicated. The patient was placed on sinus
precautions for the facial fractures and a sling was applied to
support the right clavicle and scapular fracture. Because of
her orbital and maxillary sinus fracture, the Ophthalmology
service was consulted. Outpatient follow-up was recommended.
During the remainder of the ___ hospital course, her vital
signs remained stable and she was afebrile. She was started on
a regular diet. Her foley catheter was removed on ___ and she
was voiding without difficulty. Her hematocrit was stable at 31
with a normal white blood cell count. In preparation for
discharge, the patient was evaluated by physical and
occupational therapy. Recommendations were made for discharge
to a rehabilitation facility to help the patient regain her
strength and mobility.
The patient was discharged on ___ in stable condition.
Appointments for follow-up were made with the multiple services
who were consulted in her care.
Her aspirin is on hold until ___
*****An incindental finding of a thrombosed left paraclinoid ICA
aneurysm was identified on head CT.****
*****Punctate focus of slow diffusion at the mid superior left
thalamus without corresponding blood products which may
represent an acute infarct
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Atenolol 37.5 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Citalopram 20 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Thiamine 100 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Medications:
1. Atorvastatin 10 mg PO QPM
2. Citalopram 20 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. PredniSONE 5 mg PO DAILY
5. Thiamine 100 mg PO DAILY
6. Acetaminophen 1000 mg PO Q6H:PRN Pain
7. HydrALAzine 25 mg PO Q6H:PRN SBP > 140
8. Hydrochlorothiazide 25 mg PO DAILY
9. Insulin SC
Sliding Scale
Fingerstick Q6h
Insulin SC Sliding Scale using REG Insulin
10. Aspirin 81 mg PO ON HOLD
ON HOLD, MAY RESUME ON ___. Metoprolol Tartrate 12.5 mg PO Q6H
12. Atenolol 37.5 mg PO DAILY
13. Lisinopril 20 mg PO DAILY
14. MetFORMIN (Glucophage) 500 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Trauma:
lateral/ant walls R maxillary sinus fracture
right zygomatic arch fracture
sphenoid
right orbital fracture
right rib fractures ___
displaced Right clavicle fracture
right scapula fracture
sternal fracture
Compression def T12,indeterminate age
left distal radius fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital after a fall in which you
sustained injuries to your face, ribs, scapula, clavicle,
sternum, left radius fracture, and T12 compression deformity.
You did not require any surgical intervention. You were seen by
physical therapy and recommendations were made for discharge to
a rehabilitation facility to help you regain your strength and
mobility. You are being discharged with the following
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.
Followup Instructions:
___
|
19797896-DS-13
| 19,797,896 | 29,486,556 |
DS
| 13 |
2174-09-04 00:00:00
|
2174-09-04 13:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Sudafed
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___: Replacement of right tube thoracostomy.
History of Present Illness:
___ with history of moderate dementia, on Lovenox for recent
right hip surgery (___), now 2 weeks status post fall with
right-sided rib fractures, who presents with acutely worsening
shortness of breath for the two days. Patient was seen over at
___ prior to arrival where she had a CT
of her chest which demonstrated large right pleural effusion
with consolidation of the lower lobe, no mediastinal shift,
lungs aerated and clear, no left pleural effusion along with
multiple right-sided rib fractures.
Patient denies any abdominal pain or black or bloody stools or
nausea or vomiting. No dysuria. Patient at baseline mental
status per family at bedside. Patient describes shortness of
breath with chest pain and has difficulty speaking in full
sentences. She is pleasant but confused and accompanied by her
daughter (HCP) who states that her pain and shortness of breath
acutely worsened
over the past few days, prompting the ED presentation.
Past Medical History:
PMH: Type 2 diabetes, cerebral palsy, mild mitral stenosis,
tricuspid regurgitation, hypertension, uterine cancer, pulmonary
hypertension, history of CVA, chronic back pain, spinal
stenosis,
osteoporosis, depression, anxiety and GERD.
PSH: ORIF for right trochanteric fracture (___),
hysterectomy
___ years prior)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: T98.7, HR100, BP 162/60, RR32 95%2LNC
GEN: A&Ox1, uncomfortable, tachypneic, not speaking in full
sentences
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation on left, decreased breath sounds on
right, tenderness to right lateral chest wall
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
Pertinent Results:
___ 06:50AM BLOOD WBC-6.7 RBC-3.18* Hgb-9.2* Hct-29.1*
MCV-92 MCH-28.9 MCHC-31.6* RDW-13.4 RDWSD-45.5 Plt ___
___ 06:35AM BLOOD WBC-5.5 RBC-3.06* Hgb-8.9* Hct-28.2*
MCV-92 MCH-29.1 MCHC-31.6* RDW-13.5 RDWSD-45.8 Plt ___
___ 06:45AM BLOOD WBC-6.6 RBC-3.02* Hgb-8.8* Hct-28.0*
MCV-93 MCH-29.1 MCHC-31.4* RDW-13.6 RDWSD-45.9 Plt ___
___ 02:15AM BLOOD WBC-8.2 RBC-3.37* Hgb-9.8* Hct-30.8*
MCV-91 MCH-29.1 MCHC-31.8* RDW-13.5 RDWSD-45.5 Plt ___
___ 03:00PM BLOOD WBC-8.3 RBC-3.82* Hgb-11.1* Hct-35.2
MCV-92 MCH-29.1 MCHC-31.5* RDW-13.7 RDWSD-46.4* Plt ___
___ 03:00PM BLOOD ___ PTT-32.3 ___
___ 06:50AM BLOOD Glucose-126* UreaN-8 Creat-0.4 Na-137
K-4.3 Cl-100 HCO3-29 AnGap-12
___ 06:35AM BLOOD Glucose-111* UreaN-7 Creat-0.4 Na-141
K-4.1 Cl-102 HCO3-30 AnGap-13
___ 06:45AM BLOOD Glucose-125* UreaN-8 Creat-0.4 Na-137
K-3.9 Cl-101 HCO3-29 AnGap-11
___ 02:15AM BLOOD Glucose-155* UreaN-12 Creat-0.4 Na-139
K-4.4 Cl-104 HCO3-24 AnGap-15
___ 03:00PM BLOOD Glucose-114* UreaN-12 Creat-0.5 Na-139
K-4.9 Cl-102 HCO3-25 AnGap-17
___ 03:00PM BLOOD ALT-75* AST-63* AlkPhos-134* TotBili-0.4
___ 03:00PM BLOOD proBNP-___*
___ 06:50AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.1
___ 06:35AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.9
___ 06:45AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.7
___ 02:15AM BLOOD Calcium-8.7 Phos-4.5 Mg-1.8
___ 03:19PM BLOOD Lactate-1.4
___ 3:00 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___, ___, ON
___ AT
20:00 ___.
___ 8:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 08:50PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 08:50PM URINE Blood-SM* Nitrite-POS* Protein-TR*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 08:50PM URINE RBC-7* WBC-16* Bacteri-MOD* Yeast-NONE
Epi-16 TransE-1
___ CXR:
In comparison with the study of ___, the right chest tube is
now within the thoracic cavity with the tip just above the
medial aspect of the clavicle. No evidence of post procedure
pneumothorax. There has been apparent removal of a substantial
amount of pleural fluid with residual atelectatic changes or
possible re-expansion edema at the base.
Cardiomediastinal silhouette is stable and there again is some
elevation of pulmonary venous pressure.
___ CXR:
Interval increase in small right pleural effusion. Increased
opacification of the right lower lobe of unclear etiology.
Follow-up imaging is recommended.
___ CXR:
Compared to the prior study, I doubt significant interval
change.
Again seen is a right-sided chest tube overlying the right lung,
mild
undulation as it enters chest walls noted, unchanged. No
pneumothorax. Small right greater left pleural effusion. Fluid
in the minor fissure and opacity in the right lung zone as well
as atelectasis at the left lung base again noted. Probable CHF,
unchanged.
___ CT Chest:
1. Right posterior chest tube in place. Significant decrease in
now small
right pleural effusion with a few small areas of loculated
fluid, particularly
in the fissures and at the right lung base. A discrete locule
measuring 2.6 x 1.8 cm along the right major fissure contains
several of locule of internal gas and me be related to placement
of the initial chest tube.
2. Consolidative opacity at the right lung base, concerning for
pneumonia.
3. Small left pleural effusion, increased from prior CT.
4. Re-demonstrated multiple right-sided rib fractures, detailed
above.
5. Enlarged mediastinal lymph nodes, increased from prior chest
CT, likely
reactive.
___ CXR:
FINDINGS:
The right chest tube is been removed. No pneumothorax is
identified. There are small bilateral pleural effusions.
Unchanged right basilar opacity. The right rib fractures were
better assessed on the CT scan performed yesterday.
The left lung is grossly clear. The size of the cardiac
silhouette is within normal limits. There are degenerative
changes of the right acromioclavicular joint.
IMPRESSION:
Interval removal of the right chest tube. No pneumothorax is
identified.
Brief Hospital Course:
Ms. ___ is a ___ yo F with moderate dementia, on lovenox for
recent right hip surgery (___), who presented to outside
hospital on ___ with increased shortness of breath after
fall with right sided rib fractures 2 weeks prior. She was
transferred to ___ for further management. Right chest
tube was placed in emergency department but found to be in the
subcutaneous tissues and the pleural space had not been entered.
Because of pain during initial insertion, she was taken to the
operating room and had chest tube inserted under MAC anesthesia.
Upon chest tube insertion, approximately 1200 cc of blood was
evacuated. The patient was extubated and taken to the trauma ICU
for continued monitoring and management.
Neuro: The patient was alert and oriented x1 throughout
hospitalization; pain was initially managed with a IV tyleonol
and IV dilaudid for breakthrough and then transitioned to oral
Tylenol and tramadol once tolerating a diet. Home gabapentin
regimen continued.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Intially home
lisinopril was held for kidney protection and amlodipine for
hypotension. The patient remained stable and therefore home
medications were restarted at previous dosing.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. Daily chest xrays were
obtained while chest tube was in place. Chest tube was removed
on ___ and repeat chest xray showed no pneumothorax.
Supplemental oxygen was titrated to maintain O2 sat >93%
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On ____, the NGT
was removed_____, therefore, the diet was advanced sequentially
to a Regular diet, which was well tolerated. 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.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
CARDIOVASCULAR: History of hypertension, mild mitral stenosis,
tricuspid regurgitation, pulmonary hypertension
#hypertension
-IV Lopressor 5mg q6hr
-currently hemodynamically stable
-holding home lisinopril and amlodipine
PULMONARY: hemothorax s/p chest tube placement in OR
-chest tube to suction per ACS
-daily CXR while CT in place
-titrate supplemental oxygen to >93%
GI/ABDOMEN: no history of GI disease, benign abdomen on exam
-currently NPO per ACS
-holding home lactulose
FEN:
# Fluids: LR @ 75
# Electrolytes: replete lytes PRN
# Enteral/Parenteral nutrition: NPO except meds
RENAL: Baseline renal function unknown
-No foley in place, monitor UOP
HEMATOLOGY:
Anemia: Hct 35.2 -> 30.8
-trend Hct q12hr in setting of hemothorax
-monitor chest tube output q2hr, character and output volume
-transfuse if Hct <21
DVT prophylaxis: SCDs, holding SQH in setting of bleed
TYPE AND SCREEN OUTDATES:
MSK:
___ consult when appropriate
ENDOCRINE:
#history of diabetes
Glycemic control: RISS for Goal FSBS <180, avoid hypoglycemia.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Right rib fractures and right traumatic hemothorax.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* Your injury caused right-sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
19798000-DS-10
| 19,798,000 | 26,225,415 |
DS
| 10 |
2146-03-10 00:00:00
|
2146-03-10 21:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Compazine / Morphine
Attending: ___.
Chief Complaint:
R Flank Pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
This is a ___ w/ h/o thalassemia trait, chronic anemia, kidney
stones, lap band ___ presenting w/ flank pain radiating to
right shoulder, ___ AM she developed sharp
right flank pain, radiating to right shoulder starting ___,
waxes and wanes in intensity, worse with deep breath and moving.
Over the same time has had substernal pain with swallowing,
without food sticking sensation. No pelvic pain. Has been
passing nonbloody urine. She has had subjective chills but no
documented fevers. No dysuria, doesnt remind her of prior
nephrolithiasis. Has had bloody spotting of the toilet paper
with wiping with stool, but her stool has been brown and
nonbloody. Able to eat. Ibuprofen hasnt helped.
Notes that she has ongoing heavy periods, typically lasting 2
weeks at a time, no intermenstrual bleeding. Has not been taking
her iron for at least the last month.
In the ED, initial vitals: 98.7 90 135/68 18 100% RA. She was
consistently afebrile, with normal renal function and no
leukocytosis. She had a neg abd US, no hydro. KUB w/ ?lap band
migration but UGI/barium reassuring. Cleared by bariatric
surgery. Initial plan to get CTU but barium in the bowel would
interfere so admitted to medicine to allow the barium to pass.
Meds given:
HYDROmorphone (Dilaudid) .5 mg
___ 00:21 IVF 1000 mL LR
___ 03:31 IVF 1000 mL LR
___ 03:32 IV HYDROmorphone 1mg
___ 04:48 IV Ketorolac 15 mg
___ 09:52 IVF 1000 mL LR
___ 12:43 IV HYDROmorphone 1mg
Vitals prior to transfer: 98.3 67 121/51 16 100% RA
Currently, the pt symptoms are stable as described above.
ROS: As above. Otherwise negative in detail.
Past Medical History:
ANEMIA, chronic, thalassemia trait, iron deficiency
LEFT ANKLE FRACTURE
ASTHMA
CHRONIC BACK PAIN
DEPRESSION (hx of SI)
HEALTH MAINTENANCE
MENORRHAGIA
OBESITY s/p Gastric Banding
H/O KIDNEY STONES
CERVICAL METAPLASIA
Reported celiac disease by biopsy, antibody reportedly negative
Social History:
___
Family History:
Mom, with anemia. No history of blood clots. Several cousins
with cancers at early ages, including breast and colon in ___.
Physical Exam:
ADMISSION:
Vitals- 98.3 135/62 73 18 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, pale conjuctivae and complexion, MMM,
oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT, no hepatosplenomegaly. On palpation of RUQ,
"pressure" behind right shoulder appreciated. No pain on
palpation of right chest wall. No CVAT
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Right shoulder ROM intact, no impingement signs of e/o
bursitis/tendonitis clinically
Neuro- CNs2-12 intact, motor function grossly normal
Rectal: No visible blood seen externally, external hemorrhoids
visualized
DISCHARGE:
Vitals- 98.5 120/65 66 18 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, pale conjuctivae and complexion, MMM,
oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT, no hepatosplenomegaly. No abd ttp
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro- CNs2-12 intact, sensiromotor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 09:09PM PLT COUNT-249
___ 09:09PM WBC-6.4# RBC-4.33 HGB-7.0* HCT-25.9* MCV-60*
MCH-16.2* MCHC-27.1* RDW-19.2*
___ 09:09PM WBC-6.4# RBC-4.33 HGB-7.0* HCT-25.9* MCV-60*
MCH-16.2* MCHC-27.1* RDW-19.2*
___ 09:09PM TSH-1.6
___ 09:09PM calTIBC-482* VIT B12-290 FERRITIN-3.0*
TRF-371*
___ 09:09PM ALBUMIN-4.1 IRON-13*
___ 09:09PM cTropnT-<0.01
___ 09:09PM LIPASE-32
___ 09:09PM ALT(SGPT)-10 ALK PHOS-62 TOT BILI-0.2
___ 09:09PM estGFR-Using this
___ 09:09PM GLUCOSE-94 UREA N-11 CREAT-0.9 SODIUM-138
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-25 ANION GAP-15
___ 12:47AM LACTATE-0.8
___ 12:47AM ___ COMMENTS-GREEN TOP
___ 03:20AM URINE MUCOUS-FEW
___ 03:20AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-2
___ 03:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-TR
___ 03:20AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:20AM URINE UHOLD-HOLD
___ 03:20AM URINE UHOLD-HOLD
___ 03:20AM URINE UCG-NEGATIVE
___ 03:20AM URINE HOURS-RANDOM
___ 03:20AM URINE HOURS-RANDOM
___ 06:53AM cTropnT-<0.01
DISCHARGE:
___ 07:35AM BLOOD WBC-4.6 RBC-4.07* Hgb-6.8* Hct-24.6*
MCV-60* MCH-16.6* MCHC-27.5* RDW-19.2* Plt ___
___ 07:35AM BLOOD Glucose-85 UreaN-9 Creat-0.5 Na-136 K-4.2
Cl-102 HCO3-22 AnGap-16
___ 07:35AM BLOOD ALT-9 AST-13 LD(LDH)-153 AlkPhos-56
TotBili-0.3
___ 07:35AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0
___ 04:52PM BLOOD HIV Ab-NEGATIVE
IMAGING:
EGD ___
Impression: Normal mucosa in the esophagus (biopsy)
Normal mucosa in the stomach
Normal mucosa in the duodenum (biopsy)
Otherwise normal EGD to third part of the duodenum
RUQ US ___:
1. No evidence of acute cholecystitis.
2. Echogenic liver consistent with hepatic steatosis.
3. 2.3 cm nonvascular echogenic lesion in the left lobe of the
liver, not fully characterized on this study. While may
represent a hemangioma, a nonemergent MR can be obtained for
further evaluation.
KUB ___: No evidence of bowel obstruction. Laparoscopic band
at a
more vertical angle compared to prior studies (___), raising
the concern for band slippage.
Barium swallow/UGI ___:
IMPRESSION: Unchanged position of the laparoscopic band, no
evidence of obstruction.
CXR ___
Since the prior study the impression is at the cardiac
silhouette has enlarged
but that may be attributed to portable nature of the study.
Mediastinum is
unremarkable and the lungs are clear. Repeated radiograph with
PA and lateral
views might be suggested for pre size assessment of the cardiac
silhouette.
Renal US ___
IMPRESSION:
Normal renal ultrasound with no evidence of renal calculi, no
hydronephrosis.
Brief Hospital Course:
This is a ___ w/ h/o thalassemia trait, chronic anemia, kidney
stones, lap band ___ presenting w/ flank pain.
# Flank pain: Reassuring exam, vital signs, labs. Pt noted that
the pain has been present on/off for months. On history and exam
felt to most likely be musculoskeletal lower back pain. No
stigmata of nephrolithiasis (no hydro or hematuria), and it was
felt that there was no current indication for abdominal imaging.
Used APAP, oxycodone for pain control. Recommended outpt ___,
contiuing attempts at weight loss, lidocaine patch. Consider
dedicated back imaging as outpt if pain persists or worsens.
# Odynophagia: Started after admission. EGD wnl, lap band was
functioning normally and now deflated prior to discharge. Ddx
includes motility disorder, unlikely to be celiac-related.
Tolerated POs. Received a PPI and will f/u with GI.
# Anemia: Chronic, hct slightly lower than baseline. Microcytic.
Probably combination of known thalassemia and severe iron
deficiency in the setting of menorrhagia and nonadherence with
PO iron regimen. That during this admission 2.5%. Received IV
iron and restarted on PO iron. B12 was borderline and started on
supplementation. Suggest GYN eval as outpt given persistent
anemia in the setting of heavy menstruation. Rectal bleeding as
belows
# Hematochezia: Pattern c/w hemorrhoidal source and these were
seen on exam. Does have a FH of early onset colon cancer. Last
___ ___, wnl. Outpt repeat colonoscopy can be considered, will
f/u with GI.
# Liver lesion: Likely hemangioma but radiology recommending
outpt liver MRI
# Asthma: Albuterol prn
# EKG findings: Baseline LAD and T wave inversions, all
non-specific. Consider outpt TTE to exclude HOCM, especially
given ?cardiomegaly seen on CXR
Transitional issues:
- Followup with GI regarding odynophagia, hematochezia
(hemorrhoids noted on exam), possible celiac disease
- Followup with bariatric surgery re. lap band
- Recommend GYN evaluation for menorrhagia leading to severe
anemia
- MRI of the liver for lesion seen in left lobe, likely
hemangioma
- Referred to ___ for lower back pain
- TTE for baseline EKG changes, ?cardiomegaly on exam, to
exclude HOCM.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
Daily Disp #*30 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Do not take if stools are loose
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) 1 patch to painful
site on lower back daily Disp #*30 Patch Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Do not operate motor vehicles or drink alcohol when taking this
medication
RX *oxycodone 5 mg 1 tablet(s) by mouth q6 Disp #*12 Tablet
Refills:*0
6. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth q12 hours Disp #*60
Tablet Refills:*0
7. 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
8. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Lower back pain
Odynophagia
Iron deficiency anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
with back pain and pain with swallowing. We recommend physical
therapy for your lower back pain. You had an endoscopy which was
normal. You should followup with gastroenterology, bariatric
surgery, and your primary care doctor. We have started you on
iron and vitamin B12 supplements for your anemia. If the iron
pills make your swallowing worse, please discuss with your PCP
regarding IV iron infusions. We do recommend that you be
evaluated by Ob/Gyn regarding your heavy periods and anemia.
Your PCP can help you with this referral.
You may require a colonoscopy because of the rectal bleeding you
noticed this past month - this can be discussed with your
gastroenterologist at followup.
You will require an MRI to evaluate a small, benign-appearing
spot on your liver. This likely represents an enlarged blood
vessel.
Best wishes,
Your ___ Team
Followup Instructions:
___
|
19798000-DS-12
| 19,798,000 | 23,051,141 |
DS
| 12 |
2150-04-03 00:00:00
|
2150-04-03 19:10:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Aspirin / Compazine / Morphine
Attending: ___
Chief Complaint:
Abdominal pain and food intolerance
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ PMH thalassemia trait, morbid obesity s/p
lap
band ___, presenting with 2 days of RUQ & epigastric pain. She
states that the pain began 2 days ago, and she cannot associate
the start of the symptoms with any specific inciting factor,
such
as a fatty meal. She states that the pain has increased,
especially in her lower chest, to the point where she cannot
take
a deep breath due to pain. She denies fever, chills, nausea,
vomiting, dysuria, or changes in bowel movements. She denies
sick
contacts or previous episodes of similar pain. A CT performed in
the ED was concerning for possible early appendicitis, and
___ surgery was consulted for further management.
Past Medical History:
ANEMIA, chronic, thalassemia trait, iron deficiency
LEFT ANKLE FRACTURE
ASTHMA
CHRONIC BACK PAIN
DEPRESSION (hx of SI)
HEALTH MAINTENANCE
MENORRHAGIA
OBESITY s/p Gastric Banding
H/O KIDNEY STONES
CERVICAL METAPLASIA
Reported celiac disease by biopsy, antibody reportedly negative
Social History:
___
Family History:
Mom, with anemia. No history of blood clots. Several cousins
with cancers at early ages, including breast and colon in ___.
Physical Exam:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
ABD: Obese, soft, non-tender RLQ, mildly tender RUQ, negative
___ sign, mildly tender epigastric.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 12:00AM BLOOD WBC-7.3 RBC-4.50 Hgb-10.8* Hct-36.7
MCV-82 MCH-24.0* MCHC-29.4* RDW-18.5* RDWSD-54.5* Plt ___
___ 12:00AM BLOOD Neuts-59.9 ___ Monos-7.2 Eos-3.8
Baso-0.5 Im ___ AbsNeut-4.38 AbsLymp-2.06 AbsMono-0.53
AbsEos-0.28 AbsBaso-0.04
___ 12:00AM BLOOD Plt ___
___ 12:00AM BLOOD ___ PTT-27.0 ___
___ 12:00AM BLOOD D-Dimer-272
___ 04:48PM BLOOD K-4.2
___ 12:00AM BLOOD Glucose-87 UreaN-9 Creat-0.6 Na-137
K-6.6* Cl-100 HCO3-25 AnGap-12
___ 12:00AM BLOOD ALT-15 AST-56* AlkPhos-55 TotBili-0.3
___ 12:00AM BLOOD Lipase-21
___ 12:00AM BLOOD cTropnT-<0.01
___ 12:00AM BLOOD Albumin-3.9 Calcium-9.3 Phos-4.1 Mg-1.8
___ 12:17AM BLOOD Lactate-1.6 K-3.7
Brief Hospital Course:
Ms. ___ was admitted early on ___ with abdominal pain, chest
pain, and the inability to keep food down for 2 days. A CT in
the ED was concerning for early appendicitis. Due to this and
concern for a slipped gastric lap band, she was admitted for
observation. The CT read came back negative for acute
appendicitis and the upper GI study came back negative for a
slipped band. The patient quickly expressed her desire for
discharge and left against medical advice before the paperwork
could be finalized. She received a few doses of Tylenol and one
dose of oxycodone. She was otherwise medically cleared for
discharge.
Medications on Admission:
Medications - Prescription
ALBUTEROL - albuterol 90 mcg/actuation aerosol inhaler. 2 puffs
inhale four times a day as needed for asthma
OXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth every 6
hours as needed for pain
Medications - OTC
DOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 (One)
capsule(s) by mouth twice a day
FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1
(One) tablet(s) by mouth twice a day
PRENATAL VIT-IRON FUM-FOLIC AC - prenatal vitamin-ferrous
fumarate 28 mg iron-folic acid ___ mcg tablet. 1 tablet(s) by
mouth daily
Discharge Medications:
Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Medications - Prescription
ALBUTEROL - albuterol 90 mcg/actuation aerosol inhaler. 2 puffs
inhale four times a day as needed for asthma
OXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth every 6
hours as needed for pain
Medications - OTC
DOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 (One)
capsule(s) by mouth twice a day
FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1
(One) tablet(s) by mouth twice a day
PRENATAL VIT-IRON FUM-FOLIC AC - prenatal vitamin-ferrous
fumarate 28 mg iron-folic acid ___ mcg tablet. 1 tablet(s) by
mouth daily
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, food intolerance
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital for
observation due to concern over appendicitis and a possible
slipped laparoscopic band. You were found to not have either of
these issues. You have recovered and are now ready to be
discharged to home. Please follow the recommendations below to
ensure a speedy and uneventful recovery.
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.
- You may start some light exercise when you feel comfortable.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- You may resume sexual activity unless your doctor has told
you otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during the endoscopy.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
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.
Thank you for letting us care for you!
Followup Instructions:
___
|
19798000-DS-9
| 19,798,000 | 27,868,654 |
DS
| 9 |
2144-10-27 00:00:00
|
2144-10-27 20:43:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Aspirin / Compazine / Morphine
Attending: ___.
Chief Complaint:
Intolerance to PO, solids and liquids
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F s/p adjustable gastric band in ___, p/w PO
intolerance X 4 days. She describes eating a piece of chicken on
___ that seemed to not advance past the band. Following this
she
experienced epigastric fullness to solid food that progressed to
both solid and liquid food over the past 4 days. These symptoms
are a/w N, vomiting X >10, diarrhea X 5, NB/NB. She has had
decreased PO intake over this time. She experiences epigastric
pain while vomiting, that resolves after. She denies ab. pain,
BRBPR, melena, fever, chills.
Past Medical History:
Asthma, anemia, obesity
Social History:
___
Family History:
Mom, with anemia. No history of gastrointestinal illnesses
Physical Exam:
Discharge Exam:
V: 98.6, 98.2, 58, 102/59, 18, 99% RA
Gen: NAD, comfortable, A and O X3
CV: RRR, no murmurs
Pulm: CTAB, no wheezes
Ab.: Soft, NT/ND, BS+, no rebound/guarding
Ext: WWP, no calf tenderness, no lower extremity swelling
Pertinent Results:
___ 03:30PM WBC-4.3 RBC-4.58 HGB-8.9* HCT-30.3* MCV-66*#
MCH-19.4*# MCHC-29.3* RDW-16.8*
Brief Hospital Course:
The patient was evaluated in the Emergency Department by the
Bariatrics Team for intolerance to solid and liquid PO. Her
gastric band was unfilled and the patient felt better upon
drinking water after. It was decided to admit her to advance
diet slowly, for IV hydration and for an upper GI to evaluate
for band prolapse.
She received IV fluids throughout her hospitalization and after
her upper GI on HD#1, which was unchanged from previous, she was
advanced sequentially from Bariatrics Stage I through Bariatrics
Stage III diets. She tolerated all without complaint, N/V.
Upon discharge, her vitals were stable, she was taking adequate
PO intake, she was voiding her bowels and bladder appropriately.
She will follow up with Dr. ___ in 2 weeks.
Medications on Admission:
Albuterol PRN
Ferrous sulfate
MVI
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q4H:PRN wheezing
2. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Band obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for monitoring after
intolerance to oral food, likely due to some food stuck at your
gastric band. Your band was unfilled in the Emergency Department
and you were admitted overnight. All of your blood work was
normal and the upper GI swallow study showed that the band was
in good position.
Medication:
Please continue all pre-admission medications as you were before
this hospital stay.
Diet:
Please remain on a Bariatric Stage III diet until your
post-operative visit with Dr. ___
___:
As tolerated.
Followup Instructions:
___
|
19798578-DS-33
| 19,798,578 | 20,033,975 |
DS
| 33 |
2141-07-29 00:00:00
|
2141-08-04 22:25:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nitrate Analogues / Vancomycin
Attending: ___
___ Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with a history of
recently-diagnosed Burkitt's lymphoma, a PTLD status post renal
transplant in ___ who prsented to clinic on ___ for day #14
of his first cycle of EPOCH and was found to have bandemia and
dyspnea on exertion. History is obtained from the patient as
well as oncology note in ___. He reports an episode of night
sweats the night before admission which soaked his sheets but
denies fever or chills. He felt well until he walked down the
stairs in the morning and then felt short of breath. This was
not associated with any chest pain, chest tightness, associated
naisea, diaphoresis, lightheadedness, or dizziness. He does
endorse bilateral clavicular pain which he says is common with
neupogen. He denies orthopnea, weight gain, ankle swelling, or
PND. He notes a slight cough the morning of admission with some
white sputum. His daughter has a sore throat, but he does not
feel a sore throat, sinus pain, or rinorrhea. He has missed 2
doses of Lovenox because he was waiting to have his platelet
count checked.
In clinic his vitals were as follows: BP: 123/55. Heart Rate:
70. Weight: 233.4. Height: 71.5.BMI: 32.1. Temperature: 98.3.
Resp. Rate: 20. Pain Score: 0. O2 Saturation%: 99. He was taken
to the ER where he received Cefepime 2g IV and was transferred
to the floor for further management. On arrival to the floor,
he states he is feeling well.
REVIEW OF SYSTEMS:
Complete 10 point review of systems was preformed. All were
negative except where noted above.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG in ___ and DES
placed a vein graft in ___.
2. Hyperlipidemia.
3. Diabetes type 2, complicated by retinopathy and neuropathy
4. End-stage renal disease status post renal transplant in ___
5. History of nephrolithiasis
6. DVT, ___ presumed to have PE due to symptoms of shortness
of breath but no CTA was done due to his renal function.
7. Peptic ulcer disease.
PAST ONCOLOGIC HISTORY:
___: Admitted to ___ due to dehydration and abdominal
mass felt on physical exam. CT scan showed a large 16 cm
abdominal mass involving the cecum and terminal ilium as well as
extensive omental implants.
- ___: colonoscopy with biopsy, which showed atypical
lymphoid cells
- ___: Admitted for laparoscopic omental biopsy.
Pathology from this biopsy was consistent with a high-grade
B-cell lymphoma consistent with Bu___'s lymphoma.
Immunohistochemistry showed the tumor was CD20 positive, CD10
positive, CD21 positive and BCL6 positive. The MIB-1
proliferation index was 100%, BCL2 was negative. c-MYC fusion
probe for t(8;14) was negative. The patient was transferred to
the ___ service. He was treated with rasburicase for uric acid
level of 15.
___: received EPOCH chemotherapy cycle #1.
Social History:
___
Family History:
father had CAD, stroke and Renal failure on dialysis
Physical Exam:
T 96.8 bp 120/70 HR 65 RR 17 SaO2 99 RA
GENERAL: Alert, oriented, NAD, joking
HEENT: Anicteric, mucous membranes moist;
CV: Regular rate and rhythm, nl S1/S2, no murmurs, rubs or
gallops
PULM: Clear to auscultation bilaterally, normal effort
ABD: Obese, normoactive bowel sounds, soft, non-tender,
non-distended, no masses or hepatosplenomegaly
LIMBS: Trace edema of the lower extremities bilaterally. Right
lower extremity swelling greater than right.
SKIN: No rashes or skin breakdown
NEURO: no focal deficits, attention normal
PSYCH: cooperative, appropriate
Pertinent Results:
___ 11:24PM cTropnT-<0.01
___ 01:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 12:49PM LACTATE-1.8
___ 12:40PM GLUCOSE-525* UREA N-18 CREAT-1.0 SODIUM-136
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-21* ANION GAP-12
___ 12:40PM cTropnT-<0.01
___ 12:40PM WBC-7.7# RBC-3.73* HGB-10.0* HCT-33.7* MCV-90
MCH-26.8* MCHC-29.7* RDW-14.8
___ 12:40PM NEUTS-47* BANDS-17* LYMPHS-16* MONOS-12*
EOS-0 BASOS-0 ___ METAS-5* MYELOS-3*
___ 12:40PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
___ 12:40PM PLT SMR-LOW PLT COUNT-70*
___ 12:40PM ___ PTT-34.5 ___
___ 11:30AM UREA N-20 CREAT-1.4* SODIUM-139 POTASSIUM-4.6
CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
___ 11:30AM tacroFK-6.8
___ 11:30AM WBC-2.1* RBC-4.45* HGB-12.7* HCT-38.7* MCV-87
MCH-28.6 MCHC-32.9 RDW-13.6
___ 11:30AM NEUTS-26* BANDS-3 LYMPHS-52* MONOS-5 EOS-3
BASOS-0 ___ MYELOS-0 OTHER-11*
___ 11:30AM PLT SMR-VERY LOW PLT COUNT-79*
___ 11:30AM ___ ___
Echo ___
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild regional left ventricular systolic dysfunction with
basal inferior hypokinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
.
Compared with the prior study (images reviewed) of ___, no
change
.
CXR ___: IMPRESSION: 1. No evidence of pneumonia. 2.
Small left pleural effusion.
EKG: normal sinus rhythm, no significant change from previous
tracing
.
.
___ 06:15AM BLOOD WBC-12.9* RBC-4.26* Hgb-12.1* Hct-37.3*
MCV-88 MCH-28.4 MCHC-32.4 RDW-14.5 Plt Ct-97*
___ 06:15AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL
___ 06:15AM BLOOD Glucose-115* UreaN-16 Creat-1.0 Na-138
K-4.5 Cl-106 HCO3-27 AnGap-10
___ 06:15AM BLOOD ALT-22 AST-26 LD(LDH)-305* AlkPhos-109
TotBili-0.2
___ 06:15AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8 UricAcd-8.3*
.
___ Radiology LUNG SCAN
IMPRESSION: Normal V-Q scan. Normal lung scan rules out recent
pulmonary
embolism.
.
___ URINE URINE CULTURE-FINAL- no growth.
.
___ BLOOD CULTURE x 2 - no growth to date.
Brief Hospital Course:
Mr. ___ is a ___ man with a history of renal transplant
in ___ and newly diagnosed burkitt's lymphoma who presented on
cycle 1, day 14 of EPOCH chemotherapy with an episode of mild
cough and dyspnea on exertion.
.
#Dyspnea on exertion: Pt has atyical mild chest "pressure" w/
walking down the stairs, which he says was different from his
prior episodes of stable angina. Significantly, he has a history
of clincally diagnosed PE/DVT ___ (no CTA was done given his
baseline renal insufficiency and renal transplant) and has been
on treatment with enoxaparin. There is no significant historical
or physical change to suggest that his cardiac function has
changed from Echo preformed about 2 weeks prior to admission. MI
was ruled out with unchanged ECG relative to baseline and
negative troponins. Pt was started empirically on levofloxacin
for atypical PNA or tracheobronchitis given normal appearance of
chest film w/ only small L pleural effusion. Although he had
leukocytosis this was most likely due to his use of filgrastim
just prior to admission for neutropenia. He remained afrebrile
throughout his stay. He had a V/Q scan done, which showed no
evidence at all of a pulmonary embolism. By the evening of
admission, Pt stated that he felt completely well and had no
symptoms whatsoever. His ambulatory O2 saturation was 97% on
room air. His is unlikely to have any a true pneumonia or
bronchitis, and his antibiotics were discontinued on discharge.
.
# Leukocytosis - most likely due to Pt's use of filgrastim just
prior to admission for neutropenia. This was discontinued given
current WBC counts.
.
# Coronary artery disease status post CABG in ___ and DES; vein
graft in ___. Pt was ruled out for MI (see above). Pt was
continued on his home beta blocker and statin w/out issue.
# Diabetes type 2, complicated by retinopathy and neuropathy.
70/30 insulin BID and sliding scale as per home med.
#End-stage renal disease status post renal transplant in ___.
Continued home tacrolimus, level appropriate at 5.9, avoid
nephrotoxins. Continued home ACE-I and prophylactic bactrim
w/out issue.
# Peptic ulcer disease - continued home PPI
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
ENALAPRIL MALEATE - 5 mg Tablet - 1 Tablet(s) by mouth once a
day
ENOXAPARIN - 80 mg/0.8 mL Syringe - 1 Syringe(s) every twelve
(12) hours
INSULIN ASP PRT-INSULIN ASPART [NOVOLOG MIX 70-30] -
(Prescribed
by Other Provider) - 100 unit/mL (70-30) Solution - 50 units
twice daily
___ [FIRST-MOUTHWASH BLM] - 400
mg-400
mg-40 mg-25 mg-200 mg/30 mL Mouthwash - 1 teaspoon four times
per
day as needed for mouth pain swish and spit
METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth four times
per day as needed for nausea
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - one
Tablet(s) by mouth daily
PRAVASTATIN - 40 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM DS] - 800 mg-160 mg
Tablet
- 1 Tablet(s) by mouth three times a week
TACROLIMUS - (Dose adjustment - no new Rx) - 1 mg Capsule - 3
Capsule(s) by mouth twice a day
Medications - OTC
SALIVA STIMULANT AGENTS COMB.2 [BIOTENE ORALBALANCE] - Liquid
-
use as directed four times per day
SENNOSIDES [SENNA] - 8.6 mg Tablet - 1 Tablet(s) by mouth twice
a
day as needed for constipation
Discharge Medications:
1. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) 80mg
Subcutaneous Q12H (every 12 hours).
4. insulin asp prt-insulin aspart 100 unit/mL (70-30) Solution
Sig: One (1) 50 units Subcutaneous twice a day.
5. FIRST-Mouthwash BLM 200-25-400-40 mg/30 mL Mouthwash Sig: One
(1) teaspoon Mucous membrane four times a day as needed for
mouth pain: swish and spit.
6. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for nausea.
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
8. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAYS (___).
9. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Biotene Oralbalance Liquid Sig: One (1) Mucous membrane
four times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
atypical chest pain
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 because you had
shortness of breath and chest pressure. You also had some night
sweats. You had a workup in the hospital, which showed that you
did not have a heart attack. You also had no signs of pneumonia
or other infections. You were briefly treated with antibiotics,
which were not continued on discharge. You had a scan of your
lungs, which showed no significant blood clot.
We have not made any changes to your medications. Please
continue to take them as previously prescribed.
Followup Instructions:
___
|
19798578-DS-40
| 19,798,578 | 28,174,049 |
DS
| 40 |
2141-11-15 00:00:00
|
2141-11-15 22:59:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nitrate Analogues / Vancomycin
Attending: ___
Chief Complaint:
fever, nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male with Burkitt's lymphoma who
presented to the ED on D12 of IVAC regimen with chills,
dizziness and diarrhea.
Mr. ___ was discharged from the hospital on ___ after an
admission for his last cycle of chemotherapy (R-IVAC). Since
his discharge, he has felt unwell with fatigue, nausea, and poor
po intake. He has been seen frequently in the outpatient clinic
for IV hydration and blood product transfusions. He presented
for a scheduled visit to the ___ outpatient clinic the day prior
to admission and reported profound fatigue, dyspnea on any
exertion, poor po intake, nausea, and 6 watery stools the
previous night with use of a diaper due to incontinence.
Admission was recommended but refused. He received 1 liter IV
fluid, 2 units prbc and 1 bag of platelets and went home.
.
The morning of admission, Mr. ___ called with a report of
ongoing diarrhea, chills and dizziness. He has been on cipro
during his nadir for prophylaxis. He was referred to the ED.
Vitals in the ED were: 99.5 80 147/65 18 100%. He was hydrated,
cultures were obtained, he was given cefepime and admitted.
.
On the floor on admission day, he was feeling unwell. He was
chilled and wrapped in blankets. His last po intake was ___
night. He had ~12 bowel movements in the last 24 hours. There is
no cramping or bleeding. The bowel movements are watery. He
associates them with his recent platelet transfusions. He began
Cipro on ___ for neutropenic prophylaxis. He has also
experienced a cough for the last ___ days, nonproductive. He
has no sick contacts. He has been taking his medication and he
reports normal blood sugars. He did not have any fever or
chills until the day of admission.
.
Past Medical History:
Past Oncologic History:
___: Admitted to ___ due to dehydration and abdominal
mass felt on physical exam. CT scan showed a large 16 cm
abdominal mass involving the cecum and terminal ilium as well as
extensive omental implants.
- ___: colonoscopy with biopsy, which showed atypical
lymphoid cells.
- ___: Admitted for laparoscopic omental biopsy.
Pathology from this biopsy was consistent with a high-grade
B-cell lymphoma consistent with Burkitt's lymphoma.
Immunohistochemistry showed the tumor was CD20 positive, CD10
positive, CD21 positive and BCL6 positive. The MIB-1
proliferation index was 100%, BCL2 was negative. c-MYC fusion
probe for t(8;14) was negative.
- ___: received EPOCH chemotherapy cycle #1.
- ___: EPOCH cycle 2, rituximab given ___.
- ___: EPOCH cycle 3.
- ___: EPOCH cycle 4.
- ___: due to disease profression chemotherapy changed to
R-IVAC cycle 1
- ___: R-IVAC cycle 2
.
Past Medical History:
1. Coronary artery disease status post CABG in ___ and DES
placed a vein graft in ___.
2. Hyperlipidemia.
3. Diabetes type 2, complicated by retinopathy and neuropathy
4. End-stage renal disease status post renal transplant in ___
5. History of nephrolithiasis.
6. DVT, ___ presumed to have PE due to symptoms of shortness
of breath but no CTA was done due to his renal function.
7. Peptic ulcer disease.
Social History:
___
Family History:
Mother with colon cancer in her ___. Father with heart disease.
One sister who is healthy. No family history of leukemia or
lymphoma.
Physical Exam:
Admission physical exam:
VS: 100.2 130/80 20 99% RA
Gen: wrapped in blankets, well appearing
HEENT: no conjuctival pallor, sclera anicterus, dry mucus
membranes
Neck: Supple, no LAD
Chest: CTA b/l, no wheeze rale or rhonchi
___: S1S2 rrr, no rubs, soft systolic murmur
Abd: Obese, soft, non-tender, bruise, no guarding or rigidity,
NABS present
Ext: trace pitting pedal edema, pulses +1 b/l, right amputated
toe. Open wound on dorsal surface of right ___ toe. Peeling skin
on feet.
.
Discharge physical exam:
VS: Tc 98.1 Tmax 98.4 122/64 (120'-140'/60'-70') 64 (60-70') 16
100% RA
Gen: NAD, sitting on chair, not dizzy
HEENT: no conjuctival pallor, sclera anicterus, moist mucus
membranes
Neck: Supple, no LAD
Chest: CTA b/l, no wheeze rale or rhonchi
___: S1S2 rrr, no rubs, soft systolic murmur
Abd: Obese, soft, non-tender, no guarding or rigidity, bowel
sounds present
Ext: no pitting edema, pulses +1 b/l, right amputated toe. Wound
on dorsal surface of right ___ toe. Peeling skin on feet.
Pertinent Results:
Admission labs:
===============
___ 11:35AM BLOOD WBC-0.1* RBC-2.35* Hgb-7.3* Hct-20.8*
MCV-89 MCH-31.2 MCHC-35.2* RDW-15.8* Plt Ct-25*
___ 11:50AM BLOOD Neuts-1* Bands-0 Lymphs-17* Monos-67*
Eos-0 Baso-1 Atyps-14* ___ Myelos-0
___ 11:50AM BLOOD ___ PTT-30.3 ___
___ 11:35AM BLOOD ___ Ct-20*
___ 11:50AM BLOOD Glucose-139* UreaN-12 Creat-0.8 Na-142
K-3.5 Cl-108 HCO3-21* AnGap-17
___ 11:50AM BLOOD ALT-13 AST-17 AlkPhos-111 TotBili-1.0
___ 11:50AM BLOOD Albumin-4.0 Calcium-9.3 Phos-2.4* Mg-1.3*
___ 11:52AM BLOOD Lactate-1.3
___ CMV viral load not detected
.
Stool studies:
==============
- Norovirus negative
- C. difficile DNA amplification assay negative
- STOOL FECAL CULTURE (Final ___:
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
.
Discharge labs:
===============
___ 12:10AM BLOOD WBC-7.2# RBC-2.61* Hgb-7.9* Hct-22.6*
MCV-87 MCH-30.4 MCHC-35.1* RDW-15.3 Plt Ct-23*
___ 12:10AM BLOOD Neuts-82* Bands-0 Lymphs-4* Monos-14*
Eos-0 Baso-0 ___ Myelos-0
___ 12:01AM BLOOD ___ ___
___ 12:10AM BLOOD Glucose-141* UreaN-8 Creat-0.6 Na-137
K-3.5 Cl-106 HCO3-24 AnGap-11
___ 12:01AM BLOOD ALT-11 AST-12 LD(LDH)-151 AlkPhos-87
TotBili-0.4
___ 12:10AM BLOOD Calcium-8.6 Phos-2.2* Mg-1.2*
.
Tacro trough level:
===================
___ 09:10AM BLOOD tacroFK-4.6*
___ 10:30AM BLOOD tacroFK-6.7
___ 09:54AM BLOOD tacroFK-7.1
.
Microbiology:
=============
Blood cultures - pending, no growth to date
Urine culture - no significant growth
.
Imaging:
========
___ CXR PA and LAT
FINDINGS: No focal consolidation to suggest pneumonia is seen.
There may be trace pleural effusions. No pneumothorax is
identified. The heart size is normal. A right-sided central
venous line is unchanged with tip in mid-to-low SVC. The patient
is status post median sternotomy.
Brief Hospital Course:
___ year old male with PTLD/Burkitt Lymphoma, presenting with
diarrhea, poor po intake and chills during a neutropenic period.
His symptoms improved after his WBC count recovered and he was
discharged home in stable condition. Had PET-CT scan on his
discharge day and he ___ follow with Dr ___.
.
1.Diarrhea: C. difficle and norovirus was negative. He required
IVF's and immodium along with anti-emetic agents to help control
the symptoms. He did not have abdominal pain or further fever
while in the hospital. These symptoms improved and he did not
require any further anti-emetic or anti-diarrheal agents. He
gradually tolerated oral intake and started to eat regular
meals. CMV viral load was negative.
.
2.Fever/Neutropenia: only low grade fever was on admission, none
afterwards. He was initially treated with cefepime and
daptomycin until his counts recovered. Urine culture didn't show
significant growth. Blood cultures were negative. Stool C diff
and Norovirus negative. CXR didn't reveal pneumonia.
.
3. Burkitt's lymphoma: was due for PET/CT and the day of
admission, however given his significant diarrhea the PET-CT was
postponed until his symptoms resolved. This was done just prior
to his discharge. Bactrim prophylaxis was continued as
inpatient. Neupogen was discontued after his ___ recovered.
Acyclovir 400 mg three times a day was initiated on discharge.
He ___ see Dr ___ tomorrow in the clinic.
.
4. s/p Kidney transplant: tacro trough on admission was 4.6 and
was up to 7.1 on discharge day. Renal team was following with us
during his stay. After discussing with them, it was agreed to
reduce his tacrolimus to 4 mg twice daily with repeat tacro
trough level on ___ 30 min prior to his morning
dose. Mr ___ understands the instructions. This can be done at
outside clinic with results being faxed to Dr ___.
.
5. CAD: We continued metoprolol and enalapril as inpatient.
.
6. History of UE DVT: He was on Lovenox prophylaxis which is
currently being held due to thrombocytopenia.
.
7. Diabetes: He was on insulin sliding scale only given limited
oral intake. He ___ resume his home regimen once he goes home
since he is able to eat regular meals. During his stay, blood
sugar ranged 150's-200's.
.
.
=================================
Transitional issues:
- Please follow up final report of PET-CT
- Please follow up ___ tacro level which ___ be faxed to
Dr ___
- ___ have repeat labs on ___
- Received 2nd unit of PRBC just prior to discharge
- Please follow up final report of blood cultures
- COnsider restarting lovenox when plt count recovers
Medications on Admission:
Ciprofloxacin 500 mg bid
Enalapril 5 mg daily
Novolog 70-30: 50 units bid
Metoprolol 50 mg bid
Compazine prn
Bactrim DS ___
Tacrolimus 5 mg bid
Neupogen
Discharge Medications:
1. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Novolog Mix 70-30 100 unit/mL (70-30) Solution Sig: Fifty
(50) unit Subcutaneous twice a day.
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
5. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF (___).
6. tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours).
7. acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
Disp:*90 Tablet(s)* Refills:*2*
8. Outpatient Lab Work
please check your tacrolimus level 30 min prior to your morning
dose on ___ and fax results to ___. Thanks.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
PTLD/burkitt's lymphoma
Acute Gastroenteritis
Diabetes type 2
History of upper extremity DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a great pleasure taking care of you again at ___. As
you know you were admitted because of fever, chills, nausea,
vomiting and frequent loose stools. We think this was a viral
process that resolved in a few days while we provided you
support through IV fluids, anti-vomiting and anti-diarrheal
medications. Your C diff and CMV were negative.
Initially you were given broad spectrum antibiotics however
given no source identified and no more fever except one on
admission, these were stopped. You remained without fever for 24
hour after discontinuing the antibiotics.
During your stay, you tolerated oral intake without nausea and
vomiting. You required only 1 tablets of immodium to help you
control your bowel movements. You did not have further watery
stools. You received 2 bags of red cells and 1 bag of platelet
during your stay. The 2nd bag of red cells was just before
leaving the floor.
You had PET-CT scan prior to discharge. It was initially
postponed due to your acute illness from which you recovered.
We made the following changes in your medication list:
- Please STOP neupogen injections since your ANC greatly
improved
- Please STOP lovenox injections since your platelet count is
low
- Please STOP ciprofloxacin
- Please REDUCE Tacrolimus to from 5 mg twice daily to 4 mg
twice daily
- Please START acyclovir 400 mg three times daily
Please continue the rest of your medications the way you were
taking them at home prior to admission.
Please check your tacro trough level 30 min prior to your
morning dose on ___ with the prescription provided to you
and have the lab fax the results to Dr ___ office at ___.
Please follow with your appointments as illustrated below.
Followup Instructions:
___
|
19798835-DS-17
| 19,798,835 | 28,689,781 |
DS
| 17 |
2159-12-19 00:00:00
|
2159-12-22 07:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
lisinopril / Influenza Virus Vaccines
Attending: ___.
Chief Complaint:
episodes of facial twitching
Major Surgical or Invasive Procedure:
EEG
History of Present Illness:
___ yr with HTN who presented to the ED with 5 episodes of 10
sec left ___ twitching with associated difficulty
speaking while twitching. Neurology was consulted for concerns
about TIA.
Patient is a poor historian despite her 2 daughters translating
and an interpreter. She describes episodes of a feeling that her
whole left lower face is deviating or getting pulled to the
right side with difficulty speaking during the event. these
episodes occur only during sleep. last episode occurred today
during afternoon nap for which her son brought her in. She could
not give a duration of frequency but said they happen every time
she goes to sleep. She denies associated pain, numbness in her
face. No drooling , no associated vision loss, numbness or
weakness anywhere and no twitching or jerky movements in any of
her extremities. . She is awake and aware during these episodes
and denies post-event confusion. No recent illnesses or falls.
Past Medical History:
DIABETES TYPE II
HYPERLIPIDEMIA
HYPERTENSION
OSTEOPOROSIS
KNEE PAIN
GASTROESOPHAGEAL REFLUX
CONSTIPATION
TRICUSPID REGURGITATION
H/O HELICOBACTER PYLORI
H/O PPD POSITIVE
H/O RENAL CYST
H/O HEPATIC CYST
Social History:
Country of Origin: ___
Marital status: Widowed
Children: Yes: 3 sons, 2 dtrs
Lives with: Children
Lives in: House
Work: ___
Multiple partners: ___
___ activity: Past
Sexual orientation: Male
Sexual Abuse: Denies
Domestic violence: Denies
Tobacco use: Never smoker
Alcohol use: Denies
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Family History:
Relative Status Age Problem Comments
Mother ___ ___ ASTHMA
Father ___ ___ HEALTHY
Aunt Deceased DIABETES MELLITUS maternal
Uncle Deceased DIABETES MELLITUS maternal
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Physical Exam:
Vitals: temp 97.8, HR 67, BP 165/84, RR 18, 98% RA.
General: awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: supple, no nuchal rigidity
Pulmonary: breathing comfortably on room air
Cardiac: RRR, nl
Abdomen: soft, NT/ND
Extremities: warm, well perfused
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented x 3. limited given language
barrier. poor historian . Attentive, able to name ___ backward
without difficulty. Language is fluent per daughters. Pt was
able to name both high and low frequency objects. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of 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 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred
DISCHARGE PHYSICAL EXAMINATION:
Stable, unchanged, stable gait
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
___ 05:40AM 8.0 4.27 12.9 38.6 90 30.2 33.4 14.4
47.1* 220 Import Result
___ 05:15AM 8.1 4.37 12.7 39.5 90 29.1 32.2 14.2
46.4* 208 Import Result
___ 05:45AM 6.9 4.08 12.2 37.3 91 29.9 32.7 14.4
47.8* 215 Import Result
___ 05:57PM 9.7 4.13 12.4 37.7 91 30.0 32.9 14.2
47.1* 222 Import Result
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im
___ AbsLymp AbsMono AbsEos AbsBaso
___ 05:57PM 38.8 50.2 8.1 2.0 0.5 0.4 3.76
4.86* 0.78 0.19 0.05 Import Result
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
___ 05:57PM NORMAL OCCASIONAL NORMAL OCCASIONAL
NORMAL OCCASIONAL Import Result
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Smr Plt Ct
___
___ 05:40AM 220 Import Result
___ 05:40AM 12.0 37.3* 1.1 Import Result
___ 05:15AM 208 Import Result
___ 05:45AM 215 Import Result
___ 05:57PM NORMAL 222 Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 05:40AM 113* 21* 0.9 138 3.5 100 25 17 Import
Result
___ 05:15AM 113* 20 0.8 139 3.9 ___ Import
Result
___ 05:45AM 110* 21* 0.8 139 3.7 ___ Import
Result
___ 05:57PM 96 17 1.1 136 5.1 100 26 15 Import Result
ESTIMATED GFR (MDRD CALCULATION) estGFR
___ 05:57PM Using this Import Result
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 05:57PM 57* 71 0.4 Import Result
OTHER ENZYMES & BILIRUBINS Lipase
___ 05:57PM 34 Import Result
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
___ 05:40AM 10.0 3.7 1.9 Import Result
___ 05:15AM 9.7 3.7 2.0 Import Result
___ 05:45AM 9.8 3.5 2.0 Import Result
___ 05:57PM 4.0 9.6 3.5 1.9 Import Result
DIABETES MONITORING %HbA1c eAG
___ 06:39PM 6.1* 128* Import Result
PITUITARY TSH
___ 05:57PM 1.6 Import Result
LAB USE ONLY GreenHd
___ 05:57PM HOLD Import Result
IMAGING:
MRI BRAIN: 1. No evidence of infarction, hemorrhage, mass, or
abnormal enhancement.
2. Mild diffuse parenchymal volume loss with mild probable
chronic small
vessel ischemic disease.
3. Question of vascular ectasia versus aneurysm or vascular
infundibulum of
the right carotid terminus, as described above. Recommend CTA
or MRA to
further assess.
Brief Hospital Course:
Ms. ___ is a healthy ___ woman with a past medical
history of htn, hyperlipidemia who presented with complaints of
paroxysmal head turning to the left only while sleeping. These
events have been going on for a few months and have been
occurring a few times per week. Otherwise, the patient as
feeling well.
Seizure was at the top of the differential, and her neurologic
examination was unremarkable. The patient was connected to EEG
where one of these events was captured on video EEG. No eeg
correlate to suggest epileptiform activity, however on video it
seemed to look like a focal motor seizure which may be too deep
down to have been picked up on eeg.
Next, MRI brain with and without contrast was done to evaluate
for any enhancement, strokes, or structural lesions to explain
her symptoms, however the MRI only showed small vessel disease
and some mild atrophy, but no other significant findings.
An LP was also done which was bland, however viral studies and
autoimmune/paraneoplastic studies were sent.
A trial of keppra 750 mg BID was started to see if this would
help stop her symptoms at night. The patient tolerated this
medication well. An MRA of the head and neck was lastly
conducted to rule out any aneurysms or vessel abnormalities and
was read ?of aneurysm of ICA at the level of the clinoid. We
arranged for neurosurgical/vascular follow up with Dr. ___
___ to review this and monitor the small aneurysm (incidental
finding)
The patient's exam remained stable and she was discharged home
on keppra 750mg BID and an appointment to follow up with
Neurology in ___.
Transitions of care issues:
1. Please take all of your home medications as prescribed
2. Please take your new anti seizure medication called Keppra at
750mg twice a day
3. Please follow up with us in Neurology on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Medications:
1. LevETIRAcetam 750 mg PO Q12H
2. Atorvastatin 40 mg PO QPM
3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Focal motor seizure
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 Neurology service as you were having
these strange episodes of face and head pulling to the left
while you are sleeping. You were connected to EEG and one of
these episodes were captured on EEG (measures brainwaves), but
no clear abnormalities were seen with this test. You next
underwent MRI brain which also did not show any structural
lesions to cause these symptoms. Lastly, you had a lumbar
puncture which tests your spinal fluid for any signs of
inflammation or infection to cause this, which thankfully was
normal.
We feel that you are having focal motor seizures that cause you
to be pulled to the left. We started you on a new medication
called Keppra at 750mg twice daily. Please continue to take this
medication.
You will follow with us in Neurology. You were discharged safely
to home.
We wish you the best!
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19799379-DS-18
| 19,799,379 | 22,177,074 |
DS
| 18 |
2130-05-13 00:00:00
|
2130-05-13 11:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope and lightheadedness
Major Surgical or Invasive Procedure:
left cephalic dual chamber pacemaker placement, ___
Scientific
History of Present Illness:
This is a ___ year old male patient who had a syncopal episode in
the past week. He did not incur any injury, flew home from
___ and had several episodes of lightheadedness thereafter.
He was seen in urgent care following weakness and unsteadiness
in the grocery store and found to have changes in his ECG. He
has a noted right bundle branch block, left anterior hemiblock
and prolonged AV block. He was admitted through the ED for
further workup and insertion of pacemaker.
Past Medical History:
Alcoholism, HTN, Depression, Hyperlipidemia, elevated LFTs
in past, L MCA punctate infarcts in L MCA territory.
Social History:
___
Family History:
Father - stroke. mother - pacemaker.
Physical Exam:
On the day of discharge, physical exam is as follows:
SUBJECTIVE: This is a ___ year old male with a history of RBBB
and LAFB with recent syncopal episode now s/p pacemaker
insertion. Tolerating PO diet and voiding without difficulty.
Neuro workup was negative, head CT unremarkable.
OBJECTIVE:
VS: T 98.1 HR 81 RR 18 BP 126/76 97% RA
Tele: HR 80's, occ. rare PVC
General: Age appropriate, NAD
Neck/JVD: no JVD, no carotid bruit
CV: RRR, no M/R/G
LUNGS: CTAB
ABD: soft, non-tender, +BS
Extr: feet warm, no edema
Anterior chest ___ insertion site gauze, Tegaderm c/d/I, no
erythema, excess warmth, drainage or hematoma noted, FROM wrist,
hand, elbow digits, elevates to shoulder height, understands
restrictions
Neuro: Grossly N/V/I moves all extremities well
CXR: Reviewed by Fellow, leads in good placement, no acute
process
CAROTID U/S: Read pending
LABS: Na2+ 136; K+ 3.8; Cl- 97; HCO3 28; BUN 15; Cr 1.0
Assessment/Plan:
This is a ___ year old male with recent PMH for syncope, RBBB and
LAFB now s/p insertion of pacemaker, doing well.
# Syncope, RBBB, LAFB s/p Pacemaker insertion
- ABX x 3 Days escripted to his pharmacy
- f/u device one week
- f/u Dr ___ ___ weeks
# HTN - clinically stable
- cont dyazide
# History of stroke - clinically stable
- Carotid U/S imaging updated - read pending
- Continue ASA, good BP control
Dispo:
Full Code
DC Home Today
Pertinent Results:
___ 10:22AM GLUCOSE-96 UREA N-12 CREAT-0.8 SODIUM-137
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-23 ANION GAP-19
___ 10:22AM cTropnT-<0.01
___ 10:22AM WBC-5.3 RBC-4.77 HGB-14.5 HCT-43.0 MCV-90
MCH-30.4 MCHC-33.7 RDW-12.8 RDWSD-42.4
___ 10:22AM NEUTS-62.7 ___ MONOS-7.4 EOS-2.5
BASOS-0.6 IM ___ AbsNeut-3.33 AbsLymp-1.40 AbsMono-0.39
AbsEos-0.13 AbsBaso-0.03
___ 10:22AM PLT COUNT-268
___ 05:01PM GLUCOSE-105* UREA N-14 CREAT-1.1 SODIUM-134
POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-26 ANION GAP-15
___ 05:01PM estGFR-Using this
___ 05:01PM cTropnT-<0.01
___ 05:01PM WBC-6.5 RBC-4.56* HGB-14.3 HCT-40.7 MCV-89
MCH-31.4 MCHC-35.1 RDW-12.7 RDWSD-41.5
___ 05:01PM NEUTS-61 BANDS-0 ___ MONOS-2* EOS-5
BASOS-0 ___ MYELOS-0 AbsNeut-3.97 AbsLymp-2.08
AbsMono-0.13* AbsEos-0.33 AbsBaso-0.00*
___ 05:01PM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-OCCASIONAL
POLYCHROM-NORMAL
___ 05:01PM PLT SMR-NORMAL PLT COUNT-246
___ 05:01PM ___ PTT-37.0* ___
Brief Hospital Course:
The patient was assessed in the ED by both Cardiology and
Neurology. ECG revealed sinus rhythm 64 bpm with prolonged AV
Conduction, right bundle-branch block, left anterior hemiblock
and subsequent ECG frequent VPBs. His syncopal episodes and
paroxysm of light-headedness were concerning for underlying
conduction system disease. Pacemaker was recommended, he was
consulted by the Electrophysiology team who recommended
placement of a pacemaker. Additionally, because of his history
of CVA, he was seen and evaluated by Neurology. A head CT was
performed and was negative for any acute infarction or
hemorrhage. Ventricles and sulci were normal in size and
configuration. Neurology recommended an updated carotid
ultrasound as one had not been done for several years for
comparison, results of which are pending at the time of
discharge. It was felt that the patient's symptoms were cardiac
in nature and the patient elected to proceed with pacemaker
insertion, understanding risks and benefits. There were no
intraoperative complications, the patient tolerated the
procedure well and was placed on IV antibiotics while in house
with a plan for three days oral antibiotics at discharge. His
surgical wound remained well approximated, with no signs of
erythema, excess warmth, drainage or hematoma. Surgical
dressing consisted of gauze and Tegaderm which will remain
intact for 72 hours. A chest X-Ray was performed prior to
discharge showing good lead placement and no acute process. The
device was interrogated and was operating appropriately.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clindamycin 1% Solution 1 Appl TP DAILY prn
2. Pravastatin 40 mg PO QPM
3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
4. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Pravastatin 40 mg PO QPM
3. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
4. Clindamycin 1% Solution 1 Appl TP DAILY prn
5. Cephalexin 500 mg PO Q6H Duration: 2 Days
Discharge Disposition:
Home
Discharge Diagnosis:
syncope, right bundle branch block, left anterior fascicular
block s/p insertion of pacemaker
Discharge Condition:
Stable
Discharge Instructions:
It was a pleasure caring for you at ___.
You were admitted after passing out and having episodes of light
headedness and was found to have an abnormal heart rhythm. A
pacemaker was placed and you will need to take antibiotics for
two days after the procedure and come back to have the pacer
checked in the device clinic in one week. Please see d/c
instructions for activity precautions for the next 6 weeks.
A neurologist evaluated you in the emergency room and did not
feel that you had a stroke. The head CT scan was unchanged and
the carotid ultrasound results are currently pending. Your
symptoms were cardiogenic in nature and a pacemaker was
successfully inserted. Ensure you follow up with your PCP and
stroke provider on a regular basis as scheduled.
Followup Instructions:
___
|
19799440-DS-9
| 19,799,440 | 20,039,952 |
DS
| 9 |
2141-02-08 00:00:00
|
2141-02-08 15:06:00
|
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 x 1 week
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with hypertension and asthma and one prior
episode of diverticulitis in ___ who presented with 1 week of
lower
abdominal pain.
She states she was in her usual state of health until ___
when
she began to have watery loose stool. This was followed by an
episode of sweating and some chills. She did not check her
temperature but wonders if she might have had a fever. 2 days
later she then began to have crampy lower abdominal pain that
became increasingly severe. The pain was the worst in the left
and right lower quadrants and was not associated with eating.
She then noticed that she was getting constipated and that
trying
to have a bowel movement was extremely painful. Given that pain
was worsening she called her primary care doctor who recommended
going to the emergency room for evaluation. She denies any sick
contacts, endorses nausea but no vomiting.
Of note she had one serious episode of
diverticulitis in ___ when they thought she might need surgical
intervention. She was admitted to the hospital at that time and
had several days of IV antibiotics and eventually improved
without surgery. She states she had a colonoscopy in ___
that was per report normal.
Past Medical History:
- Hypertension
- Asthma
- Obesity
Social History:
___
Family History:
Aunt with colon cancer at age ___. Father's PMH is unknown, her
mother has HTN and high cholesterol. Siblings have no
significant medical problems. No family history of strokes or
MIs.
Physical Exam:
Admission Exam
VS: ___ Temp: 98.0 PO BP: 133/89 HR: 65 RR: 20 O2 sat:
94% O2 delivery: 2L NC
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions
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, tender in the right and left
lower quadrants no rebound no guarding
extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. ___ strength throughout.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
Pertinent Results:
Admission Labs
___ 10:35AM BLOOD WBC-7.1 RBC-4.99 Hgb-15.4 Hct-48.6*
MCV-97 MCH-30.9 MCHC-31.7* RDW-14.6 RDWSD-52.3* Plt ___
___ 10:35AM BLOOD Glucose-85 UreaN-15 Creat-0.6 Na-142
K-4.2 Cl-101 HCO3-26 AnGap-15
___ 10:35AM BLOOD ALT-27 AST-23 AlkPhos-65 TotBili-0.4
___ 10:35AM BLOOD Albumin-4.2
CT A/P
1. Subtle stranding adjacent to a sigmoid diverticulum,
suggestive of mild
uncomplicated sigmoid diverticulitis.
2. Interval decrease in size of 2 left adnexal cysts, measuring
up to 2.5 cm
on current exam, previously measuring up to 3.1 cm.
Discharge Labs:
Brief Hospital Course:
___ woman with hypertension and asthma and one prior
episode of diverticulitis in ___ presents with 1 week of lower
abdominal pain found to have diverticulitis.
.
Acute problems:
#Diverticulitis
Uncomplicated diverticulitis based on CT A/P. This was treated
with oxycodone and cipro/flagyl.
#Oxygen requirement
Noted to be placed on 2 L of oxygen from the emergency room
breathing comfortably, likely due to splinting in the setting of
severe abdominal pain. Oxygen requirement resolved the next day
#Asthma
We continued home albuterol
#Hypertension
We continued home lisinopril and amlodipine
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
4. albuterol sulfate 90 mcg/actuation inhalation Q4H:PRN
wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with diverticulitis. We
treated you with pain and nausea medications and started you on
two antibiotics called cipro and flagyl which we would like you
to take after leaving the hospital.
Followup Instructions:
___
|
19799506-DS-9
| 19,799,506 | 26,501,243 |
DS
| 9 |
2132-12-10 00:00:00
|
2132-12-11 17:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Motor vehicle collision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M status post motor vehicle collision, restrained driver, +
head strike, no LOC. Complained of nausea, vomiting, neck pain
and spine tenderness on arrival. GCS 15.
Past Medical History:
Platelet disorder
Social History:
___
Family History:
Non contributory
Physical Exam:
Gen:
VS: T:96.8 HR: 78 BP: 114/98 RR:17 Sat: 98% on room air
HEENT: PEERL.
Neck: supple. MIld tenderndess on cervical spine.
Cardiac: RRR, normal S1,S2
Respiratory: clear
Abdomen: NT, ND.
Extremities: DP++ b/l. No edema
Pertinent Results:
___ 05:15PM COMMENTS-GREEN TOP
___ 05:15PM GLUCOSE-83 LACTATE-1.0 NA+-141 K+-3.9 CL--100
TCO2-26
___ 05:06PM UREA N-11 CREAT-1.0
___ 05:06PM estGFR-Using this
___ 05:06PM ALT(SGPT)-15 AST(SGOT)-22 ALK PHOS-107 TOT
BILI-1.0
___ 05:06PM LIPASE-226*
___ 05:06PM LIPASE-226*
___ 05:06PM ALBUMIN-5.5*
___ 05:06PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:06PM WBC-10.4# RBC-4.81 HGB-15.6 HCT-43.9 MCV-91
MCH-32.4* MCHC-35.4* RDW-12.6
___ 05:06PM PLT COUNT-137*
___ 05:06PM ___ PTT-34.6 ___
___ 05:06PM ___
___ ___ ___ ___
Radiology Report MR CERVICAL SPINE W/O CONTRAST Study Date of
___ 10:25 AM
___ CC6A ___ 10:25 AM
MR CERVICAL SPINE W/O CONTRAST Clip # ___
Reason: Please r/o ligamentous injuries
UNDERLYING MEDICAL CONDITION:
___ h/o platelet d/o s/p MVC, restrained driver, + head
strike, - LOC, c/o
nausea, neck pain, T-spine pain. Imaging normal, lipase
elevated (226).
REASON FOR THIS EXAMINATION:
Please r/o ligamentous injuries
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
EXAMINATION:
MRI OF THE CERVICAL SPINE
INDICATION: ___ h/o platelet d/o s/p MVC, restrained driver, +
head strike, -
LOC, c/o nausea, neck pain, T-spine pain. Imaging normal, lipase
elevated
(226). // Please r/o ligamentous injuries
TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient
sequence T2
axial images of cervical spine obtained.
COMPARISON: CT of ___.
FINDINGS:
There is no evidence of acute bony or ligamentous injury
identified. No
evidence of ligamentous disruption seen. No evidence of spinal
cord
compression or intraspinal hematoma. No abnormal signal seen
within the spinal
cord. Mild degenerative disc disease is seen from C3-4 through
the C5-6
levels. Linear hyperintensity adjacent to the left upper
esophagus appears to
be slightly prominent lymphatic duct, an incidental finding.
IMPRESSION:
Mild degenerative changes. No evidence of bony or ligamentous
injury
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ headache, nausea, vomiting after motor vehicle
collision
TECHNIQUE: Routine unenhanced head CT was performed and viewed
in brain,
intermediate and bone windows. Coronal and sagittal reformats
were also
performed.
DOSE: DLP: 891.93 mGy-cm
CTDI: 48.28 mGy
COMPARISON: None.
FINDINGS:
There is no acute intracranial hemorrhage,acute infarction, mass
or midline
shift. There is no hydrocephalus. Visualized paranasal sinuses
and mastoid
air cells are clear. There is no fracture.
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ post motor vehicle collision.
TECHNIQUE: Contiguous axial images were obtained. Sagittal and
coronal
reformatted images were generated. No contrast was
administered.
CTDIvol: 768.18 mGy
DLP: 36.85 mGy-cm
COMPARISON: None
FINDINGS:
Alignment of the cervical vertebral bodies is normal without
subluxation. No
fractures are identified. There is no evidence of spinal canal
or neural
foraminal narrowing. No prevertebral soft tissue swelling is
present. The
visualized soft tissues are unremarkable. Visualized lung
apices are clear.
IMPRESSION:
No acute fracture or traumatic malalignment.
INDICATION: ___ with nausea and vomiting after motor vehicle
collision
TECHNIQUE: MDCT axial images were acquired through abdomen and
pelvis
following intravenous contrast administration with split bolus
technique.
Coronal and sagittal reformations were performed and submitted
to PACS for
review.
No oral contrast was administered.
DOSE: DLP: 1043.56 mGy-cm (abdomen and pelvis.
COMPARISON: None.
FINDINGS:
CHEST:
The thyroid is unremarkable. Prominent thymic tissue is noted.
The heart and
great vessels are unremarkable. There is no mediastinal, hilar,
axillary, or
supraclavicular lymphadenopathy.
The central airways remain patent. There is no pulmonary
parenchymal
abnormality. Mild bibasilar atelectasis is present. There is no
pleural
effusion or pneumothorax.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within
normal limits,
without stones or gallbladder wall thickening.
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 stones, focal renal lesions or
hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no
perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber,
wall
thickness and enhancement throughout. Colon and rectum are
within normal
limits. Appendix contains air, has normal caliber without
evidence of fat
stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and
mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no
calcium burden
in the abdominal aorta and great abdominal arteries.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There
is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid
in the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal
limits
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic
wall is within
normal limits.
IMPRESSION:
No evidence of acute abnormality in the chest, abdomen, or
pelvis.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
The patient presented to Emergency Department on ___ after
being on a motor vehicle collision. He was evaluated by the
Acute Care Service on arrival. Primary and secondary survey did
not reveal any acute life threating lesion. Given complains of
headache, nausea, vomiting and spine tenderness, the patient
underwent CT head/spine and torso which demonstrated no acute
fractures or organ lesions. Due to persistent pain on his
cervical spine he underwent a MRI to rule out ligamentous
injuries, which were none. His c-collar was cleared without any
complication. Tertiary survey was completed with no new
lesions.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The diet was advanced sequentially to a Regular diet,
which was well tolerated. 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.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan
Medications on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheezing
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN migraine
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg 1
capsule(s) by mouth Q6-8H Disp #*30 Capsule Refills:*0
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheezing
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*20 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every
four (4) hours Disp #*30 Tablet Refills:*0
5. Fluconazole 100 mg PO Q24H
RX *fluconazole [Diflucan] 100 mg 1 tablet(s) by mouth daily
Disp #*16 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Motor vehicle collision
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
19799964-DS-18
| 19,799,964 | 21,550,227 |
DS
| 18 |
2144-04-22 00:00:00
|
2144-04-23 12:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
___ EGD
History of Present Illness:
Mr. ___ is a ___ with hx of systolic heart failure (last EF
45-50% from ___, low of 20% in the past, ICD in place), CAD
s/p DES to LAD ___, EtOH abuse, obesity, afib on warfarin,
HTN, HLD, RCC s/p cryoablation gallstones, initially presented
to ___ on ___ for melena. Notably, pt was just discharged on
___ after admission for cholangitis s/p ERCP and stent revision.
Pt was in ___ for planned cardiac cath on ___ (DES x2 placed to
mid-LAD and started clopidogrel) when he was found to be
jaundiced. ERCP revealed distal CBD stricture as well as
gastritis/duodenitis, and a plastic stent was placed. Viral
hepatitis work-up and autoimmune labs were negative, as were
smooth muscle Ab, AMA, ___, and IgG subclasses. Biliary stent
was removed and replaced ___ at ___, with second stent
removed on ___ ___ at ___.
He was again admitted to ___ on ___ after presenting w/
jaundice and dark urine. Further workup included CT abd/pelvis
noted "New intrahepatic and extrahepatic biliary ductal
dilatation as compared to ___.. Possible filling defect
common duct. Several small, new low attenuation lesions with the
liver, very concerning for metastatic disease. Abnormal
appearing gallbladder demonstrating new areas of enhancement,
with possible associated cystic enhancing mass."
Case was reviewed with ERCP at ___, and decision was made to
transfer to ___ given concern for new malignancy, antiplatelet
therapy, and medical complexity.At time of arrival to ___, pt
reported that he was informed that there may be an infection in
the gallbladder. He denied abdominal pain, SOB, chest pain, and
noted continued dark urine and lighter colored stools. He
underwent ERCP on ___ w/ stent placement notable for copious
pus. He was then placed on a 2 week course of cipro/flagyl (day
1 = ___ and discharged on ___.
Later in the afternoon of ___, pt said he had a "darker" brown
stool but didn't think much of it. Earlier today, he noticed his
stool had become dark and tarry. He also said after getting up
to leave the bathroom that he felt a little lightheaded but
denied any syncope or fall. Also denies any abdominal pain, n/v
or prior history of GI bleed. He went to ___ this morning and
was found to have H/H 10.2/30.4, INR 1.5, and ___ 17.7. He was
hypotensive and was given 2 Units of PRBC and 10mg Vit K. BP
improved w/ pRBCs.
He was transferred to ___ for further evaluation of his GIB.
In the ED, vitals were as follows:
Temp: 97.5 HR: 80 BP: 95/54 Resp: 18 O(2)Sat: 100 Normal
DRE revealed melena. Started on protonix drip and labs drawn.
Notable for H/H 10.8/31.6, bicarb 21, BUN 32, and Cr 1.5. GI was
consulted.
On arrival to the MICU, he is hemodynamically stable w/ HR in
___ and BP of 100s/50s. He denies any abdominal pain or n/v and
is AAOx3. Denies any prior hx of GIB.
Review of systems: Negative other than above.
Past Medical History:
CAD s/p DES to the LAD ___
sCHF, most recent EF 45-50% (s/p ICD for prior EF of 20%)
Alcohol abuse
Atrial fibrillation on Coumadin (no h/o CVA)
CKD stage III (found in d/c summary from ___
HTN
Hyperlipidemia
RCC s/p ablation - around ___
h/o gallstones
s/p left knee arthoscopy
Social History:
___
Family History:
Per OMR, confirmed with patient:
Father died from lung CA (heavy smoker), mother died from
endocarditis.
Physical Exam:
ADMISSION EXAM:
=================
Vitals: T 97.3, HR 92, BP 114/61, RR 15, SaO2 99% RA
GENERAL: NAD, mildly jaundiced
HEENT: Scleral icterus, clear oropharynx, PERRL
LUNGS: CTAB
CV: RRR, no murmur
ABD: Obese, soft, NTND
EXT: Warm, well-perfused, 2+ peripheral pulses
NEURO: A&O x3
DISCHARGE EXAM:
=================
Pertinent Results:
ADMISSION LABS:
=================
___ 02:00PM BLOOD WBC-14.1* RBC-3.37* Hgb-10.8* Hct-31.6*
MCV-94 MCH-32.0 MCHC-34.2 RDW-17.8* RDWSD-58.4* Plt ___
___ 02:00PM BLOOD Neuts-78* Bands-2 Lymphs-8* Monos-9 Eos-1
Baso-1 ___ Metas-1* Myelos-0 AbsNeut-11.28* AbsLymp-1.13*
AbsMono-1.27* AbsEos-0.14 AbsBaso-0.14*
___ 07:20PM BLOOD ___ PTT-33.0 ___
___ 02:00PM BLOOD Glucose-123* UreaN-32* Creat-1.5* Na-134
K-4.3 Cl-97 HCO3-21* AnGap-20
___ 02:00PM BLOOD ALT-100* AST-105* AlkPhos-516*
TotBili-5.2*
DISCHARGE LABS:
=================
IMAGING:
=========
None
Brief Hospital Course:
___ with h/o CAD s/p ___, EtOH abuse, biliary
strictures s/p ERCP x 3 with stents and recent cholangitis on
cipro/flagyl, now with melena x 1 day on ___ with ICU stay with
resolving Hgb/SBP without intervention tx to floors given
further workup of possible GI bleeding and biliary involvement.
#GI Bleeding: Unclear etiology, possible small bowel vs colon.
Now with EGD showing normal gastric/duodenal studies with mild
bleeding from the ampulla. Low concern for varices,
___ tears, or ulcers given EGD. Less likely very
lower GI bleed given melena without hematochezia. Pt was
continued on protonix BID (initially protonix drip). Pt's Upper
GI study showed mild oozing at ampulla which could be probable
source of melena. ERCP on ___ involved a sphincterotomy (in
the setting of continued Plavix/aspirin intake), lithotripsy of
cystic duct obstructing stone, and removal of prior stent.
#Liver lesions: Concerning for mets vs related to cholangitis
on prior CT image. Pt needs to be ruled out for colon cancer in
setting of this GIB, some weight loss but possible related to
stopping etOH. Last colonoscopy per patient was ___ years ago
which was notable for benign polyps. Pt had a triple-phase CT
image study (given that his ICD made him ineligible for MR
studies) which showed resolution of the previously seen liver
lesions and interval development of another lesion, suggesting
possible infectious etiology (see below). Pt also had stable
LFTs at time of discharge and will require a colonoscopy
outpatient.
#Cholangitis: Pt had a recent admission for cholangitis
diagnosed by pus on ERCp. Pt never endorsed fevers chills,
abdominal pain, negative ___. Pt was continued on
cipro/flagyl and will continue these medications through ___.
Repeat CT scan on ___ showed possible gallbladder perforation
with very small adjacent fluid collection. Patient appeared
well clinically and was tolerating PO. Surgery was consulted
and felt he should have repeat CT imaging in several weeks and
if the fluid collection is walled off, he should have
percutaneous cholecystostomy to drain it.
#Afib with RVR and aberrancy. CHADsVasc is 3. CHF + HTN + Age
Pt conintued on home on digoxin, Metoprolol; Plavix and
aspirin. No warfarin in the setting of GI bleeding while
hospitalized but pt can continue this after discharge. It was
deemed not necessary to bridge the pt whiel inpatient.
#CAD s/p DES: Pt with known history. Pt will continue aspirin,
Plavix outpatient. Pt will restart home warfarin dose
outpatient.
TRANSITIONAL
=============
- Pt should continue cipro/flagyl through ___
- Pt will need a colonoscopy outpatient.
- Pt will restart home warfarin starting ___.
- Pt requires surgery followup on ___ and interval CT imaging
for management of gallbladder perforation and fluid collection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Digoxin 0.125 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. Spironolactone 25 mg PO DAILY
6. Warfarin 5 mg PO 4X/WEEK (___)
7. Warfarin 2.5 mg PO 3X/WEEK (___)
8. Lisinopril 5 mg PO DAILY
9. Metoprolol Succinate XL 200 mg PO DAILY
10. Ciprofloxacin HCl 500 mg PO Q12H
11. MetroNIDAZOLE 500 mg PO Q8H
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
2. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Ciprofloxacin HCl 500 mg PO Q12H
5. Clopidogrel 75 mg PO DAILY
6. Digoxin 0.125 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Metoprolol Succinate XL 200 mg PO DAILY
10. MetroNIDAZOLE 500 mg PO Q8H
11. Spironolactone 25 mg PO DAILY
12. Warfarin 5 mg PO 4X/WEEK (___)
13. Warfarin 2.5 mg PO 3X/WEEK (___)
14.Outpatient Lab Work
Please check CBC on ___
ICD 10: ___.1
Results should be faxed to: ___.
___
___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
cystic duct obstruction (probable Mirizzi's syndrome)
SECONDARY DIAGNOSES:
liver lesions
cholangitis
Atrial fibrillation with RVR and aberrancy
coronary artery diseases s/p drug-eluting stent
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted for your black stools and biliary duct
obstruction. With a scope we were able to remove the stent in
the biliary tract and open the sphincter, dissolving the stone
obstructing the tract. After your procedure, you were stable
with no signs of gastrointestinal bleeding. We found a possible
hole in your gallbladder wall with some surrounding pus, so you
will need to see our surgeons on ___ to have another CT scan
and discuss whether you need a procedure to drain the pus.
Please restart your warfarin on ___.
It was a pleasure taking care of you.
Your ___ Team
Followup Instructions:
___
|
19800188-DS-28
| 19,800,188 | 23,723,446 |
DS
| 28 |
2133-04-21 00:00:00
|
2133-04-21 23:47:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Bactrim / Keflex
Attending: ___.
Chief Complaint:
weakness, muscle aches, gait instability
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ female with IV heroine use, endocarditis, hepatitis
C, recent admission for ___ Syndrome presenting with
weakness and unsteady gait. Pt herself is unable to give
detailed history. She states that she has been falling at home
and feeling shaky on her feet. She reports having used crack
cocaine and IV heroine yesterday. Denies LOC or head trauma. Per
ED report, pt was sent in by son who was concerned that she has
been weak and unable to walk. She was seen by her PCP ___
for low grade temps (99-100), tachycardia, DOE and crackles at
bases of lungs. PCP was concerned about infectious process and
ordered CXR and ___ (given prior hx of endocarditis) but pt did
not undergo these studies.
.
Pt had recent complicated hospital admission ___.
She had previously been on methadone for her hx of IV heroine
use but used IV heroine prior to her 75th birthday and developed
cellulitis at site of injection at RUE. She was seen at the ED
and prescribed bactrim and keflex and subsequently developed a
desquamating rash consistent with ___. She
was followed by dermatology service and provided with supportive
care including IV hydration and wound care. Her cellulitis was
treated with vancomycin. She developed abdominal pain and was
noted to have elevated lipase 2795; MRI abdomen was consistent
with chronic pancreatitis and she was also treated supportively.
Hospital course was further complicated by acute kidney injury
(baseline Cr 1.0 rising to 1.6) for which she was seen by renal
team who found no significant findings on urine sediment and
advised supportive care. She was discharged to rehab for further
care. At rehab, A1c was 6.4 and she was started on Januvia and
Lantus which her PCP subsequently discontinued.
.
In the ED, initial VS: 95.8 116 134/76 16 96%RA. Labs
significant for K 3.2, Mg 1.5, Phos 1.8; serum tox negative. She
received 40meq potassium chloride po and 1 packet neutra-phos
prior to transfer.
.
REVIEW OF SYSTEMS:
Reports shortness of breath
Denies fever, chills, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
- Eosinophilia - Followed by primary care physician. In ___,
had chest CT which showed "centrilobular nodules and ___
nodular appearance in both lungs favor a bronchiolitis,
infectious and/or inflammatory in nature." Per PCP notes,
patient is supposed to have a repeat CT chest to follow-up. SPEP
and UPEP also to be sent.
- Hepatitis C
- Distant history of lumbar osteomyelitis
- Polysubstance abuse, previously on methadone
- Anxiety
- Depression
- Hypertension
- History of endocarditis
- Chronic bronchitis
- ___
- Chronic pancreatitis
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission PHYSICAL EXAM:
VS - 97.8 152/98 93 18 100%RA
GENERAL - Mildly fatigued but answering questions appropriately,
NAD
HEENT - PERRL, EOMI, sclerae anicteric, dry MM, OP clear
NECK - Supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - bibasilar crackles, good air movement, mildly
tachypneic, no accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, no lumbar
spine tenderness
SKIN - LUE with chronic scar tissue from previous surgery
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout
DISCHARGE PHYSICAL EXAM
VS: 98.0, BP 117/74, HR 86, RR 20, sat 97% on RA
GEN: A & O X3, NAD
HEENT: PERRL, MMM, OP clear, conjunctiva non-injected
NECK: supple, JVP flat, no LAD
HEART: RRR, good S1, S2, no m/r/g
LUNG: CTA ___
ABD: soft, NT/ND, no HSM, +BS
EXT: Tender on palpation over right shoulder, limited ROM,
tender on palpation over bilateral thigh
Pertinent Results:
___ 08:54PM TYPE-ART TEMP-36.8 PO2-76* PCO2-57* PH-7.31*
TOTAL CO2-30 BASE XS-0 INTUBATED-NOT INTUBA COMMENTS-O2 DELIVER
___ 06:29PM PO2-88 PCO2-58* PH-7.32* TOTAL CO2-31* BASE
XS-1
___ 06:15PM GLUCOSE-111* UREA N-12 CREAT-1.1 SODIUM-144
POTASSIUM-3.2* CHLORIDE-110* TOTAL CO2-26 ANION GAP-11
___ 06:15PM estGFR-Using this
___ 06:15PM CALCIUM-8.6 PHOSPHATE-1.8* MAGNESIUM-1.5*
___ 06:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:15PM WBC-7.6 RBC-3.35* HGB-10.5* HCT-31.2* MCV-93
MCH-31.2 MCHC-33.5 RDW-14.2
___ 06:15PM NEUTS-76.5* LYMPHS-17.3* MONOS-3.1 EOS-2.7
BASOS-0.4
___ 06:15PM PLT COUNT-258
___ 06:15PM ___ PTT-29.0 ___
___ 05:55AM BLOOD WBC-5.3 RBC-3.43* Hgb-10.9* Hct-32.4*
MCV-94 MCH-31.7 MCHC-33.6 RDW-14.2 Plt ___
___ 05:15PM BLOOD ESR-37*
___ 05:15PM BLOOD CRP-1.8
___ 10:00AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.1
___ 10:00AM BLOOD CK(CPK)-414*
___ 05:29AM URINE Color-Straw Appear-Clear Sp ___
___ 05:29AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 05:29AM URINE RBC-0 WBC-6* Bacteri-FEW Yeast-NONE ___ Urine culture mixed flora
___ BLood cultures x 2 - no growth to date
___ RadiologyCHEST (PA & LAT)
FINDINGS: PA and lateral views of the chest are compared to
previous exam
from ___. Left-sided PICC is no longer seen. Lungs
are
essentially clear noting minimal left basilar opacity compatible
with
atelectasis on the frontal view. Costophrenic angles are sharp.
Cardiomediastinal silhouette is normal, as are the osseous and
soft tissue
structures.
IMPRESSION: No acute cardiopulmonary process.
___ CardiovascularECHO
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is low normal
(LVEF 50%). Right ventricular chamber size and free wall motion
are normal. There are focal calcifications in the aortic arch.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate (___) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
No definite vegetations seen but CANNOT be excluded on ther
basis of this technically suboptimal study.
IMPRESSION: Suboptimal image quality. Consider TEE if the
clinical suspicion for endocarditis is high
Brief Hospital Course:
___ female with IV heroin use, endocarditis, hepatitis
C, recent admission for ___ Syndrome presenting with
unsteady gait and delirium.
# gait instability: Ms. ___ likely has a multifactorial gait
disorder. With further history she reports feeling unsteady
upon standing up and then requires a moment to level out before
she feels comfortable on her feet again suggesting there is an
orthostatic componenet to her unsteadiness. She has LLE
weakness that she reports she has had since her
endocarditis/osteomyelitis which likely also contributes to her
unsteadiness. Suspect that her gait instability was due to a
combination of dehydration and electrolyte changes from her
diarrhea (see below), baseline weakness, and pharmacological
effects of mixing heroin and cocaine with her prescription
medications, including quetiapine and citalopram. Pt had a
negative infectious workup including chest XR and ___, and was
treated with IV fluids and repleted for magnesium and phosphate.
Her quetiapine and citalopram were held the evening of admission
but restarted w/out issue the following day. She has responded
well to her supportive treatment and was seen twice by ___, who
felt she was safe to go home.
# mental status changes: Pt was reported altered in the ED.
Suspect this was due to crack cocaine and heroin effect
synergizing w/ quetiapine and citalopram. Could also have been
exacerbated by Pt's electrolyte abnormalities (see above). Pt
improved w/ electrolyte repleting and IV fluids. Social work was
consulted to help w/ Pt's continued substance abuse. Pt was back
to baseline prior to discharge.
# Bilateral thign pain: Likely related with cocaine use, no
evidence of compartment syndrome. CK elevated at 414 from
baseline of ___, but improving. Renal function normal. ___
felt Pt was ready to go home after two sessions as inpatient.
# Low grade fevers: It seems unlikely Ms. ___ currently has
an underlying infectious process. She has been afebrile with a
normal white count since entering the hospital. UA was
unremarkable, blood and urine cultures are pending. However,
given her history of IV drug use, low grade fevers, and concern
of PCP, ___, which was not an optimal study but showed
no evidence of endocarditis. Pt's ESR is at baseline in ___ and
CRP normal at 1.7. Blood cultures showed no growth to date.
# Diarrhea: Pt complained of occasional watery diarrhea for the
past 2 months, seems to be worse with milk products. Have
counseled Pt to avoid milk products for the next ___ weeks and
monitor her BMs. If diarrhea continues, would consider further
workup.
# HTN: continued home dilt
# ?Diabetes: Ms. ___ blood glucose was normal during
hospitalization.
# Depression: restarted home citalopram and quetiapine after
return to baseline mental status
# HCV: Currently normal LFT's.
# anemia: chronic, at baseline.
Transitional issues:
-drug abuse counseling / prevention
-follow up blood culture final results
-consider lactose breath testing or further workup of diarrhea
if symptoms continue
Medications on Admission:
1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic BID (2
times a day): apply to both eyes.
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. diltiazem HCl 180 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
4. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime: 10 units or as directed at 9pm daily.
5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. promethazine 12.5 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for insomnia.
7. quetiapine 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO QHS (once a day (at bedtime)).
8. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID
(2 times a day).
Discharge Medications:
1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic BID (2
times a day): apply to both eyes.
2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. diltiazem HCl 180 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
4. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime: 10 units or as directed at 9pm daily.
5. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. promethazine 12.5 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for insomnia.
7. quetiapine 200 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO QHS (once a day (at bedtime)).
8. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic BID
(2 times a day).
Discharge Disposition:
Home With Service
Facility:
___
Discharge ___:
Primary diagnosis:
dehydration
heroin and cocaine intoxication
Secondary diagnoses:
- Eosinophilia
- Hepatitis C
- Distant history of lumbar osteomyelitis
- Polysubstance abuse, previously on methadone
- Anxiety
- Depression
- Hypertension
- History of endocarditis
- Chronic bronchitis
- history ___
- Chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You came to the hospital because you were unsteady on your feet
and felt weak. You recently had some cocaine and heroin and also
had some diarrhea. We feel that the most likely explanation of
your symptoms is a combination of dehydration and electrolyte
abnormalities in your blood caused by your diarrhea, and an
interaction between the heroin, cocaine, and your prescription
medications. Your symptoms resolved on their own after we gave
you IV fluids and replaced some of your blood salts. You were
seen by our physical therapists, who felt that you were safe to
go home. You also had an ultrasound of your heart
(echocardiogram), which your primary care physician, ___.
___ you needed to rule out an infection of your
heart valves given your recent low fevers. Your heart study did
not show any sign of infection. You were also seen by our social
workers to help you enroll in programs to stop your drug use.
From your description of your symptoms, your diarrhea may be
related to lactose intolerance. Please avoid milk and diary
products for the next ___ weeks and monitor your bowel
movements. Please let Dr. ___ if you continue to
have diarrhea.
We also found that there was evidence of mild muscle damage
which likely happened in the setting of cocaine use and may
explain your thigh pain. After going home, please make sure
that you are well hydrated.
We have not made any changes to your medications. Please
continue to take them as previously prescribed.
Followup Instructions:
___
|
19800206-DS-16
| 19,800,206 | 23,637,191 |
DS
| 16 |
2166-07-11 00:00:00
|
2166-07-13 21:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Presyncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with a history of right
cerebellar hemangioblastoma s/p resection in ___,
hypercholesterolemia, prior Lyme infection, and treatment 2
months ago for presumed (not serologic) anaplasmosis. She was
recently admitted for myalgias, transaminitis, and atrial
tachycardia and represented with presyncope tonight.
Patient was discharged on ___ after presenting with myalgias,
transaminitis, and atrial tachycardia. Myalgias and
transaminitis were thought to be due to her statin, which was
stopped. She was also noted to have ectopic atrial tacyhcardia,
which was asymptomatic and felt to be unrelated to presenting
symptoms. She was seen by EP, who advised Holter monitor with
outpatient follow-up.
Since discharge, she reports myalgias have come and gone. They
might be somewhat better than before hospitalization, but are
still bothersome. She has had ongoing bifrontal HA, which has
been present and unchanged since mid ___. She had one episode
of swelling of her L middle finger, associated with a "nodule"
that resolved spontaneously. She has had some intermittent pain
in R elbow but no other joint pain.
Of note, patient was treated for presumptive anaplasmosis with a
3-week course of doxycycline in ___. PCP reports that ___
Lyme IgM returned positive, suggesting recent infection.
Ehrlichiosis titers negative, babesosis titers indeterminate.
On the evening of presentation, patient was doing some tasks
around the house around 9:30 pm when she began to feel
lightheaded, as if she was going to faint. She called for her
son-in-law. She also felt warm, nauseous, had darkening of her
vision. She denies palpiatations, CP, SOB, fall, LOC, or
headstrike. She has not had recent fevers, chills, GI upset, or
other symptoms.
In the ED initial vitals were: 99.1 117 ___ 100% room air.
EKG showed ectopic atrial tachycardia @ 115. Labs showed
unremarkable CBC and chem-10, BNP 42, trop negative x 1,
negative UA. Patient was given full dose aspirin and 1L NS.
Vitals prior to transfer were: 110 104/71 19 98% RA.
On the floor, patient feels well but is concerned about what
heart rhythm she may have been in at the time of her presyncope.
She has not had recent known tick bites or rashes.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- two prior episodes of lyme infection, one with erythema
migrans
- hypercholesterolemia
- right cerebellar hemangioblastoma s/p resection in ___
Social History:
___
Family History:
breast cancer in sister, no family hx autoimmune, rheumatologic
disease. Mother had hyperthyroidism
Physical Exam:
Admission Exam:
Vitals 98.3 106/71 116 96 RA
GENERAL: Well-appearing, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema. No swelling,
erythema, induration, or other deformity of L middle finger. L
elbow is mildly warm but non-tender and patient ranges it
passively with no pain. PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge Exam:
Vitals 98.3 106/71 116 96 RA
Telemetry: ST, HR 105-112
GENERAL: Well-appearing, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender, able to touch chin to chest put complains of
stiffness, however she has full ROM. no LAD, no JVD
CARDIAC: Tachycardic, 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: no cyanosis, clubbing or edema. No swelling,
erythema, induration.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs:
___ 12:15AM PLT COUNT-188
___ 12:15AM NEUTS-65.6 ___ MONOS-4.4 EOS-2.6
BASOS-1.0
___ 12:15AM WBC-10.0# RBC-4.91 HGB-14.5 HCT-42.2 MCV-86
MCH-29.4 MCHC-34.3 RDW-13.5
___ 12:15AM CALCIUM-8.4 PHOSPHATE-3.3 MAGNESIUM-2.1
___ 12:15AM proBNP-42
___ 12:15AM cTropnT-<0.01
___ 12:15AM ALT(SGPT)-96* AST(SGOT)-63* ALK PHOS-114* TOT
BILI-0.3
___ 12:15AM estGFR-Using this
___ 12:15AM GLUCOSE-144* UREA N-18 CREAT-0.8 SODIUM-136
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-28 ANION GAP-15
___ 01:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:20AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:20AM URINE GR HOLD-HOLD
___ 01:20AM URINE UHOLD-HOLD
___ 04:48AM PLT COUNT-171
___ 04:48AM WBC-6.9 RBC-4.41 HGB-13.2 HCT-38.2 MCV-87
MCH-29.8 MCHC-34.4 RDW-14.0
___ 04:48AM WBC-6.9 RBC-4.41 HGB-13.2 HCT-38.2 MCV-87
MCH-29.8 MCHC-34.4 RDW-14.0
___ 04:48AM IgG-648* IgM-195
___ 04:48AM ALT(SGPT)-78* AST(SGOT)-48* ALK PHOS-96 TOT
BILI-0.3
___ 04:48AM ALT(SGPT)-78* AST(SGOT)-48* ALK PHOS-96 TOT
BILI-0.3
___ 04:48AM GLUCOSE-119* UREA N-14 CREAT-0.7 SODIUM-139
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-26 ANION GAP-11
ECGStudy Date of ___ 11:47:34 ___
Ectopic atrial rhythm. Compared to the previous tracing of
___ no change.
Portable TTE (Complete) Done ___
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF =
60%). Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. There is mild posterior
leaflet mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
CHEST (PA & LAT)Study Date of ___
IMPRESSION:
No acute cardiopulmonary process.
ABDOMEN US (COMPLETE STUDY)Study Date of ___
IMPRESSION:
Normal study.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of cerebellar
hemangioblastoma s/p resection, anxiety, concern for ___
illness with +Lyme IgM ___ and recent admission for myalgias
and transaminitis, attributed to her statin. She was also found
to have an asymptomatic ectopic atrial tachycardia. She was
placed on a Holter monitor on ___. The evening after the
placement of the Holter monitor, she presented with presyncope.
# Presyncope: On admission the patient was monitored with
continuous telemetry and her Holter monitor was interrogated.
She was found to have paroxysmal supraventricular tachycardia
that was most likely atrial tachycardia with rates that were
mostly under 100. There were no alarming events during her
episode of presyncope. Review of her EKGs did not show any
prolonged PR interval. She had an echochardiogram which was
normal. Her associated symptoms were most closely consisted with
vasovagal syncope. She remained hemodynamically stable with
heart rates in the low 100s during hospitalization.
# Myalgias: The patient was admitted with complaints of
myalgias. On her previous admission she was found to have a
transaminitis which was attributed to her statin. During this
admission her ALT/AST were 78 and 48, decreased since ___.
Because of her mild transaminitis she had an abdominal
ultrasound which was normal. ___ and anti-sooth antibody labs
were drawn and were pending at time of discharge.
# Depression: The patient was continued on home citalopram.
TRANSITIONAL ISSUES
-Follow up with PCP within one week
-Follow up with cardiology on ___
-Statin was held during hospitalization due to myalgias;
consider working up myalgias in outpatient setting
-Will need to follow up on ___ and Anti-smooth antibody labs
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO EVERY OTHER DAY
2. Calcium Carbonate 600 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO EVERY OTHER DAY
2. Calcium Carbonate 600 mg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Ibuprofen 400 mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Presyncope
Secondary diagnoses:
History of Lyme's infection
Hypercholesterolemia
Right cerebellar hemangioblastoma s/p resection in ___
Depression
Anxiety
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 ___
because you almost lost consciousness. There were concerns that
you were having an abnormal heart rhythm. Your heart monitor was
evaluated, and it was determined that you were not having a
worrisome heart rhythm that caused your symptoms.
You need to follow-up with your PCP, ___ further
management. It was a pleasure caring for you, and we are glad
that you have started to feel better.
Take care!
Your ___ Team
Followup Instructions:
___
|
19800320-DS-9
| 19,800,320 | 27,810,286 |
DS
| 9 |
2185-05-09 00:00:00
|
2185-05-10 19:45:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of dementia, diabetes (on insulin with prior
hospitalizations for DKA), CKD, HTN, HLD presents with
hyperglycemia discovered today by ___. Pt reports forgetting to
take his insulin. He does not know how many doses he missed.
Today, his ___ came to check his sugars and vitals, and he was
found to be hyperglycemic to 600s. She told him to go to the ED.
Of note, he lives alone and has ___ services ___ times per week.
He reports feeling no symptoms, including weakness and dizziness
which he normally gets with hyperglycmia/hypoglycemia. Pt denies
all pain, denies excessive urination, denies exesive thirst,
denies n/v/d, denies fever or chills. Pt is oriented per
baseline, transported to BID w/o incident.
Per ___ notes, his BG has been poorly controlled lately at
home. ___ reports sugars in 300s-500s. Pt forgets to take
insulin and forgets to take sugars. He does not comply with
diabetic diet.
In the ED, initial vital signs were T 97.9 P 63 BP 119/60 R 17
O2 sat 100% on RA. Labs were notable for BG 715, K of 7.1.
Patient was given 1L LR, 1L NS, 10 units regular insulin,
insulin drip was initiated at 8 units per hour. His repeat labs
showed BG 364 and K 4.9. Insulin drip was d/c'd. He received his
___ dose of SQ insulin. Vitals on Transfer were 97.9, 62, 18,
100% RA.
On the floor, the pt continues to deny any cp, sob, dizziness,
lightheadedness, n/v/d. Does endorse some constipation. No abd
pain. He notes numbness in his hands and feet.
ROS:
(+) as per HPI
(-) polyuria, polydipsia, HA, vision changes.
Past Medical History:
Type 2 DM for ___ years- Insulin dependent. Last HbA1c is 8.5%
in ___.
Hypertension
Hyperlipidemia
CKD Stage 3
Diabetic nephropathy.
Hypothyroidism
Dementia
Social History:
___
Family History:
father died of lung CA, denies known DM or CAD
Physical Exam:
Admission physical exam:
Vitals- 97.7, 144/66, 67, 18, 100RA
General- Alert, oriented x2, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Skin - onychomycosis
Discharge physical exam:
VS - 98.3, 119/55, 70, 18, 100RA
General- Alert, oriented x2, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Skin - onychomycosis
Pertinent Results:
Admission labs:
___ 11:35AM BLOOD WBC-5.1 RBC-4.35* Hgb-13.0* Hct-39.5*
MCV-91 MCH-30.0 MCHC-33.0 RDW-13.0 Plt ___
___ 11:35AM BLOOD Glucose-715* UreaN-74* Creat-3.8* Na-124*
K-7.1* Cl-91* HCO3-20* AnGap-20
___ 08:25AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.2
___ 11:48AM BLOOD Lactate-1.3 K-6.7*
___ 04:24PM BLOOD K-4.9
Pertinent labs:
___ HgbA1c 17.1
Discharge labs:
___ 07:45AM BLOOD WBC-6.0 RBC-3.74* Hgb-11.5* Hct-33.5*
MCV-90 MCH-30.7 MCHC-34.2 RDW-13.6 Plt ___
___ 07:45AM BLOOD Glucose-103* UreaN-73* Creat-3.4* Na-137
K-4.6 Cl-109* HCO3-18* AnGap-15
Pertinent micro:
___ 2:22 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
Blood cultures pending X2
Brief Hospital Course:
___ with PMH of poorly controoled DM2, diabetic
neuropathy/nephropathy/retinopathy, HTN, HLD, dementia presents
with hyperglycemia in the setting of poor home insulin regimen
compliance.
#Hyperglycemia:
Likely due to poor compliance with home diabetes regimen, which
can be attributed to pt's memory loss. He came in with BG 715,
Na of 125, K of 7.1, Cr of 3.8, HCO3 of 20, lactate 1.3, and
negative urine ketones. All labs improved with administration of
insulin and IVF. Not consistent with DKA. Off insulin drip and
put on home regimen with sliding scale. FSBG were in the
100s-300s from that point on. We consulted ___, who felt that
he was on an appropriate basal insulin regimen given his
baseline of sugars in the 300s-500s. The pt has been admitted
multiple times, including an ICU stay, for this issue. He
reports simply forgetting to take the insulin and denies having
an aversion to taking. An attempt was made to send the pt to an
assisted living facility or nursing home, however he was very
resistant. Despite his memory loss, he was felt to have
capacity. We were unable to contact his HCP, his daughter, who
may have provided more insight into the issue. We tried to set
him up with the PACE program, which provides nursing home-level
care from home, but were told this has to be done as an
outpatient. It was felt that the pt would be safe to leave the
hospital and follow up with his PCP at ___ in 2 days to then
be set up with PACE. He was given his evening dose of insulin
and sent home to have a nurse visit him in the morning. We
recommend occupational therapy for the pt to assist him in ways
to remember taking his medicines.
___ on CKD:
Fluid losses due to dehydration vs worsening of present CKD. CKD
Stage 4 - Diabetic nephropathy. Not on HD. Baseline Cr about
2.8. Cr improved slightly from admission but remained somewhat
elevated above baseline, even with 3L IVF. He had good urine
output with no signs of retention. We did not feel further
workup was necessary as an inpatient. The pt will follow with
___ and his PCP for further ___. Once his Cr stabilizes, we
recommend adding on an ___ to his regimen.
#Hyponatremia:
Dehydration plus uncorrected for hyperglycemia. Improved with
IVF.
Hypertension:
Continued home metoprolol and lisinopril. CAD prevention with
daily ___.
T2DM:
Poorly controlled. BG has been 300s-500s at home per prior
notes. Last A1c 17.2 in ___. Management as above. Continued
gabapentin for diabetic neuropathy.
Hyperlipidemia:
Continued home statin.
Hypothyroidism:
Last TSH wnl. Continued home levothyroxine.
Dementia:
Etiology ___. Possibly early onset Alzheimer's vs vascular
dementia, although pt has no known hx of stroke. Chronic decline
per ___ notes. He remained at baseline throughout his stay.
CAD:
On Plavix for NSTEMI at outside hospital.
Glaucoma:
Continued dorzolamide/timolol eye drops.
Vit D deficiency:
Continued home supplement.
Transitional Issues:
#Pending blood cultures
#Outpatient OT to help with medication training
#Add ___ to diabetes regimen
#Dementia workup
Medications on Admission:
Unable to obtain information regarding preadmission medication
at this time. Information was obtained from ___.
1. AndroGel *NF* (testosterone) 1 %(50 mg/5 gram) Transdermal
daily
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. Humalog ___ 40 Units Breakfast
Humalog ___ 40 Units Bedtime
4. Lovastatin *NF* 80 mg ORAL DAILY
5. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Senna 1 TAB PO BID:PRN constipation
hold for loose stool
9. Aspirin 81 mg PO DAILY
10. Gabapentin 300 mg PO BID
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Gabapentin 300 mg PO BID
6. Humalog ___ 45 Units Breakfast
Humalog ___ 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
hold for loose stool
9. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
10. AndroGel *NF* (testosterone) 1 %(50 mg/5 gram) Transdermal
daily
11. Lovastatin *NF* 80 mg ORAL DAILY
12. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
1. Hyperglycemia
2. Type 2 diabetes mellitus
3. Chronic kidney disease
Secondary diagnoses:
1. Hypertension
2. Hypercholesterolemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for high blood sugars and abnormal
potassium and sodium levels. You were given IV fluids and
insulin, and your blood sugars came down. We now feel it is safe
for you to leave the hospital.
We did not make any changes to your medications. PLEASE REMEMBER
TO TAKE YOUR INSULIN EVERY DAY IN THE MORNING AND AT NIGHT.
Please follow up with your PCP at the appointment made below. A
visiting nurse ___ come to see you tomorrow morning to help you
with your medications.
Followup Instructions:
___
|
19800337-DS-3
| 19,800,337 | 21,535,326 |
DS
| 3 |
2168-09-23 00:00:00
|
2168-10-03 13:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OTOLARYNGOLOGY
Allergies:
Penicillins / Levofloxacin
Attending: ___.
Chief Complaint:
R Neck swelling/tenderness/redness, pain with swallowing
Major Surgical or Invasive Procedure:
___ Right neck lymph node excisional biopsy.
History of Present Illness:
The patient is a ___ yo F who underwent LN excision on the
right level II with Dr. ___ 2 days ago. She was doing
well at home but over the past 24hrs has developed worsening
dysphagia and erythema of the neck. She presented to ___ this
AM for evaluation.
Past Medical History:
hx of pneumonia
Social History:
___
Family History:
Her mother had colon cancer, and her daughter
had a brain tumor. There is also a history of hearing loss, and
migraines.
Physical Exam:
V: 98 76 133/76 16 96%
Gen: NAD, lying comfortably in bed
HEENT: EOM intact, PERRLA, b/l auricles without inflammation or
lesions. Neck: R sided erythema superior and inferior to
incision extends to submentum. Tender to palpation. No crepitus,
no drainage from incision site, with full ROM.
___: RRR no murmors on exam
RESP: CTAB
Neuro: CN VII, XI, XII intact
FOE: Right pyriform/lateral pharyngeal wall with mild but
improved edema and includes the lateral pharyngeal wall. The
posterior cricoid has minimal edema, right AE fold is still
mildly edematous, with no obstructive of the glottic introitus.
The cords are bilaterally visualized and mobile.
Pertinent Results:
___ 01:09PM BLOOD WBC-8.8 RBC-4.60 Hgb-13.1 Hct-38.7 MCV-84
MCH-28.4 MCHC-33.8 RDW-13.9 Plt ___
Brief Hospital Course:
This is a ___ yo F who underwent right level II lymph node
dissection on ___. She was doing well at home but two days
later she developed worsening dysphagia and erythema of the
neck. She presented to ___ after 24 hours of these symptoms
(morning of ___ for evaluation. She was readmitted that day
for IV antibiotics. She was started on Levo/clinda but was
switched to cipro/clinda due to what appeared to be an allergic
rash to the Levofloxacin.
A CT scan of her neck revealed Post-surgical changes right upper
neck with foci of air and fat stranding most pronounced between
the sternocleidomastoid muscle and the submandibular gland and
extending medially to the parapharyngeal space with mild
narrowing of the hypopharyngeal airways. There appeared to be no
vascular injury and no abscess formation, and no evidence of a
prevertebral or retropharyngeal abscess.
She remained afebrile and her condition improved on IV
antibiotics over the next three days, with reduction of
aryepiglottic fold edema on FOE exam and improvement of her R
neck swelling/erythema.
She was discharged on po Bactrim and Kelex on ___ in stable
condition, and a follow up Dr. ___ was planned for the
next week.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL ___ ml by mouth every four hours Disp
#*250 Milliliter Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days
Take one tablet twice a day for 10 days
4. Cephalexin 500 mg PO Q12H Duration: 10 Days
Take one tablet twice a day for 10 days.
Discharge Disposition:
Home
Discharge Diagnosis:
-R Neck cellulitis
-R Neck hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Continue to slowly increase po intake as tolerated
-Please take Bactrim and Keflex daily as prescribed for ten
days.
-No heavy lifting or strenuous activity for at least one week
-Return to the clinic for follow up with Dr. ___ in
___ days
Followup Instructions:
___
|
19800649-DS-2
| 19,800,649 | 25,623,386 |
DS
| 2 |
2175-07-09 00:00:00
|
2175-07-09 16:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending: ___.
Chief Complaint:
Skin lesions, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o bipolar disorder, CKD, neurogenic bladder, HTN who
presents with several months of skin lesions. Patient reports
that approximately 3 months ago, he first noticed a multiple
isolated lesions on his legs, arms, and trunk that he thought
were bedbug bites. These were pruritic and became even more
itchy when scratched. He denies exposure to sick contacts,
outdoors, new detergents. He went to his dermatologist who took
a biopsy and diagnosed with him contact dermatitis. He was
referred to an allergist, but was unable to be tesed ___ active
rash. His dermatologist prescribed steroids which helped the
pruritus but caused him to break out into boils. His steroids
were discontinued, and he was instructed to soak in the bath,
and use warm towel compresses to try to express the fluids from
the boils. He says that he was able to express very little
purulent material. He went to his dermatologist again on ___,
who swabbed the lesions for culture, and prescribed
dicloxacillin. Patient did not improve on this over the next
few days, and reported chills and a fever of 102.6F (tympanic)
today. The final culture for the swab returned today, growing
MRSA, and the patient was contacted by his dermatologist who, in
the context of high fever, referred him to the ED for further
evaluation and management.
On arrival to the ED, initial vitals were: 99 126 142/64 18 95%
RA. Labs notable for WBC 16.6 w/ L shift and Cr 1.7 (baseline).
Blood and urine Cx drawn and given Vanc 1g IV x1. VS at
transfer: 98.4 100 126/75 18 95% RA.
Currently, patient is comfortable. Reports mild pruritus of the
lesions, but otherwise denies chills, lightheadedness,
dizziness, chest pain, joint pain.
ROS is positive for new cough, SOB, dysuria with increased
urinary frequency (patient has been self-catheterizing for ___
years for neurogenic bladder--negative uro workup), hard stools
in the setting of discontinuing laxatives for ~week.
ROS: per HPI, otherwise for headache, vision changes, sinus
congestion, sore throat, abdominal pain, n/v/d, BRBPR, melena,
hematochezia, hematuria
Past Medical History:
? SLEEP APNEA
ANAL PRURITUS
BACK PAIN
___ ESOPHAGUS
BIPOLAR AFFECTIVE DISORDER
BLADDER DISORDER
BPH
CHEST PAIN
HERNIATED CERVICAL DISC
HYPERCHOLESTEROLEMIA
HYPERHOMOCYSTEINEMIA
HYPERTENSION
INTERNAL HEMORRHOIDS
MENISCUS TEAR, RIGHT
NEVUS, ATYPICAL
OSTEOARTHRITIS
PAIN IN JOINT
PSYCHOSIS
RECTAL PAIN
RENAL INSUFFICIENCY
SCIATICA
UTI
URINARY RETENTION
Social History:
___
Family History:
Father died of liver or kidney disease at ___. Maternal uncle
with prostate CA. ?CAD, CVA hx in family. No known autoimmune
disease; no Chrohn's, no h/o of allergies/eczema or skin
conditions in family. Sister has "blood disease"
Physical Exam:
EXAM ON ADMISSION:
VS - 99.1 114/76 98 18 97% RA
General: well-appearing Caucasian gentleman, reclining
comfortably in bed
HEENT: NCAT, MMM, eyes equal and reactive to light; no lesions
of mucosal membranes
Neck: supple; no cervical LAD; posterior neck/nape of neck
erythematous; no lesions
CV: RRR, ___ holosystolic murmur loudest at apex, no
gallops/rubs; no JVD
Lungs: CTAB; no rhonchi/crackles; skin findings on back as
mentioned below
Abdomen: soft, NTND; skin findings as mentioned below
GU: deferred
Ext: nonedematous, WWP, sensation intact; 2+ pulses throughout;
skin findings as below
Neuro: AOx3, grossly intact with no focal abnormalities
Skin: scattered hemangiomas and few scattered, non-pruritic,
blanching, indurated, erythematous, painless papular lesions of
back, on L buttock, bilateral arms, RLQ of abdomen; multiple
indurated, some crusted/scabbed/excoriated coalescing papules of
anterior shin and medial thighs bilaterally; dorsal aspect of
feet bilaterally with excoriated and crusted
herpetiform/eczematous papules
EXAM ON DISCHARGE:
General: well-appearing Caucasian gentleman, reclining
comfortably in bed
HEENT: NCAT, MMM, eyes equal and reactive to light; no lesions
of mucosal membranes
Neck: supple; no cervical LAD
CV: RRR, ___ holosystolic murmur loudest at apex, no
gallops/rubs; no JVD
Lungs: CTAB; no rhonchi/crackles; skin findings on back as
mentioned below
Abdomen: soft, NTND; skin findings as mentioned below
GU: deferred
Ext: nonedematous, WWP, sensation intact; 2+ pulses throughout;
skin findings as below
Neuro: AOx3, grossly intact with no focal abnormalities
Skin: scattered hemangiomas; few scattered, scabs with small
amounts of serous drainage on very mildly erythematous base at
sites of previously indurated and erythematous lesions;
lichenified skin over dorsal aspect of feet and ankles
Pertinent Results:
___ 01:22PM BLOOD WBC-16.6*# RBC-3.83* Hgb-11.8* Hct-35.0*
MCV-91 MCH-30.9 MCHC-33.8 RDW-11.9 Plt ___
___ 01:22PM BLOOD Neuts-89.8* Lymphs-5.0* Monos-3.9 Eos-0.9
Baso-0.4
___ 06:00AM BLOOD WBC-8.1 RBC-3.60* Hgb-11.5* Hct-33.4*
MCV-93 MCH-31.9 MCHC-34.4 RDW-12.2 Plt ___
___ 01:22PM BLOOD Glucose-118* UreaN-47* Creat-1.7* Na-137
K-4.0 Cl-101 HCO3-23 AnGap-17
___ 07:17AM BLOOD Glucose-101* UreaN-39* Creat-1.5* Na-144
K-5.0 Cl-107 HCO3-26 AnGap-16
___ 06:00AM BLOOD Glucose-95 UreaN-42* Creat-1.8* Na-141
K-4.2 Cl-105 HCO3-27 AnGap-13
___ 06:55AM BLOOD HIV Ab-NEGATIVE
CXR ___:
Questionable infectious process in the lungs. Given the
patient's history, followup of the patient in four weeks after
completion of antibiotic therapy is required. If finding is
persistent, assessment with chest CT might be considered to
exclude other potential etiologies for the lung abnormalities.
Brief Hospital Course:
___ with BPD, CKD, neurogenic bladder, HTN, and recent allergic
dermatitis presenting with fever and worsening skin lesions
despite antibiotics.
# Skin lesions/fever: Patient with history of chronically dry
skin presenting with multiple MRSA+ abscesses over bialteral
legs, arms, and back. Patient was afebrile during course of
hospitalization and blood and urine cultures were not positive
for
infection. Patient came in to the BI on dicloxacillin, which
had been prescribed by his dermatologist. Dicloxacillin was
discontinued and patient was given IV vancomycin x48 hours with
great improvement of skin lesions. For his pruritus, patient
was given sarna lotion and diphenhydramine with moderate effect.
His dermatologist was contacted and recommended bleach baths
3x/week and mupirocin. Dermatology scheduled follow-up visit
with patient. Patient received an HIV test ___ concern for
immunocompromise in the setting of diffuse involvement. One day
prior to discharge, patient was transitioned to PO doxycycline
(versus Bactrim, given CKD). Patient tolerated this well, and
was discharged on a 14 day course of doxycycline.
# Dysuria: Patient has a ___ year history of neurogenic
bladder which has been worked up extensively in the past, per
the patient. Also documented history of BPH. Patient has been
self-cathing for the past ___ years and reports occasional
UTIs. On admission, patient reported recent dysuria and
increased frequency. As patient had a CC of fever, UA and UCx
were obtained. Both were negative. Patient continued to
self-cath during hospitalization without event/complaint.
# cough, SOB: Patient has extensive smoking history and may have
mild COPD or other lung disease. CXR was obtained and was
questionable for infectious process in the lungs; however,
patient improved subjectively without intervention. No oxygen
requirement during hospitalization. However, given
abnormalities on CXR, it was recommended that patient have
repeat CXR in 4 weeks.
# CKD: On admission, patient's creatinine elevated to 1.8. He
was slightly tachycardic with increased BUN (although this
appeared to be the patient's baseline). Possibly volume down in
setting of decreased PO and increased urinary frequency.
BUN/creat > 20. Patient given 1L NS for possible prerenal
etiology. Creatinine trended down to 1.5. One day prior to
discharge, patient again with creatinine of 1.8 and was again
given 1L NS. Given patient's CKD, he was written for
doxycycline versus bactrim for continued treatment of his MRSA
skin infection. Medications, otherwise, were all renally dosed.
# Bipolar disorder: Continued home meds.
# Hemorrhoids: Continued home bowel regimen in addition to
senna, colace.
# HTN: Continued home meds.
TRANSITIONAL ISSUES:
# abnormal CXR: Radiology suggested that patient, given h/o
smoking and COPD, should receive repeat CXR in 4 weeks. If CXR
findings persistent, assessment with CT recommended.
# Continued bactroban and bleach baths given extent of MRSA
infection
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Carbamazepine (Extended-Release) 500 mg PO HS
3. BuPROPion (Sustained Release) 200 mg PO QAM
4. QUEtiapine Fumarate 300 mg PO QPM
5. RISperidone 6 mg PO DAILY
6. Ketoconazole 2% 1 Appl TP BID
7. Lorazepam 0.5 mg PO HS
8. guar gum *NF* 1 gram Oral QHS
9. Polyethylene Glycol 17 g PO DAILY
10. Simvastatin 40 mg PO DAILY
11. DiCLOXacillin 500 mg PO Q6H
12. Omeprazole 40 mg PO BID
13. Aspirin 81 mg PO DAILY
14. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Ketoconazole 2% 1 Appl TP BID
3. Lisinopril 20 mg PO DAILY
4. Lorazepam 0.5 mg PO HS
5. Omeprazole 40 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY
7. QUEtiapine Fumarate 300 mg PO QPM
8. RISperidone 6 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. BuPROPion (Sustained Release) 200 mg PO QAM
11. Carbamazepine (Extended-Release) 500 mg PO HS
12. Hydrochlorothiazide 12.5 mg PO DAILY
13. guar gum *NF* 1 gram Oral QHS
14. Mupirocin Nasal Ointment 2% 1 Appl NU BID Duration: 12 Days
RX *mupirocin calcium [Bactroban Nasal] 2 % 1 application NU
twice a day Disp #*1 Tube Refills:*0
15. Sarna Lotion 1 Appl TP TID:PRN itching
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % Apply lotion
to skin three times a day Disp #*1 Bottle Refills:*0
16. Doxycycline Hyclate 100 mg PO Q12H Duration: 11 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*21 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
MRSA cellulitis/abscesses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___ for skin infection. You required
intravenous antibiotics for several days during your
hospitalization. After we saw that your skin was getting
better, we switched you to oral antibiotics. You should
continue taking these oral antibiotics after discharge. It is
very important you finish the entire course of your antibiotics,
even if you feel you do not need them anymore. Please continue
taking your other medications, as they are written below.
While you were here, we spoke to your dermatologist about your
skin condition. She recommended doing the following once you
are home, in addition to taking your antibiotics:
SWIMMING POOL BATHS: Mix ___ cup Clorox bleach in a bathtub
full of warm water. Soak for 10 minutes. Do this at least
three times a week.
Please follow up with your dermatologist after discharge.
It was a pleasure caring for you while you were here. We wish
you a speedy recovery!
Followup Instructions:
___
|
19800781-DS-10
| 19,800,781 | 28,847,173 |
DS
| 10 |
2152-07-28 00:00:00
|
2152-07-31 16:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Uremia
Major Surgical or Invasive Procedure:
Coronary Catherization (DES placed to L Cx)
Hemodialysis
History of Present Illness:
Mr ___ is a ___ year old male with a history of diabetes, ESRD
who presents with worsening fatigue, nausea, and LLQ abdominal
pain. His fatigue has been present for a year or so, most
significantly progressing over the past few weeks at which point
he has developed daily nausea which is not associated with
vomiting. He additionally describes developing LLQ pain at this
point, which is intermittent though he can identify no specific
trigger and he does not describe colic type symptoms. At its
worst the pain is ___ and is completely absent at other times.
The pain does not radiate to the groin, but at times is
associated with back pain. He denies any hematuria or changes in
urination. He denies any bruising or easy bleeding. He denies
any chest pain, sob, or orthopnea.
Of note, he had a RUE AVF placed in ___ in anticipation of
HD, and is reportedly mature. HD was initially being delayed but
given new symptoms and discussion with Renal team, patient
agreed to initiate HD this admission. Additonally, he has a
history of a silent inferior MI, with an EF of 34% and denies
any chest pain or shortness of breath currently.
In the ED, initial vitals: 97.7 84 156/84 14 100% on RA
Labs were notable for: Trop-T: 0.16, proBNP: 7251, Wbc: 7.4,
Hgb:11.1
Plt: 223, na: 140, Cl: 109, BuN: 66, Glu: 147, K: 4.8 Bic: 21
Cre: 5.1. He had a UA w/ 600 prot 150 glu 7wbc and few bact
He had an EKG which showed sinus narrow intervals, no peaked Ts,
no ischemia. CT showed no acute process to explain abdominal
pain
On arrival to the floor, pt reports no acute symptoms except for
his stable ___ LLQ pain. He remained hypertensive to the 180s,
did not respond to 10mg IV hydralazine and was restarted on home
antihtn as well as 50q6h of po hydralazine.
Past Medical History:
DM2 with retinopathy, neuropathy, autonomic neuropathy and
nephropathy
CKD IV/V ___ biopsy proven diabetic nephropathy with nephrotic
range proteinuria
PVD s/p bilateral bypass surgeries
HLD
HTN
Colon Ca s/p partial colectomy ___
CAD , s/p silent inferior MI
Social History:
___
Family History:
History of DM on both sides of family, denies any history of CHF
or heart attacks
Physical Exam:
Admission Physical
=====================
Vitals- 98.4 181/78 84 18 97% on RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft,bowel sounds present, mildly tender to deep
palpation in LLQ, no rebound tenderness or guarding, no
organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis,
trace edema
Neuro- CNs2-12 intact, motor function grossly normal
Discharge Physical
=====================
Vitals- 98.4 110s-140s/50s-70s ___ 18 98%
General- Alert, oriented, nad
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2 no murmurs rubs gallops
Abdomen- soft,bowel sounds present no rebound tenderness or
guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis
Neuro- CNs2-12 intact, full strength and sensation to light
touch/pain bilaterally
Pertinent Results:
Admission Labs
=====================
___ 08:30AM BLOOD WBC-7.4 RBC-3.80* Hgb-11.1* Hct-32.5*
MCV-86 MCH-29.2 MCHC-34.2 RDW-13.2 Plt ___
___ 08:30AM BLOOD Neuts-68.2 Lymphs-17.7* Monos-10.2
Eos-3.1 Baso-0.7
___ 08:30AM BLOOD ___ PTT-33.2 ___
___ 08:30AM BLOOD Glucose-147* UreaN-66* Creat-5.1* Na-140
K-4.8 Cl-109* HCO3-21*
___ 08:30AM BLOOD cTropnT-0.16* proBNP-7251*
___ 08:30AM BLOOD Calcium-8.7 Phos-4.0 Mg-1.8
Discharge Labs
====================
___ 06:00AM BLOOD WBC-6.2 RBC-3.55* Hgb-10.7* Hct-30.5*
MCV-86 MCH-30.0 MCHC-34.9 RDW-13.7 Plt ___
___ 05:00AM BLOOD Glucose-100 UreaN-29* Creat-5.9* Na-137
K-3.9 Cl-98 HCO3-31 AnGap-12
Pertinent Labs
====================
___ 01:10PM BLOOD PTH-118*
___ 01:10PM BLOOD 25VitD-18*
___ 01:10PM BLOOD calTIBC-252* Ferritn-103 TRF-194*
___ 06:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 06:10AM BLOOD HCV Ab-NEGATIVE
___ 08:30AM BLOOD cTropnT-0.16* proBNP-___*
___ 06:10AM BLOOD cTropnT-0.14*
___ 05:05AM BLOOD cTropnT-0.13*
Imaging Results
====================
Cardiac Echo ___
IMPRESSION: Mild symmetric LVH with normal biventricular
regional/global systolic function.
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 report of the prior study (images unavailable
for review) of ___, I did not appreciate the regional wall
motion abnormalities noted on the prior study today. 2D strain
shows normal intrinsic myocardial contractility in the basal
inferior wall
CT Head wo contrast ___
IMPRESSION:
1 cm hypodensity within the left globus pallidus is worrisome
for a large
subacute lacunar infarct or edema surrounding a lesion.
Recommend dedicated
MR for further evaluation.
MRI/MRA (Time of Flight) head/neck
IMPRESSION:
1. Study is mildly degraded by motion, and examination of
bilateral common
carotid and vertebral artery origins limited secondary to motion
artifact.
2. Within limits of examination, no definite dissection or
significant
occlusion of head or neck MRA.
3. 7 mm left insula subacute infarct.
4. Additional curvilinear region of restricted diffusion in left
temporal lobe
may represent acute infarct, or may be artifactual in nature.
Recommend
clinical correlation and attention on followup imaging.
Brief Hospital Course:
___ year old male with a history of CKD secondary to DM and past
silent inferior MI who presented with worsening uremic symptoms
and abdominal pain admitted for initiation of HD. Additionally,
he underwent cardiac catheterization with a DES placed to the
left circumflex, complicated by embolism in L MCA territory
without persistent neurologic sequelae.
#ESRD: Patient w/ ESRD s/p fistula placement presented with
progressing symptoms of uremia. His dialysis proceeded
successfully, with one session delayed for AM nausea which
responded well to metoclopramide. PPD was placed and negative,
he was started on nephrocaps, and he was transitioned to an
outpatient TTS schedule. HBV unexposed
-HBV immunization as outpatient
#Type II NSTEMI: Patient w/ elevated troponin to 0.16 -> 0.14 on
follow up. No evidence of acute ischemic change on ekg, BNP of
7251. History of past silent inferior MI. Most likely a
combination of demand ischemia in setting of HTN as well as
renal failure and impaired clearance. However, given his risk
factors and history of CAD he was started on a heparin drip and
was catheterized with a drug eluting stent placed to the left
circumflex, a procedure which had been planned before surgery
but delayed until HD initiation given contrast load. Home beta
blockade was continued, see afterload management below. He was
discharged on aspirin and plavix for minimum of 6 months. His
discharge metoprolol dose was Metoprolol Succinate 25mg daily
and atorvastatin 80mg He should not stop these medications until
talking to his cardiologist.
#Embolic Ischemic Stroke: Immediately post catheterization, he
experienced transient word finding difficulties which fully
resolved within minutes. The next morning headache and nausea
prompted a head ct which was negative for acute bleed, but
subtle findings prompted an MRI which was most consistent with
recent embolic activity in the Left insula and temporal lobe. He
had no focal findings beyond his baseline neuropathy and no
lateralizing signs.
-No further follow up necessary
#HTN: On 75mg irbesartan at home, was initially covered with
25mg losartan but remained hypertensive to the 180s and
hydralazine was added. He became symptomatically orthostatic,
likely secondary to his autonomic neuropathy, and when his
hydralazine was held he became hypertensive to the 200s after
catheterization and briefly required a nitroprusside drip. He
was discharged on 150mg irbesartan without any hydralazine.
-Antihypertensive titration
# DM: Used 60 u detemir + aspart sliding scale at home. Last A1c
7.7 in ___. Past complications include retinopathy,
neuropathy, autonomic neuropathy and nephropathy. He was
initially treated with 60 Lantus BID and sliding scale, with the
lantus downtitrated secondary to low glucose levels. He is
discharged on 40 u detemir BID plus the sliding scale, with
instructions to adjust with his outpatient providers if coverage
is insufficient.
-Follow up sugars and adjust detemir accordingly
#GERD: Patient reports worsening over past few months of
substernal chest pain. Brief episodes ~5 seconds of squeezing
pain associated with gasping hiccup. Increased cough over same
period. Denies dysphagia, possible but less likely to be DES.
-8 weeks of high dose ppi, to be followed up as outpatient
-transition to 40mg pantoprazole bid, given omeprazole
interaction with clopidogrel.
#Cardiac echo: normal EF with no wall motion abnormalities, as
well as mild symmetric left ventricular hypertrophy. Echo with
mildly dilated ascending aorta, seen in ___ as well.
-Recommend follow up echo in ___ year
# Anemia: Normocytic, and stable at hgb ___, adequate per
renal. Likely secondary to deficiency of renal epo production.
Recent baseline ___
-EPO or iron as per his outpatient renal team
#LLQ Pain: Presented with intermittent LLQ pain, with no
reliable pattern. CT negative for acute processes, stones, signs
of diverticulitis or other acute process. Resolved without
intervention.
Transitional Issues
========================
-Intermittently hypertensive and orthostatic, will discharge
with 150mg irbesartan qd, please follow up and adjust
medications
-DES of Lcx on ___, will need minimum 6 months dual
antiplatelet therapy.
-Trialing 8 week course of high dose ppi (40 mg bid
pantoprazole), followup to assess effect
-periods of hyperglycemia with in house conversion of detemir to
lantus. Will discharge with 40 U Detemir BID from 60 U BID,
follow up to assess sugars and possible need to change when on
home diet
-5s run of narrow complex tachycardia, continue on home beta
blocker
-If palpitations from tachycardia persist, increase metoprolol
to 50mg
-___ outpatient Dialysis schedule
-Echo with mildly dilated ascending aorta, seen in ___ as
well. Recommend follow up echo in ___ year
-Negative hepatitis B serology, will need outpatient vaccination
Code status: Full
Proxy: ___, Relationship: fiancee, Phone number:
___
Patient Contact Number: ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 80 mg PO QPM
2. Omeprazole 20 mg PO DAILY
3. irbesartan 75 mg oral DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
6. Desipramine 10 mg PO DAILY
7. Levemir (insulin detemir) 60 U subcutaneous BID
8. NovoLOG FLEXPEN (insulin aspart) 100 unit/mL subcutaneous TID
W/MEALS
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Desipramine 10 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
6. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth per day Disp #*30
Tablet Refills:*0
7. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth per day Disp #*30 Capsule Refills:*0
8. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Twice per day Disp
#*20 Tablet Refills:*0
9. NovoLOG FLEXPEN (insulin aspart) 100 unit/mL subcutaneous TID
W/MEALS
10. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
three times per day Disp #*30 Tablet Refills:*0
11. irbesartan 150 mg oral DAILY
RX *irbesartan 150 mg 1 tablet(s) by mouth daily Disp #*15
Tablet Refills:*0
12. Levemir (insulin detemir) 40 U subcutaneous BID
13. Metoclopramide 5 mg PO BID:PRN Nausea Duration: 10 Days
RX *metoclopramide HCl [Reglan] 5 mg 1 tablet by mouth twice
daily as needed for nausea Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
====================
End Stage Renal Disease, w/ hemodialysis initiation
NSTEMI II
Cornary Artery Disease
Hypertensive Urgency
Embolic Ischemic Stroke
Diabetes
Secondary Diagnoses
====================
GERD
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
for initiation of dialysis after your symptoms from your kidney
disease worsened. You had 3 sessions of dialysis that well.
While, here you had chest pain that was concerning for blockages
to the vessels of your heart. You had a catheterization where
they placed a stent to open a coronary artery. You had some
confusion afterwards, and we got imaging of your brain which
showed 3 small lesions in the left side of your brain which were
likely due to your catheterization procedure, and you are
neurologically back to normal with no residual deficits.
We also made some changes to your blood pressure and diabetes
management. We would like you to increase your irbesartan to
150mg per day from 75, and to follow up with your primary care
doctor. Your sugars also ran lower while you were here. We would
like you to decrease your levemir to 40 U twice a day from 60.
If your glucose is greater than 200 for a day, you can increase
your levemir by 5 units. Please call you doctor if it is
persistently less than 100 or more than 300.
Please call a doctor if you experience shortness of breath,
chest pain, confusion, change in vision, weakness numbness or
tingling, fevers >101, or for any symptoms that concern you.
Thanks,
Your ___ Care team
Followup Instructions:
___
|
19800909-DS-7
| 19,800,909 | 21,685,167 |
DS
| 7 |
2155-11-19 00:00:00
|
2155-11-19 13:40:00
|
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 and vomiting
Major Surgical or Invasive Procedure:
Exploratory laparatomy, excision of hernia sac, explant of mesh,
primary closure.
History of Present Illness:
Ms. ___ is a pleasant ___ woman who underwent a
laparoscopic incisional hernia repair with mesh on ___ and
presented to the ED earlier this evening with a chief complaint
of increasing abdominal pain and emesis. Patient reports she had
been recovering well until this morning, at which point she
noticed increasing pain in the region of her ventral hernia
repair and subsequently had several episodes of emesis. Last BM
was this morning, no flatus or BM since that time. No fevers or
chills. Reports that the pain is dull, constant, with radiation
to the sides of her abdomen. No urinary symptoms.
Past Medical History:
PMH: ventral/incisional hernia, obesity, L ovarian cyst
PSH: L salpingo-oophorectomy (robotic), ventral hernia repair
with mesh (laparoscopic)
Social History:
___
Family History:
Mother with breast cancer diagnosed in ___. Father with SLE.
Physical Exam:
Discharge exam:
Gen: NAD
N: AAOx3
CV: RRR no M/G/R
P: CTAB no W/R/R
GI: obese, S/ND appropriately tender, incisions intact
Ext: no C/C/E
TLD: none
Pertinent Results:
___ 05:20PM WBC-20.2*# RBC-5.51* HGB-14.8 HCT-44.8
MCV-81* MCH-26.9 MCHC-33.0 RDW-12.7 RDWSD-37.4
___ 05:20PM LIPASE-22
___ 05:20PM ALT(SGPT)-21 AST(SGOT)-15 ALK PHOS-81 TOT
BILI-0.2
___ 05:20PM GLUCOSE-130* UREA N-17 CREAT-0.7 SODIUM-138
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16
___ 05:20PM ___ PTT-36.3 ___
___ 05:20PM PLT COUNT-352
___: CT Abdomen and pelvis with contrast:
IMPRESSION:
Incarceration of small bowel loops within the ventral hernia
sac, with
adjacent stranding and free fluid extending to the liver and
spleen. There is mild prominence of the small bowel, measuring
up to 3.1 cm. No evidence of pneumatosis, or intraperitoneal
free air.
Brief Hospital Course:
___ was admitted from the ___ ED on ___ for
exploratory lapratomy for her incarcerated verntral hernia seen
on CT. For more details of her operation, see operative report.
The patient was taken from the OR to the PACU in stable
condition with foley, NG tube, and ___ drain in place. The
patient was then taken from the PACU to the surgical floor in
stable condition. POD#1 the patient's Foley catheter was removed
and she voided freely. She was maintained NPO and on IV fluids
with an NGT in place. On POD#4 the NG tube output had decreased,
and the patient tolerated a clamp trial well. The NG tube was
removed and the patient was started on sips and oral pain
medications. On POD#5 the patient's diet was advanced to a
regular diet. The JP output continued to decrease and cleared
up, so the JP drain was removed on POD6. The patient was
discharged home on POD#6, and was ambulating independently,
voiding without difficulty and tolerating oral diet and pain
medications. All of her questions were answered.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 2 SPRY NU Frequency is Unknown
2. Acetaminophen Dose is Unknown PO Q6H:PRN pain
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*50 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID constipation
take for as long as you take Oxycodone.
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*30 Capsule Refills:*0
3. Acetaminophen 1000 mg PO Q6H:PRN pain
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Incarcerated ventral hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Do not lift anything heavier than 10 lbs until after you see
your surgeon. You may shower, but do not submerge your wound.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
19801123-DS-2
| 19,801,123 | 25,167,545 |
DS
| 2 |
2188-02-25 00:00:00
|
2188-02-25 22:11:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
arm pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HOSPITALIST ADMISSION NOTE
PCP:
Name: ___ MD
Email: ___
- HAS ONLY SEEN PATIENT ONCE ___ YEAR AGO
Ms. ___ is a ___ yo F with h/o opioid dependence/IVDU
previously on suboxone, anxiety, back pain, G6 P1 and 15 weeks
pregnant, who presents with acute L arm pain and redness. The
patient states she last injected heroin yesterday, and reports
using clean needles that she licks. She states she subsequently
developed L arm pain and redness near the site of injection.
She also reports full body aches, fever, chills, sweats,
anxiety, and joint pains currently, all consistent with opioid
withdrawal. She is also complaining of significant pain to LUE.
"Tylenol is not going to be enough!"
She reports using about ~0.5g daily of heroin. She desires
sobriety and is amenable to rehab. She reports that she had one
ob/gyn visit since becoming pregnant. She is not taking
prenatal vitamins.
In ED, bedside US did not demonstrate fluid collection in arm.
She was started on Vancomycin.
She otherwise denies CP, SOB, cough, dyusuria, joint swelling.
10 point review of systems reviewed, all others negative except
as listed above
Past Medical History:
? HCV
Opioid dependence with IVDU, previously on suboxone and
methadone
Migraines
Back pain
Social History:
___
Family History:
Her mother died of stroke at age of ___. Her father has a
history of hypertension. Paternal grandmother, history of
diabetes. No history of cancer in the family.
Physical Exam:
VS:98.7 PO 102 / 66 100 18 99 RA
GEN: lying in bed, very uncomfortable generally
HEENT: NC/AT, ears intact, MM dry, OP clear, anicteric sclera,
PERRL
NECK: supple no LAD
CV: Regular, tachy, in NAD
PULM: CTAB no wheezes or crackles
GI: soft. mild TTP at flanks, no rebound or guarding +BS
EXT: Mild soft tissue swelling medial LUE with assoc erythema
and significant tenderness to erythema. Induration noted no
clear area of fluctuance. Injection site noted is non-tender
DERM: skin as above, no rashes or lesions noted otherwise
NEURO: no focal deficits
DC EXAM:
VS: 98.4 PO 99 / 63 84 18 100 RA
GEN: lying in bed, mild discomfort in NAD
HEENT: NC/AT, ears intact, MMM, OP clear, anicteric sclera,
PERRL
NECK: supple no LAD
CV: Regular, tachy, faint ___ SEM noted and stable
PULM: CTAB no wheezes or crackles
GI: soft. NT/ND, no rebound or guarding +BS
EXT: soft tissue swelling medial LUE with assoc erythema and
significant tenderness to erythema. The erythema has extended
beyond the marked boundaries. Induration noted no clear area of
fluctuance. There is a palpable painful cord running along the
medial aspect of her forearm. Injection site noted is
non-tender
DERM: skin as above, no rashes or lesions noted otherwise
NEURO: no focal deficits
Pertinent Results:
INITIAL LABS:
___ 09:30AM URINE HOURS-RANDOM
___ 09:30AM URINE UCG-POSITIVE
___ 09:30AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 09:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-150 KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-NEG
___ 09:30AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-5
___ 09:30AM URINE MUCOUS-RARE
___ 09:00AM URINE HOURS-RANDOM
___ 07:48AM GLUCOSE-149* UREA N-7 CREAT-0.5 SODIUM-135
POTASSIUM-3.0* CHLORIDE-102 TOTAL CO2-18* ANION GAP-18
___ 07:48AM estGFR-Using this
___ 07:48AM ___
___ 07:48AM WBC-12.6*# RBC-3.26* HGB-9.9* HCT-30.2*
MCV-93 MCH-30.4 MCHC-32.8 RDW-15.5 RDWSD-51.8*
___ 07:48AM NEUTS-86.2* LYMPHS-7.3* MONOS-5.6 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-10.82*# AbsLymp-0.92*
AbsMono-0.70 AbsEos-0.01* AbsBaso-0.01
___ 07:48AM PLT COUNT-158
___ 07:48AM ___ PTT-31.1 ___
___ 06:52AM LACTATE-1.4
US:
IMPRESSION:
1. Single, live intrauterine pregnancy. Gestational age by
ultrasound is 15 weeks and 3 days.
___ 6:40 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BETA STREPTOCOCCUS GROUP A. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP A
|
CEFTRIAXONE-----------<=0.12 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.12 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___, ___, ON
___
AT 20:15 .
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
ULTRASOUND ___
FINDINGS:
There is normal flow with respiratory variation in the bilateral
subclavian
vein.
The left internal jugular and axillary veins are patent, show
normal color
flow and compressibility.
The left brachial vein contains partially occlusive thrombus
throughout. The
left basilic and left cephalic vein demonstrate near occlusive
thrombus.
No fluid collection is identified.
IMPRESSION:
1. Partially occlusive deep vein thrombosis of the brachial
veins.
2. Near occlusive thrombus in the left basilic and left cephalic
vein,
superficial vessels.
3. No fluid collection identified.
___ ECHO:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. There is a probable
vegetation on the aortic valve. There is no aortic valve
stenosis. The mitral valve leaflets are structurally normal. No
mass or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION:
1) Possible aortic valve endocarditis (0.3 x 0.3 echo-dense
undulating structure likely attached to RCC). However, image
quality not adequate to be certain. Alternatively could be beam
widening artifiact.
2) Moderate pulmonary systolic arterial hypertension. LV
diastolic dysfunction could not be assess however the pulmonary
acceleration time appears short with possibly mid-systolic
notching suggesting tentatively that the PASP is elevated due to
elevated pulmonary vascular resistance (~ ___ ___.
DC LABS:
___ 06:50AM BLOOD WBC-6.6 RBC-2.77* Hgb-8.3* Hct-25.6*
MCV-92 MCH-30.0 MCHC-32.4 RDW-16.4* RDWSD-55.8* Plt ___
___ 06:50AM BLOOD Glucose-87 UreaN-4* Creat-0.5 Na-138
K-3.8 Cl-106 HCO3-21* AnGap-15
___ 06:50AM BLOOD ALT-88* AST-79* AlkPhos-103 TotBili-0.4
___ 06:50AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.6
___ 06:50AM BLOOD HBsAg-Negative HBcAb-Negative
___ 06:50AM BLOOD HIV Ab-Negative
Brief Hospital Course:
Ms. ___ is a ___ yo F with h/o opioid dependence and IVDU
with recent use, 15 weeks pregnant, who presents with L arm
redness and swelling c/w cellulitis in the setting of recent
injection drug use in the area, found to have GPC bloodstream
infection and LUE DVT.
Acute Group A Strep bloodstream infection:
LUE cellulitis with septic thrombophlebitis:
Possible acute aortic valve endocarditis
Source of BSI is LUE cellulitis caused by injection use in that
arm. US negative for abscess, though exam has a superficial
thrombophlebitis. The erythema has extended beyond the initial
boundaries, which could be due to her DVT. She is on
appropriate antibiotic therapy based on culture data so for now
will monitor. There is no sign for septic joint currently based
on exam. Her echo was reviewed and findings raised concern for
AV endocarditis/vegetation. She currently has no signs/symptoms
of CHF
- ID consulted: recommending CTX 2g IV q24, day 1 = ___. ___
weeks of treatment recommended
- SHE WILL REQUIRE TEE TO EVALUATE FOR AV ENDOCARDITIS.
- Monitor LUE for extension of erythema swelling. Could
consider re-imaging if continues to worsen.
- Pain control with PO and IV Morphine as below.
Hypotension:
Hypotension on the night of admission since stabilized. Likely
multifactorial to include clonidine use for withdrawal symptoms
the first nite, and infection with volume depletion. BP
improved with IVF. Normal lactate re-assuring.
- Clonidine stopped
- Monitor BP. DC BP 110s/80s
Acute LUE DVT:
Found on US. Likely provoked in setting of IVDU and cellulitis.
Her pregnancy state is also contributing. This is likely
contributing to her worsening LUE swelling
- Elevation, warm packs
- Lovenox 1mg/kg q12 startged: 50mg SC q12
- In discussion with ___, recommend continuing therapy for 6
months and/or 6 weeks after delivery of her baby
Opioid dependence with IVDU and withdrawal:
Has had periods of sobriety with medication maintenance:
suboxone and methadone in the past. She came in with mild-mod
withdrawal, but became hypotensive with clonidine. Given her
ongoing pain, she was initiated on PO and IV Morphine which
would alleviate her withdrawal symptoms. Please see below for
dosing. SW met with the patient and she expressed desire to
stop IV heroin.
Pregnancy:
US reviewed. ___ consulted here. Started prenatal vitamins.
HIV and HBV negative. GC/Chlamydia negative.
- RPR, rubella, varicella, PENDING ON TRANSFER
HCV:
HCV serology negative last year. This is reported and will need
confirmation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
MEDICATION LIST ON TRANSFER
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Moderate
2. CefTRIAXone 2 gm IV Q 24H
3. Enoxaparin Sodium 50 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
4. Morphine Sulfate ___ ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
5. Morphine Sulfate ___ mg IV Q4H:PRN BREAKTHROUGH PAIN
6. Nicotine Patch 21 mg TD DAILY
7. Prenatal Vitamins 1 TAB PO DAILY
8. Promethazine 25 mg PO Q6H:PRN nausea
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Group B strep acute bloodstream infection/sepsis
Left upper extremity cellulitis
Left upper extremity DVT with superficial thrombophlebitis
Opioid dependence/IV heroin use
Chronic HCV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for left arm pain, redness, and swelling and
diagnosed with infection (cellulitis), and blood clot in your
arm. Your infection also extended to your bloodstream which is
a serious infection. You will need a course of antibiotics to
be determined and close follow up with infectious disease.
You were also diagnosed with a blood clot and will need to
continue your Lovenox blood thinner treatment.
You will be transferred to ___ for ongoing
care of the issues above
Followup Instructions:
___
|
19801386-DS-17
| 19,801,386 | 28,249,572 |
DS
| 17 |
2176-07-25 00:00:00
|
2176-07-25 14:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
odynophagia
Major Surgical or Invasive Procedure:
upper endoscopy
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a long history of
___ disease on Humira (last administration ___
presenting with odynophagia, dysphagia, anorexia, vomiting,
sputum production for ___ weeks after an admission in ___
for reported Viral meningitis. Unclear if he received
antibiotics on that admission, but likely given that he
underwent LP and CSF culture. He reports intermittent
nausea/vomiting, dry heaving, mouth dryness, early satiety,
anorexia, weight loss, variable ostomy output, dark urine, poor
PO intake that has been worsening in the last ___ weeks. He
also vomits up recently ingested, undigested food and liquids.
He also reports some congestion and cough without wheeze, worse
in the morning. Denies abdominal pain, mostly central chest pain
during eating. He has had oral and esophageal thrush treated
with fluconazole in the past. He contacted his PCP/GI Dr.
___ recommended presenting to the ER for further
evaluation.
.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, cough, shortness of breath,
chest pain, abdominal pain, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria. All other ROS negative.
Past Medical History:
___ disease dx ___, s/p total colectomy ___, with
enterocutaneous fistula, perianal fistulas. Now treated with
remicaid: last infusion ___
-___ inflammation/absesses/ECF treated with
Remicaid/Antibiotics (ECF now closed), s/p parastomal hernia
repair w/ mesh ___
- s/p open ccy complicated by small bowel injury (primary
repair)
- s/p appendectomy in ___
- History of acute renal failure
-___ disease dx ___, s/p total colectomy ___, with
enterocutaneous fistula, perianal fistulas. Now treated with
remicaid: last infusion ___
-___ inflammation/absesses/ECF treated with
Remicaid/Antibiotics (ECF now closed), s/p parastomal hernia
repair w/ mesh ___
- s/p open ccy complicated by small bowel injury (primary
repair)
- s/p appendectomy in ___
- History of acute renal failure
- Chronic pain from a peripheral tendonopathy
Social History:
___
Family History:
Father - ___, Father's Sister with ___
Physical Exam:
VS: 97.3 116/48 71 19 100%RA
GENERAL: Well-appearing thin man in NAD, comfortable,
appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry, OP with
streaks of white but no clear thrush
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, multiple fistulas appearing to be healing,
wounds clean, dressed and dry. Ostomy im place.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
___ 11:05PM BLOOD WBC-12.9* RBC-4.30* Hgb-12.7* Hct-36.6*
MCV-85 MCH-29.6 MCHC-34.8 RDW-14.8 Plt ___
___ 05:18AM BLOOD WBC-7.7 RBC-3.40* Hgb-10.3* Hct-29.1*
MCV-86 MCH-30.3 MCHC-35.5* RDW-15.1 Plt ___
___ 11:05PM BLOOD Neuts-80.2* Lymphs-14.8* Monos-3.2
Eos-1.6 Baso-0.2
___ 11:05PM BLOOD Glucose-107* UreaN-46* Creat-3.8*# Na-134
K-3.7 Cl-104 HCO3-18* AnGap-16
___ 06:01AM BLOOD Glucose-75 UreaN-30* Creat-1.7* Na-140
K-3.4 Cl-108 HCO3-26 AnGap-9
___ 11:05PM BLOOD Albumin-4.1 Calcium-10.9* Phos-3.4#
Mg-1.2*
___ 06:01AM BLOOD Calcium-9.3 Phos-3.0 Mg-1.8
___ 06:25AM BLOOD 25VitD-25*
___ 1:30 pm TISSUE ESOPHOGUS.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD)
(Preliminary):
___ 11:27 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
CXR
IMPRESSION: No radiographic evidence for acute cardiopulmonary
process.
The study and the report were reviewed by the staff radiologist.
EGD
Findings: Esophagus:
Mucosa: Diffuse candidiasis was seen in the whole Esophagus.
Cold forceps biopsies were performed for histology at the upper
third of the esophagus. Cold forceps biopsies were performed for
histology at the middle third of the esophagus. Cold forceps
biopsies were performed for histology at the lower third of the
esophagus. Cold forceps biopsies were performed for histology at
the esophagus for CMV.
Stomach: Normal stomach.
Duodenum: Normal duodenum.
Impression: Esophageal candidiasis (biopsy, biopsy, biopsy,
biopsy)
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ with ___ on Humira and metronidazole, h/o candidiasis,
p/w odynophagia, dysphagia, and weight loss.
# Odynophagia/dysphagia: Symptoms and EGD consistent with
candidal esophagitis. Patient's symptoms improved quickly after
starting fluconazole. He was discharged on fluconazole for two
weeks with GI and ID follow up.
# Severe malnutrition/weight loss: TPN was initiated on ___.
He was discharged on TPN via PICC.
# ___ disease: last dose of Humira was on ___ (prior to
admission). Held metronidazole. Humira and metronidazole were
restarted on discharge.
# Acute kidney disease and Chronic Kidney Disease: Elevated Cr
on admission, UNa<10, suggesting volume depletion. Per patient,
his Creatinine always increases substantially when he is volume
depleted, and later improves. He said that he has been evaluated
by Nephrology in the past and told that his kidneys are normal.
His creatitine improved to his recent baseline 1.7 with
hydration.
# Hypercalcemia: Resolved with hydration.
# Chronic pain with anxiety: continued Methadone & oxycodone at
home dosing.
Medications on Admission:
adalimumab [Humira Pen] 40 mg/0.8 mL Q14 days, last dose
___
methadone 50mg PO QAM & Q1200; 40mg PO Q1700.
oxycodone 5 mg PO PRN pain
Flagyl 500 mg PO BID (longstanding med)
Prevacid 24Hr 20mg PO BID
Probiotic -- Unknown Strength
cyanocobalamin (vitamin B-12) 1,000 mcg/mL INJ Qmonth (last dose
weeks prior to admission)
Multivitamin PO Daily
Discharge Medications:
1. methadone 10 mg Tablet Sig: Five (5) Tablet PO QAM (once a
day (in the morning)).
2. methadone 10 mg Tablet Sig: Five (5) Tablet PO Q1200 ().
3. methadone 10 mg Tablet Sig: Four (4) Tablet PO Q1700 ().
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain, .
5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day
for 11 days.
Disp:*11 Tablet(s)* Refills:*0*
6. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) Injection once a month.
8. Probiotic Oral
9. multivitamin Oral
10. adalimumab 40 mg/0.8 mL Pen Injector Kit Sig: One (1)
Subcutaneous q14days.
11. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-___ esophagitis
-Weight loss and severe malnutrition
-___ disease
-Leukocytosis
-Acute renal failure
-Metabolic acidosis
-Hypercalcemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because of pain with swallowing. You underwent
an endoscopy, which showed esophagitis, likely due to ___
(YEAST), which you have had before after being on antibiotics.
You were started on an anti-fungal medication called
fluconazole, and you noticed immediate improvement in your pain.
You were started on TPN for nutrition. Initially the TPN will
cycle for 16 hours, but your infusion company will be able to
lower this slowly from 16 to 12 to 10 over the next week.
Medications changes:
You are being discharged with a prescription for fluconazole.
You will complete a 2 week course of this.
Followup Instructions:
___
|
19801386-DS-18
| 19,801,386 | 27,835,893 |
DS
| 18 |
2176-10-24 00:00:00
|
2176-10-26 15:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o M with ___ disease complicated by
enterocutaneous fistulas (on Humira) and traumatic MVC
ultimately requiring end ileostomy who presented with acute
onset abdominal pain. Per the patient he noted a new buldge in
his lower abdomen that was firm to the touch and extremely
painful. Also reports increased drainage from previous fistulas.
Reports no recent change in ostomy output. Denies N/V. Is being
weaned off TPN; currently gets TPN every other day. Reports
subjective fevers last night; no documented fevers. He took an
extra 500mg flagyl tablet and a few tablets of advil. He called
his gastroenterologist regarding the symptoms and was advised to
present to ED.
In the ED, initial VS: 98.5 95 132/89 18 100%. CT abdomen showed
enlarged size of previously known fistula at midline. No
abscesses were seen by study was limited by lack of iv contrast.
He was seen by colorectal surgery who recommended admission to
medicine for GI consult and continued antibiotics. He was given
vancomycin 1g IV, zosyn 4.5g IV, flagyl 500mg IV, morphine 5mg
IV, and methadone 40mg po (home dose) prior to transfer to
floor. Admission Vitals: Temp: 98 °F (36.7 °C), Pulse: 89, RR:
17, BP: 115/81, O2Sat: 99%, O2Flow: ra, Pain: 5.
Overnight the patient did well. Reports that pain is reasonably
well controlled. Afebrile.
Past Medical History:
- ___ disease dx ___ s/p enterocutaneous fistula, perianal
fistulas. remicaid: last infusion ___
- MVC in the late ___ after which he required multiple bowel
surgies and eventuall colectomy and ileostomy
-___ inflammation/absesses/ECF treated with
Remicaid/Antibiotics (ECF now closed), s/p parastomal hernia
repair w/ mesh ___
- s/p open ccy complicated by small bowel injury (primary
repair)
- s/p appendectomy in ___
- Chronic pain from a peripheral tendonopathy
Social History:
___
Family History:
Father - ___
Aunt - ___
Physical Exam:
On Admission:
VS - 98.6 ___ 18 97%RA
GENERAL - Thin male, no acute distress, pleasant and cooperative
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - Ostomy at LLQ, several enterocutaneous fistulas at
midline with serosanguinous/purulent drainage, exquisite
tenderness to palpation medial to ostomy site where there is a
new bulge, diffuse erythema along midline of abdomen to
suprapubic region
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact
On Discharge:
Vitals - 98.3 110/60 72 16 99%RA
GENERAL - Thin male, no acute distress, pleasant and cooperative
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - Overall appearance of fistulas and surrounding
cellulitis is greatly improved
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
On Admission:
___ 07:20PM BLOOD WBC-10.7 RBC-3.72* Hgb-11.3* Hct-33.8*
MCV-91 MCH-30.4 MCHC-33.5 RDW-12.9 Plt ___
___ 07:20PM BLOOD Neuts-70.3* ___ Monos-5.1 Eos-2.1
Baso-0.2
___ 07:20PM BLOOD ___ PTT-42.3* ___
___ 07:40AM BLOOD ESR-121*
___ 07:20PM BLOOD Glucose-99 UreaN-36* Creat-1.9* Na-136
K-4.6 Cl-102 HCO3-23 AnGap-16
___ 07:40AM BLOOD ALT-14 AST-19 LD(LDH)-89* AlkPhos-107
TotBili-0.1
___ 07:20PM BLOOD Calcium-9.4 Phos-4.3 Mg-2.0
___ 06:27AM BLOOD Ferritn-573*
___ 07:40AM BLOOD CRP-10.9*
On Discharge:
___ 08:00AM BLOOD WBC-9.0 RBC-3.89* Hgb-11.8* Hct-36.9*
MCV-95 MCH-30.3 MCHC-31.9 RDW-13.0 Plt ___
___ 08:00AM BLOOD Glucose-82 UreaN-21* Creat-2.0* Na-139
K-3.8 Cl-104 HCO3-24 AnGap-15
___ 08:00AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.8
Microbiology:
BACILLUS SPECIES; NOT ANTHRACIS
|
CLINDAMYCIN----------- 0.5 S
GENTAMICIN------------ <=2 S
LEVOFLOXACIN----------<=0.25 S
VANCOMYCIN------------ <=1 S
Studies:
CT Abdomen - IMPRESSION: 1. Previously on the MRI from ___ seen midline enterocutaneous fistulous tract (slightly
inferior and to the right relative to the ileostomy bag) has
slightly increased in diameter. There is no definite evidence of
abscess formation. However, evaluation is limited without
intravenous contrast. MRI/MRE with contrast could be considered
for further assessment if required. 2. Complex subcutaneous
fistulous formation in the right lower quadrant anterior
abdominal wall is similar compared to the MRI from ___,
allowing for the noncontrast CT technique. 3. Left lower
quadrant ileostomy appears intact without change or evidence of
abscess formation. 4. Unchanged small bowel containing right
lower quadrant anterior abdominal wall hernia and fat-containing
left mid epigastric paramedian abdominal wall hernia. 5.
Bilateral pulmonary nodules are new since ___ and
may be infectious or inflammatory in nature, particularly if the
patient is on TNF inhibitor treatment; follow-up CT is
recommended in 3 months after appropriate treatment for presumed
infection.
UE US - IMPRESSION: No drainable fluid collection at the right
elbow.
ECHO - The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Brief Hospital Course:
Mr. ___ is a ___ male with ___ disease
complicated by enterocutaneous fistulas s/p end ileostomy on
humira who presented with acute onset abdominal pain related to
a new entero-cutaneous fistula. Found to have bacillus
bacteremia.
# Abdominal pain/Fistula: The patient has a history of multiple
fistulas related to ___ disease. Presented to the ED in the
setting of abdominal pain and a CT scan revealed a progression
of known fistulas. The patient had last taken Humira on the day
prior to admission and takes it once every other week. He was
started on vancomycin and zosyn in the ED. Continued on flagyl.
Admitted to the medicine floor. On the floor the patient was
seen by GI and colorectal surgery. He was not a surgical
candidate. Placed on octreotide although this made him vomit and
the medication was stopped. Pain was controlled with home
methadone and oxycodone regimen. The patient's ___
pain and erythema greatly improved on antibiotics. As discussed
below, the ___ hospital course was complicated by a
bacillus bacteremia. Once this bacteremia cleared he was given
an additional 40mg of humira and his dosing was increased to
weekly for 1 month. A PICC line was placed for TPN and the
patient was instructed to remain on clears only. Flagyl was
discontinued but the patient remained on vancomycin (2
weeks)/zosyn (10 days). He was discharged with plans for close
outpatient follow-up.
# Bacteremia - The patient's blood culture drawn in the ED grew
___ bottles with bacillus species. The patient was maintained on
vancomycin and zosyn. Infectious disease was consulted who
recommended removal of the PICC line (suspected source), holding
of TPN and echocardiogram. The TTE was unremarkable and a TEE
was not pursued. Patient remained HD stable. Surveillance blood
cultures were taken and remained negative. A PICC line was
replaced. The patient was discharged with plans to complete a
total 2 week course of vancomycin and 10 days of zosyn.
# Chronic kidney disease: Baseline Cr 1.7 to 2.0. Cr remained
near baseline throughout the patient's stay. Nephrotoxins were
avoided where able.
# Candidal esophagitis: The patient has a history of candidal
infections when on broad spectrum antibiotics. In the hospital
he was placed on fluconazole prophylactically
# Transitional Issues:
- F/u CT scan for pulm nodule 3 months
- Continue humira weekly for 1 month then return to
every-other-week dosing
Medications on Admission:
1. methadone 10 mg Tablet Sig: Five (5) Tablet PO QAM (once a
day (in the morning)).
2. methadone 10 mg Tablet Sig: Five (5) Tablet PO Q1200 ().
3. methadone 10 mg Tablet Sig: Four (4) Tablet PO Q1700 ().
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain, .
5. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
6. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) Injection once a month.
7. Probiotic Oral
8. multivitamin Oral
9. adalimumab 40 mg/0.8 mL Pen Injector Kit Sig: One (1)
Subcutaneous q14days.
10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Medications:
1. methadone 10 mg Tablet Sig: Five (5) Tablet PO QAM (once a
day (in the morning)).
2. methadone 10 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
3. methadone 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
6. fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Please continue until 7 days after the completion of
your antibiotic course.
Disp:*30 Tablet(s)* Refills:*0*
7. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every ___
hours as needed for pain.
8. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) Injection
once a month.
10. Humira 40 mg/0.8 mL Kit Sig: One (1) Subcutaneous once a
week: Please continue once weekly for the next 4 weeks then
space dosing to every other week. .
11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 11 days.
Disp:*11 Doses* Refills:*0*
12. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 gram/100ml Piggyback Intravenous Q8H (every 8 hours)
for 6 days.
Disp:*18 Doses* Refills:*0*
13. Zofran 8 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
14. Outpatient Lab Work
Vancomycin Level: Please draw 30min before starting vancomycin
dose on ___. Please also check Chem 7, CBC with differential
with this blood draw.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bacillus cereus bacteremia
Enter-cutaneous fistula
___ disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at ___!
You were admitted due to an infection in your blood and a new
fistula from your Crohns. In the hospital you were treated with
high dose antibiotics and your condition greatly improved. You
were also given an extra dose of Humira and discharged on an
increased Humira regimen. You will be discharged with plans to
complete a course of antibiotics and follow-up closely with your
gastroenterologist.
See below for changes made to your home medication regimen:
1) Please CONTINUE Zosyn 4.5g intra-venously every ___ hours and
continue for 6 additional days to complete a ___) Please CONTINUE Vancomycin 1,000mg every 24 hours for 11
additional days to complete a ___) Please INCREASE your Humira dosing to 40mg weekly for the
next month then return to your every-other week schedule as
directed by your gastroenterologist.
4) Please START Zofran 8mg every 8 hours as needed for nausea
5) Please STOP Flagyl (metronidazole)
6) Please STOP your probiotic
See below for instructions regarding follow-up care:
Followup Instructions:
___
|
19801386-DS-23
| 19,801,386 | 25,838,528 |
DS
| 23 |
2181-05-26 00:00:00
|
2181-05-26 19:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___
Chief Complaint:
dehydration
Major Surgical or Invasive Procedure:
Central Tunneled Line Placement ___
History of Present Illness:
Patient is a ___ with a complex PMHx including ___ disease
short bowel syndrome secondary to mesh erosion from surgery for
MCV, CKD (Cr ___ in ___, s/p removal of Hickman and
abscess I&D in ___, chronic pain on methadone, recently
left AMA from ___ when admitted with renal failure (underwent
renal biopsy c/b hematoma), and Stenotrophomonas bacteremia, now
presenting with concern for persistent dehydration.
To briefly summary his ___ course, patient was admitted
___ with R sided flank pain, found to have acute on
chronic renal failure (Cr 8.2) and Stenotrophamonas bacteremia.
Patient was seen by renal while inpatient and underwent renal
biopsy. There was concern that his renal failure may have been
worsened by NSAID and/or anabolic steroid use. CT and renal
ultrasound showed2mm non-obstructing, right sided stone and
absence of hydronephrosis. Biopsy showed collapsing
glomerulopathy, IgA nephropathy and focal global and segmental
glomerulosclerosis. Biopsy showed combination of lesions that
were most likely related to three different and potentially
independent disease processes: collapsing glomerulopathy, IgA
nephropathy, and severe vascular sclerosis. He was started on
sevelamer during hospitalization.
In terms of his bacteremia, source was though to be his port,
given that he gives himself TPN and LR at home. ___ removed his
port on ___ and ID recommended that he remain line-free for at
least one 1 week. He was initially started on ceftazidime then
switched to levofloxacin based on sensitivities. TTE was
negative for vegetations. Per discharge summary, patient was
discharged on IV levofloxacin for 14 day course (last day
___. However, patient states that he was discharged without
any antibiotics.
He was also found to have anemia consistent with Fe deficiency.
U/S after renal biopsy showed stable hematoma. He received 2U
PRBCs on ___. H/H could not be reliably trended due to
patient's refusal to have blood draws.
He was also hypertensive to 200s requiring IV labetalol. He was
not discharged on anti-HTN.
Care was difficult has patient refused blood draws, frequently
left floor with abusive outbursts towards staff, delaying
treatment such as blood transufions. He left AMA on ___. He was
seen by psych, ID, renal, and colorectal surgery while admitted.
In the ED, initial vitals:
98.3 ___ 18 100% RA
- Labs notable for: WBC 16.8 (10.5 on discharge from ___), Hgb
9.6, Cr 10.0
- Patient given: 1L LR
Foley placement was attempted however patient was unable to
tolerate.
- Vitals prior to transfer:
98.2 100 130/90 20 100% RA
On arrival to the floor, pt reports that he feels like he was
getting dehydrated. he states that he feels "tired and
lethargic", exhausted. Just "feels like I'm dehydrated". No
confusion, n/v, CP, fevers/chills, abdominal pain. No cough. No
dysuria. He notes that the output from his ostomy is slightly
looser than usual. He does note a different taste in his mouth
than usual. He states that he left AMA because he was "losing
faith" in their care and was hearing different things from
different teams. He denies being discharged on any antibiotics.
He was not discharged with any IV access. He states that he got
dehydrated because he didn't have any access.
He has not noticed any changes in his urination. Has noticed
some decreased UOP, which he attributes to being dehydrated. He
was "heavy" in to Advil (15 per day), last before ___
hospitalization. He was using these in attempt to wean
methadone.
He states that he uses anabolic steroids, 200mg per week,
injected. He does this because of short gut syndrome - to help
retain fluids.
Past Medical History:
___ disease: Dx ___, s/p total colectomy w ileostomy ___
c/b enterocutaneous fistula, perianal fistulas
#short bowel syndrome
#HTN
#chronic pain - states due to nerve damage in extremities (from
flagyl use and h/o surgeries)
#h/o abscess
#vit B12 deficiency
#GERD
#s/p appendectomy
#s/p open cholecystectomy c/b small bowel injury
#hip replacement
#multiple abdominal surgeries
Social History:
___
Family History:
Father- ___
Brother- ?___ vs. IBS
Aunt and 2 cousins also w ___
Physical Exam:
==============
ADMISSION EXAM
==============
Vitals: 98.8 131/83 102 19 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Chest: dressing over prior port site c/d/I without any
surrounding erythema or skin changes.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding. Multiple scars from prior
abdominal surgeries. Ostomy in place.
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
===============
DISCHARGE EXAM
===============
Vitals: 97.9 163/83 73 18 98% RA
General: Alert, oriented, no acute distress, very muscular
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Heart: Regular rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Chest: central line in place without erythema or discharge.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding. Multiple scars from prior
abdominal surgeries. Ostomy in place.
Ext: Warm, well perfused, no cyanosis or edema.
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact.
Pertinent Results:
================
ADMISSION LABS
================
___ 08:50PM BLOOD WBC-16.8*# RBC-3.87* Hgb-9.6* Hct-30.9*
MCV-80*# MCH-24.8*# MCHC-31.1* RDW-21.0* RDWSD-60.4* Plt ___
___ 06:37AM BLOOD ___ PTT-30.4 ___
___ 08:50PM BLOOD Glucose-105* UreaN-57* Creat-10.0*#
Na-134 K-4.8 Cl-93* HCO3-18* AnGap-28*
___ 08:50PM BLOOD Albumin-2.9* Calcium-8.1* Phos-6.6*
Mg-1.6 Iron-37*
___ 08:50PM BLOOD calTIBC-352 Ferritn-110 TRF-271
================
DISCHARGE LABS
================
___ 07:19AM BLOOD WBC-6.7 RBC-2.99* Hgb-7.4* Hct-24.7*
MCV-83 MCH-24.7* MCHC-30.0* RDW-19.9* RDWSD-60.4* Plt ___
___ 10:46AM BLOOD ___ PTT-34.8 ___
___ 07:19AM BLOOD Glucose-95 UreaN-50* Creat-8.6* Na-143
K-3.7 Cl-109* HCO3-20* AnGap-18
___ 07:19AM BLOOD Calcium-8.6 Phos-4.9* Mg-2.0
==========
IMAGING
==========
- RUQ US ___:
1. No hydronephrosis seen in either kidney.
2. Two small simple left renal cysts.
3. Perinephric fluid collection around the right kidney, with
internal echogenicity, consistent with known history of hematoma
after recent kidney biopsy at outside hospital, as detailed in
OMR.
- UPPER EXTREMITY VEIN MAPPING ___:
On the right, the cephalic vein measures 0.1-0.2 cm. The
basilic vein measures 0.1-0.2 cm. Of note, the proximal aspect
of the right cephalic vein is very thick-walled likely due to
prior thrombus. The brachial artery measures 0.___rtery measures 0.2 cm.
On the left, cephalic vein ranges from 0.1-0.3 cm. The
distal-most aspect of the cephalic vein on the left appears to
be clotted. The the basilic vein measures 0.1-0.2 cm. The
brachial artery measures 0.___rtery measures 0.3
cm.
- TUNNELED LINE PLACEMENT ___:
Successful placement of a double-lumen ___ tunneled line via
the right internal jugular venous approach. The tip of the
catheter terminates in the right atrium. The catheter is ready
for use.
========
MICRO
========
___: NO GROWTH TO DATE
Brief Hospital Course:
___ year old male with PMHx of short gut syndrome on chronic TPN,
___ disease, CKD (unclear etiology), recent hospitalization
for renal failure and Stenotrophamonas bacteremia, now
presenting with fatigue and concern for dehydration, found to
have renal failure and leukocytosis.
==============
ACUTE ISSUES
==============
# Acute renal failure on CKD: Patient with known CKD of unclear
etiology. Review of OMR and ___ hospital show that he has had
multiple episodes of ___. He was recently admitted to ___ where
he underwent a renal biopsy which revealed multiple pathologies
(collapsing glomerulopathy, IgA nephropathy, and severe vascular
sclerosis). In terms of collapsing glomerulopathy, can be
associated with infections such as HIV, however his HIV ab is
negative. Can also be related to anabolic steroids, which he
uses. Vascular sclerosis can be secondary to HTN, however path
report states that primary causes are more likely. Primary forms
of vascular/endotherlial injury include pro-coagulant state,
autoimmune d/o, drug-induced, paraproteinemia. This acute
episode is likely related to recent dehydration and lack of TPN
(as his central line was removed during OSH hospitalization due
to bacteremia), as his Cr started to improve with aggressive
hydration and resumption of TPN.
# HTN: Patient without a diagnosis of HTN, but with BPs ranging
from 130s-170s/60s-90s. He was started on amlodipine while in
the hospital which was uptitrated to 10 mg prior to discharge.
# Recent Stenotrophamonas bacteremia: Patient presented with WBC
16.8 from ~10.5 at discharge from ___. No fevers or no
localizing symptoms. His central line, through which he was
receiving TPN for short gut syndrome) was removed during his ___
hospitalization. He was not discharged on antibiotics (per DC
summary, were planning on discharging on levofloxacin 500mg
Iq48h but patient left AMA and did not receive antibiotic
script). He was restarted on levofloxacin PO renally dosed 250
mg q48h to complete previously prescribed course. Leukocytosis
resolved prior to discharge and blood cultures without any
growth x 4 days.
# Anemia: Stable. Patient with a history of anemia. Iron: 37,
Ferritin: 110, likely a combination of iron deficiency and
chronic disease/renal failure. Trended down slightly with
administration of IVF (likely a component of dilution) and he
remained stable while in the hospital.
# Short gut syndrome: Patient is chronically on TPN, however has
not been on this due to lack of access (port dc'ed due to
bacteremia as above). He underwent vein mapping to determine
which side to replace his TPN line and which side to save for
potential dialysis in the future. He was restarted on TPN prior
to discharge through newly placed tunneled line.
==============
CHRONIC ISSUES
==============
# Chronic pain: Continued home methadone and oxycodone.
====================
TRANSITIONAL ISSUES
====================
* Renal
[] repeat BMP ___ sent to PCP
[] Patient needs outpatient renal follow up
[] Patient needs outpatient renal transplant follow up in the
event he will require renal transplant in the future
* HTN
[] f/u BPs, Started on amlodipine for HTN
* Anemia:
[] repeat CBC ___ sent to PCP
*ID
[] bcx final result pending on discharge
*OTHER:
# CODE STATUS: Full Code
# CONTACT: roommate/girlfriend ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. sevelamer CARBONATE 800 mg PO TID W/MEALS
2. Cyanocobalamin 1000 mcg IM/SC MONTHLY
3. Methadone 50 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
6. TPN Electrolytes (sodium-pot-mag-Ca-chlor-acetat) unknown
injection 6X/WEEK
7. LOPERamide 2 mg PO QID
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Levofloxacin 250 mg PO Q48H
RX *levofloxacin 250 mg 1 tablet(s) by mouth q48 hours Disp #*2
Tablet Refills:*0
3. Cyanocobalamin 1000 mcg IM/SC MONTHLY
4. LOPERamide 2 mg PO QID
5. Methadone 50 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9.Outpatient Lab Work
Lab: BMP, CBC
ICD10: N17.9
Send to: Dr. ___
___ number: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Discharge Worksheet-Discharge ___
___., MD on ___ @ 1245
Primary Diagnosis:
Acute Kidney Injury
Secondary Diagnosis:
Chronic Kidney Disease
Short Gut Syndrome
___ Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were hospitalized because you were feeling dehydrated. While
you were here, you were found to have severe kidney injury. We
believe this kidney injury is related to chronic kidney problems
which were exacerbated by dehydration. We recommend that you
stop taking steroids and testosterone because these can worsen
your kidney injury and lead to dialysis.
While you were in the hospital, you had a central line placed
and were restarted on TPN. Your kidney function started to
improve with intravenous fluids and TPN.
While you were here, you were also restarted on antibiotics
which you should continue to take for 5 more days.
Please follow up with the kidney doctors and your ___ PCP.
It was a pleasure meeting and taking care of you while you were
in the hospital.
- Your ___ Team
Followup Instructions:
___
|
19801386-DS-24
| 19,801,386 | 26,091,160 |
DS
| 24 |
2181-06-18 00:00:00
|
2181-06-18 16:49:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with HTN, ___ disease s/p
colectomy now with short gut syndrome on chronic TPN, CKD, with
recent admissions for acute on chronic kidney failure and
Stenotrophamonas bacteremia, who presents with increase in Cr.
To briefly summarize his course, pt was admitted to ___
___ with R sided flank pain, found to have acute on
chronic renal failure (Cr 8.2) and Stenotrophamonas bacteremia.
Renal failure likely precipitated by combination of NSAID and
steroid abuse. Renal bx showed 3 different and potentially
independent disease processes: collapsing glomerulopathy, IgA
nephropathy, and severe vascular sclerosis. Bacteremia was
thought ___ to port which pt uses to give himself TPN and LR at
home. Port was removed and pt was given IV abx (initially
ceftazidime, then levofloxacin intended for 14 day course) but
left AMA on ___.
Pt next admitted to BI ___ with c/f persistent
dehydration and acute on chronic renal failure thought to be ___
to lack of dehydration and lack of TPN as central line was not
replaced. Cr improved with aggressive hydration and resumption
of TPN. Pt was restarted on PO levofloxacin to complete prior
intended course for Stenotrophamonas bacteremia.
Pt has since been home and continuing on his TPN therapy. He
denies any redness around the catheter site or difficulty with
feeds. Notes a recent change in feeding regimen after changing
doctors at the ___. Used to be on 3000 mg total (60 dextrose,
125 AA, 30 lipids every other day), now changed to 2500 mg total
(60 dextrose, 105 AA, ___ lipids every other day). Over the
last 48 hours pt noticed feeling of warmth, chills, and a
"buzzing in his head". Also noticed tremulousness in hands. Two
days prior to admission he was visited by staff from ___
___, who deliver TPN and obtain labs from him weekly.
The next day they informed him that his labs were abnormal (in
particular Cr elevated) and advised that he come to the ED. On
review of systems pt has also had "chest congestion worse on the
R" for ___ days and a cough for the last week productive of
white sputum. He has not noticed any change in his urine output.
Has not had any chest pain, shortness of breath, or headache.
In the ED, initial VS were 98.6 94 166/92 16 97% RA
Exam notable for no redness at central catheter insertion site
or around colostomy bag.
Labs/imaging showed
- CBC with Hgb/HCT 9.4/31.1
- BMP with Cr of 10.0 (pt with Cr 1.6-1.7 in ___, no other
recordings until ___ when Cr has been 8.6-10), BUN 90.0, K
2.79, HCO3 50, Cl 80.
- Divalents with Phos 4.6
- VBG with pH 7.54, pCO2 68, HCO3 60.
- U/A with >600 protein, small blood, few bacteria
- CXR showed no acute cardiopulmonary process.
Received IV potassium repletion and 1 L NS.
Transfer VS were 98.3 ___ 98% RA
Decision was made to admit to medicine for further management.
On arrival to the floor, patient is in no acute distress. He
confirms the above history.
Past Medical History:
-___ disease: Dx ___, s/p total colectomy w ileostomy ___
c/b enterocutaneous fistula, perianal fistulas
-short bowel syndrome
-HTN
-steroid use
-chronic pain - states due to nerve damage in extremities (from
flagyl use and h/o surgeries)
-h/o abscess
-vit B12 deficiency
-GERD
-s/p appendectomy
-s/p open cholecystectomy c/b small bowel injury
-hip replacement
-multiple abdominal surgeries
Social History:
___
Family History:
Father- ___
Brother- ?___ vs. IBS
Aunt and 2 cousins also w ___
Physical Exam:
=============
ADMISSION
=============
VS: 98.3 ___ 98% RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, dentures in place
NECK: nontender supple neck
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes/rales/rhonchi, no dullness to
percussion, breathing comfortably without use of accessory
muscles ABDOMEN: ostomy bag in LLQ dry and intact,
nondistended, nontender in all quadrants, no rebound/guarding,
no hepatosplenomegaly
EXTREMITIES: no cyanosis or edema, moving all 4 extremities with
purpose, clubbing
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII grossly intact, significant asterixis in b/l UE
and ___
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
=============
DISCHARGE
=============
VS: 98.4 157/78 77 20 98% RA
GENERAL: walking in the halls
HEENT: anicteric sclera, pink conjunctiva, moist mucous
membranes, dentures in place, round face
NECK: nontender supple neck, central line in place without
discharge or surrounding erythema
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes/rales/rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: ostomy site in LLQ c/d/i, nondistended, nontender in
all quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis or edema, moving all 4 extremities with
purpose, no edema
PULSES: 2+ DP pulses bilaterally
NEURO: no asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
===============
ADMISSION LABS
===============
___ 03:00PM BLOOD WBC-7.1 RBC-3.60* Hgb-9.4*# Hct-31.1*#
MCV-86 MCH-26.1 MCHC-30.2* RDW-17.9* RDWSD-56.8* Plt ___
___ 03:00PM BLOOD Neuts-77.2* Lymphs-13.3* Monos-8.5
Eos-0.4* Baso-0.3 Im ___ AbsNeut-5.47 AbsLymp-0.94*
AbsMono-0.60 AbsEos-0.03* AbsBaso-0.02
___ 03:00PM BLOOD Glucose-125* UreaN-90* Creat-10.0*#
Na-141 K-2.9* Cl-80* HCO3-50* AnGap-14
___ 03:00PM BLOOD ALT-18 AST-42* AlkPhos-66 TotBili-0.5
___ 03:00PM BLOOD Albumin-2.8* Calcium-9.1 Phos-4.6* Mg-2.0
___ 03:00PM BLOOD Albumin-2.8* Calcium-9.1 Phos-4.6* Mg-2.0
___ 05:40PM BLOOD ___ pO2-42* pCO2-68* pH-7.54*
calTCO2-60* Base XS-29
___ 05:40PM BLOOD freeCa-1.02*
============
IMAGING
============
-___ CXR: No acute cardiopulmonary process.
-___ Renal US:
1. Minimal prominence of the left renal collecting system is
noted without hydronephrosis.
2. Unchanged right perinephric fluid collection consistent with
known
perinephric hematoma following outside hospital kidney biopsy.
================
DISCHARGE LABS
================
___ 05:00AM BLOOD WBC-9.1 RBC-2.87* Hgb-7.5* Hct-25.5*
MCV-89 MCH-26.1 MCHC-29.4* RDW-16.5* RDWSD-53.5* Plt ___
___ 05:00AM BLOOD Glucose-68* UreaN-74* Creat-11.3* Na-138
K-5.1 Cl-100 HCO3-21* AnGap-22*
___ 05:00AM BLOOD Calcium-11.3* Phos-3.0 Mg-2.6
___ 07:41AM BLOOD Type-MIX Temp-36.9 pO2-155* pCO2-48*
pH-7.35 calTCO2-28 Base XS-0 Intubat-NOT INTUBA Comment-GREEN
TOP
___ 07:41AM BLOOD freeCa-1.45*
Brief Hospital Course:
Mr. ___ is a ___ man with HTN, ___ disease s/p
colectomy now with short gut syndrome on chronic TPN, CKD, with
recent admissions for acute on chronic kidney failure and
Stenotrophamonas bacteremia (completed course of antibiotics),
who is now presenting with metabolic alkalosis.
=============
ACUTE ISSUES
=============
# Metabolic alkalosis with compensation from respiratory
acidosis: Admission labs significant for HCO3 50 and pH 7.54
with PCO2 68 representing respiratory compensation. Metabolic
alkalosis is likely related to exogenous bicarb administration
from the large amount of acetate that patient was receiving in
his TPN. Could had also had some degree of contraction
alkalosis, although no increase in stool output from ostomy.
Resolved completely with discontinuation of acetate from TPN and
fluid resuscitation. Due to patient's baseline acidemia from
renal failure, he was restarted on acetate in his TPN but at a
much lower dose (90 meq per bag).
# Hypokalemia/Hypocalcemia: Metabolic derangements secondary to
metabolic alkalosis (see above). Improved with supplementation
and resolution of metabolic alkalosis.
================
CHRONIC ISSUES
================
# Anemia: Available records document slow drop in Hgb since ___. Likely a combination of iron deficiency and chronic
disease/renal failure.
# Chronic renal failure: Patient with known CKD with renal
biopsy showing multiple pathologies - collapsing glomerulopathy,
IgA nephropathy, and severe vascular sclerosis. Previous
baseline ___, most recently ___. No indication for urgent
hemodialysis initiation at this time and will follow up with
renal as an outpatient.
# Short gut syndrome: Patient with central line for chronic TPN.
Patient arranged to see Dr. ___ as an outpatient who will
manage his TPN.
====================
TRANSITIONAL ISSUES
====================
[] Patient will have labs checked on ___ and ___, then
weekly, results to be sent to Dr. ___ be managing his
TPN), PCP, and ___ doctor
[] Patient should follow up with Dr. ___ will manage his
TPN going forward
[] Patient should follow up with nephrology as an outpatient
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. LOPERamide 2 mg PO QID
2. Methadone 50 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
5. sevelamer CARBONATE 800 mg PO TID W/MEALS
6. amLODIPine 10 mg PO DAILY
7. Cyanocobalamin 1000 mcg IM/SC MONTHLY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Cyanocobalamin 1000 mcg IM/SC MONTHLY
3. LOPERamide 2 mg PO QID
4. Methadone 50 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. OxyCODONE (Immediate Release) 30 mg PO Q6H:PRN Pain -
Moderate
7.Outpatient Lab Work
Lab: Chem-10
ICD-10: N18.9
Send results to:
Dr. ___: ___ AND
Dr. ___ ___ AND
Dr. ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Metabolic Alkalosis
Compensatory Respiratory Acidosis
Hypokalemia
Hypocalcemia
Secondary Diagnosis:
Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to the hospital because you were feeling
tired. You were found to have many abnormalities in your blood
work which can cause fatigue and weakness. We believe that these
abnormalities are related to an ingredient in your TPN. We
changed the TPN formulation and your blood work and symptoms
improved dramatically.
Please get your labs checked on ___ and ___, then
weekly. The results will be sent to your primary care doctor and
your kidney doctor.
Please follow up at the appointment scheduled with your primary
care provider (see below). You will hear from the kidney doctors
about ___ follow up appointment within the next ___ days. You will
also hear from Dr. ___ office to schedule an appointment,
this is a surgeon who will help manage your TPN after you go
home.
It was a pleasure taking care of you while you were in the
hospital.
-Your ___ Team
Followup Instructions:
___
|
19801515-DS-18
| 19,801,515 | 26,150,573 |
DS
| 18 |
2151-10-14 00:00:00
|
2151-10-15 21:48:00
|
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:
VATS, pericardial window ___
History of Present Illness:
___ yo M with no PMHx who presents as transfer from ___
with
SOB found to have a pericardial effusion. He complains of 5 days
of worsening SOB and chest tightness. He also endorses
lightheadedness, generalized malaise, poor PO intake, subjective
fevers and fatigue over the same time course. He denies
preceding
viral illness. He does endorse a new rash on both forearms.
On arrival to ___, he was noted to have RUE swelling. CTA
Chest was done showing no evidence of PE but did show a
pericardial effusion so he was transferred to ___ for further
management.
In the ED,
- Initial vitals were: afebrile, HR 106, BP 128/80, RR 18, 97%
RA
- Exam notable for: right upper extremity with edema. 2+ radial
pulse. Pulsus 12.
- Labs notable for:
At ___: ___ 18.3, K 3.3, Cr 1.4, D-Dimer 704, trop<0.01
At ___ 16.3, k 3.7, Cr 1.3, INR 1.4, Lactate 1.3
- Studies notable for: bedside TTE with RV diastolic collapse
with increased transmitral respiratory inflow variation
consistent with likely early tamponade physiology. However, TTE
limited by poor subcostal views making definitive echo diagnosis
of tamponade difficult. At most at 1cm anteriorly.
- Patient was given: 500 cc IVF bolus
On arrival to the CCU, patient confirms the above history.
Past Medical History:
None
Social History:
___
Family History:
Father with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: Reviewed in MetaVision
GENERAL: Well developed, well nourished in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: Normocephalic, atraumatic. Sclera anicteric. PERRL. EOMI.
NECK: Supple. No JVD
CARDIAC: Normal rate, regular rhythm. No murmurs, rubs, or
gallops. No friction rub.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No adventitious breath
sounds.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: Diffuse macular rash on bilateral forearms. No pruritic.
PULSES: Distal pulses palpable and symmetric.
NEURO: CNII-XII grossly intact. No focal deficits. Moving all 4
extremities with purpose.
Pertinent Results:
ADMISSION LABS
===============
___ 04:30AM BLOOD WBC-16.3* RBC-4.69 Hgb-14.4 Hct-41.6
MCV-89 MCH-30.7 MCHC-34.6 RDW-12.8 RDWSD-41.5 Plt ___
___ 04:30AM BLOOD Neuts-59 Lymphs-12* Monos-1* Eos-28*
Baso-0 AbsNeut-9.62* AbsLymp-1.96 AbsMono-0.16* AbsEos-4.56*
AbsBaso-0.00*
___ 04:30AM BLOOD Polychr-1+*
___ 04:30AM BLOOD ___ PTT-32.7 ___
___ 04:30AM BLOOD Plt Smr-NORMAL Plt ___
___ 04:30AM BLOOD Glucose-106* UreaN-10 Creat-1.3* Na-136
K-3.7 Cl-102 HCO3-20* AnGap-14
___ 04:30AM BLOOD ALT-14 AST-11 AlkPhos-116 TotBili-0.5
___ 01:41PM BLOOD Calcium-8.8 Phos-2.2* Mg-1.9
___ 10:29AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 04:30AM BLOOD ___ CRP-47.9*
___ 01:41PM BLOOD CMV IgG-POS* EBV IgG-POS* EBNA-POS* EBV
IgM-NEG EBVI-Results in
___ 10:29AM BLOOD HIV Ab-NEG
___ 10:29AM BLOOD HCV Ab-NEG
___ 04:46AM BLOOD Lactate-1.3
IMAGING
=========
UPPER EXTREMITY VENOUS DOPPLERS ___
No evidence of deep vein thrombosis in the bilateral upper
extremity veins
TTE ___ #1
CONCLUSION:
The left atrium is normal in size. The right atrial pressure
could not be estimated. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
and global left ventricular systolic function. The visually
estimated left ventricular ejection fraction is 65%. Left
ventricular cardiac index is normal (>2.5 L/min/m2). There is no
resting left ventricular outflow tract gradient. No ventricular
septal defect is seen. Normal right ventricular cavity size with
normal free wall motion. There is a normal descending aorta
diameter. The aortic valve leaflets (3) appear structurally
normal. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve
leaflets appear structurally normal with no mitral valve
prolapse. There is trivial mitral regurgitation. The pulmonic
valve leaflets are normal. There is physiologic tricuspid
regurgitation. The pulmonary
artery systolic pressure could not be estimated. There is a
large circumferential pericardial effusion. There is increased
respiratory variation in transmitral inflow c/w increased
pericardial pressure/
tamponade physiology. There is early right ventricular diastolic
collapse consistent with early tamponade physiology.
IMPRESSION: Focused study. Large (max 2.3 cm, located adjacent
to the mid-anterolateral wall) circumferential pericardial
effusion with increased respiratory variation in transmitral
inflow and right ventricular outflow tract invagination in early
diastole consistent with increased pericardial
pressure/tamponade physiology. Mild symmetric left ventricular
hypertrophy with normal cavity size and biventricular systolic
function.
TTE ___ #2
CONCLUSION:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Left ventricular cardiac index is normal (>2.5 L/min/m2). There
is no resting left ventricular outflow tract gradient. No
ventricular septal defect is seen. Normal right ventricular
cavity size with normal free wall motion. The
aortic sinus diameter is normal for gender with normal ascending
aorta diameter for gender. There is a normal descending aorta
diameter. The aortic valve leaflets (3) appear structurally
normal. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets appear structurally normal. There is
trivial mitral regurgitation. The pulmonic valve leaflets are
normal. The tricuspid valve
leaflets appear structurally normal. There is trivial tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a moderate to large circumferential
pericardial effusion.
There is increased respiratory variation in
transmitral/transtricuspid inflow but no right atrial/right
ventricular diastolic collapse.
IMPRESSION: Moderate to large pericardial effusion as described
above with increased respiratory variation in transtricuspid
inflow but no overt right atrial or right ventricular diastolic
collapse.
Compared with the prior TTE (images reviewed) of ___ ,
subcostal views do not demonstrate clear evidence of right
ventricular diastolic collapse (previously not well seen).
TTE ___
The estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. Overall left ventricular systolic function is normal. The
visually estimated
left ventricular ejection fraction is >=60%. Normal right
ventricular cavity size with normal free wall motion. The aortic
valve leaflets (?#) appear structurally normal. The mitral valve
leaflets appear structurally normal. There is a moderate
circumferential pericardial effusion, most prominent inferor and
lateral to the left ventricle with minimal (<1 cm) anterior to
the right ventricle and right atrium. There is
no respiratory eccentuation of of transmitral flow. There is
right ventricular diastolic collapse c/w increased pericardial
pressure/tamponade physiology.
IMPRESSION: Moderate circumferential pericardial effusion most
prominent inferior and lateral to the left ventricle with
echocardiographic evidence for increased pericardial
pressure/tamponade physiology. Mild symmetric left ventricular
hypertrophy with normal biventricular cavity sizes
and global biventricular systolic function.
Compared with the prior TTE (images reviewed) of ___, the
findings are similar.
TTE ___
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is suboptimal image
quality to assess regional left ventricular function. Overall
left ventricular systolic function is normal. The visually
estimated left ventricular ejection fraction is >=55%. Normal
right ventricular cavity size with normal free wall motion. The
aortic sinus is mildly dilated. There is a normal descending
aorta diameter. The aortic valve is not well seen. The mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. The pulmonic valve leaflets are normal. The tricuspid
valve leaflets appear structurally
normal. There is trivial tricuspid regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: No pericardial effusion present. Mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function. Normal estimated pulmonary
artery systolic pressure.
Compared with the prior TTE ___ , there has been interval
resolution of pericardial tamponade.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 5:57 ___
FINDINGS:
LOWER CHEST: There is a small left pleural effusion with
overlying compressive
atelectasis. There is trace right basilar atelectasis. The
previously seen
large pericardial effusion is largerly resolved.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is a 1.4 cm cyst in the lower pole of the left kidney.
There is no
evidence of hydronephrosis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder is decompressed. The distal ureters
are
unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. No evidence of mass or lymphadenopathy in the abdomen and
pelvis.
2. Small left pleural effusion and bibasilar atelectasis.
DUPLEX DOP ABD/PEL LIMITED Study Date of ___ 1:30 ___
FINDINGS:
Liver: The visualized hepatic parenchyma is within normal
limits.
Doppler evaluation:
Right, middle and left hepatic veins are patent, with
appropriate waveforms.
Visualized IVC is patent with normal Doppler waveform.
IMPRESSION:
Patent hepatic veins.
Pathology
===========
#####################Pathology Examination
Name ___ Age Sex Pathology # ___ MRN#
___ ___ ___ Male ___
Report to: ___. ___
___ by: ___. ___
SPECIMEN SUBMITTED: Immunophenotyping: peripheral blood
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
Previous biopsies: ___ PERICARDIUM, BIOPSY OR TISSUE
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, Lambda,
___ ___ antigens 2, 3, 4, 5, 7, 8, 10, 11c, 13, 14, 16,
19, 20, 23, 33, 34, 38, 45, 56, 64 and 117.
RESULTS:
10-color analysis with CD45 vs. side-scatter gating is used to
evaluate for leukemia/lymphoma.
Approximately 90.5% of total acquired events are evaluable
non-debris events.
The viability of the analyzed non-debris events, done by 7-AAD
is 90.0%.
CD45-bright, low side-scatter gated lymphocytes comprise 6.1% of
total analyzed events.
B cells comprise 5.5% of lymphoid gated events, are polyclonal
and do not co-express aberrant antigens.
T cells comprise 79.0% of lymphoid gated events and express
mature lineage antigens (CD3, CD5, CD2 and CD7).
A minor subset of T cells (mix of CD4 positive and CD8 positive
T cells) shows dim/variable loss of CD7 (non-specific finding).
T cells have a CD4:CD8 ratio of 1.3 (usual range in blood
0.7-3.0).
CD56 positive, CD3 negative natural killer cells represent 12.8%
of gated lymphocytes and are normal in number (usual range in
blood ___. They co-express CD2, CD7 and CD8 (subset).
No abnormal events are identified in the blast gate.
INTERPRETATION:
Non-specific T cell predominant lymphoid profile; diagnostic
immunophenotypic features of involvement by leukemia/lymphoma
are not seen in this specimen. Correlation with clinical and
other ancillary findings is recommended. Flow cytometry
immunophenotyping may not detect all abnormal populations due to
topography, sampling or artifacts of sample preparation.
Note: The Technical component of this test was completed at
___, ___ / ___ # ___. The
Professional component of this test was completed at ___
___, Pathology, ___, ___. This test was
developed and its performance characteristics determined by
NeoGenomics Laboratories. It has not been cleared or approved by
the ___. Food and Drug Administration. The FDA has determined
that such clearance or approval is not necessary. This test is
used for clinical purposes. It should not be regarded as
investigational or for research. This laboratory is certified
under the Clinical Laboratory Improvement Amendments of ___
(___) as qualified to perform high complexity clinical testing.
#########################CYTOGENETICS REPORT - Revised
Clinical: eosinophilia
___: peripheral blood
CYTOGENETIC DIAGNOSIS: Cell culture for chromosome analysis in
progress. See FISH results
below.
FISH: NEGATIVE for REARRANGEMENT of PDGFRA, PDGFRB and FGFR1. No
evidence of
interphase peripheral blood cells with rearrangement of the
PDGFRA, PDGFRB and FGFR1 genes.
Uncultured cells for fluorescence in situ hybridization (FISH)
analysis with the ___ Molecular 4q12 tri-color
rearrangement break apart probe set: SpectrumGreen directly
labeled probe for the ___ gene centromeric to the 5'
end of the FIP1L1 gene on ___, SpectrumOrange directly labeled
probe for the LNX gene telomeric to the 3' end of
FIP1L1, and SpectrumAqua directly labeled probe for the KIT gene
and the telomeric 3' end of the PDGFRA gene. This
probe combination detects the cytogenetically cryptic
FIP1LI/PDGFRA gene rearrangement associated with chronic
eosinophilic leukemia, as well as other rearrangements of
PDGFRA.
FINDINGS: A total of 200 interphase nuclei were examined with
the 4q12 tri-color break apart probe set and
fluorescence microscopy. 200 cells (100%) had the normal 2
green-red-aqua fusion signals. 0 cells (0%) had 1
green-red-aqua fusion signal and 1 green-aqua signal. 0 cells
(0%) had 1 green-red-aqua fusion signal, 1 green-red
___ ___
Department of Pathology Patient: ___
Page 2 of 3
signal and 1 aqua signal. Normal cut-off values for this probe
set include: 91% for the normal 2 green-red-aqua fusion
signal pattern, 1% for a 1 green-red-aqua fusion and 1
green-aqua fusion pattern, and 7% for a 1 green-red-aqua fusion,
1 green-red fusion and 1 aqua signal pattern. nuc
ish(___,LNX,3'PDGFRA/KIT)x2[200]
A second hybridization was performed with the ___ PDGFRB
dual color break apart probe set: ___
(red) directly labeled probe for a DNA sequence centromeric to
the 3' end of the PDGFRB gene on ___ and
___ (green) directly labeled probe for a DNA
sequence telomeric to the 5' end of the PDGFRB gene. This
probe combination detects rearrangements of the PDGFRB gene
which can be seen in some myeloproliferative
disorders, often with eosinophilia.
FINDINGS: A total of 200 interphase nuclei were examined with
the PDGFRB break apart probe set and fluorescence
microscopy. 200 cells (100%) had ___ yellow (red-green fusion)
signals. 0 cells (0%) had ___ yellow (red-green fusion)
signal, 1 red signal and 1 green signal. Normal cut-off values
for this probe set include: 92% for a normal ___ yellow
(red-green fusion) signal pattern and 2.5% for a ___ yellow
(red-green fusion), 1 red and 1 green signal pattern.
nuc ish(PDGFRBx2)[200]
A third hybridization was performed with the Cytocell FGFR1
tri-color break apart probe set: Red fluorophore directly
labeled probe for a DNA sequence centromeric to the 3' end of
the FGFR1 gene on 8p11.2, green fluorophore directly
labeled probe for a DNA sequence telomeric to the 5' end of the
FGFR1 gene, and blue fluorophore directly labeled
probe for the centromeric region of chromosome 8. This probe
combination detects rearrangements of the FGFR1 gene
associated with the 8p11 myeloproliferative syndrome and some
lymphoid neoplasms. Amplification of FGFR1, seen in
some solid tumors, can also be detected.
FINDINGS: A total of 200 interphase nuclei were examined with
the FGFR1 tri-color break apart probe set and
fluorescence microscopy. 200 cells (100%) had the normal 2
red-green fusion signals and 2 aqua signals. 0 cells (0%)
had 1 green-red fusion signal, 1 red signal, 1 green signal and
2 aqua signals. Normal cut-off values for this probe set
include: 95% for the normal 2 red-green fusion and 2 aqua signal
pattern and 2% for a 1 red-green, 1 red, 1 green and 2
aqua pattern. nuc ish(FGFR1,8cen)x2[200]
This test was developed and its performance characteristics
determined by ___.
It has not been cleared or
approved by the ___ Food and Drug Administration (FDA). The FDA
does not require this test to go through premarket FDA review.
This test is used for
clinical purposes. It should not be regarded as investigational
or for research. This laboratory is certified under the Clinical
Laboratory Improvement
Amendments (CLIA) as qualified to perform high complexity
clinical laboratory testing.
2) FISH: NEGATIVE for JAK2 REARRANGEMENT. No evidence of
interphase peripheral blood
cells with rearrangement of the JAK2 gene. This FISH assay does
not test for the JAK2 V617F
mutation that requires molecular analysis for detection.
Uncultured cells for fluorescence in situ hybridization (FISH)
analysis with the ___ JAK2 dual color break apart
probe set: PlatinumBright___ (red) directly labeled probe for a
DNA sequence telomeric to the 5' end of the JAK2 gene
on ___ and PlatinumBright495 (green) directly labeled probe for
a DNA sequence centromeric to the 3' end of the JAK2
gene. This probe combination detects rearrangements of the JAK2
gene which can be seen in myeloproliferative
neoplasms.
FINDINGS: A total of 200 interphase nuclei were examined with
the JAK2 break apart probe set and fluorescence
microscopy. 200 cells (100%) had ___ yellow (red-green fusion)
signals. 0 cells (0%) had ___ yellow (red-green fusion)
signal, 1 red signal and 1 green signal. Normal cut-off values
for this probe set include: 96% for a normal ___ yellow
(red-green fusion) signal pattern and 2% for a ___ yellow
(red-green fusion), 1 red and 1 green signal pattern. nuc
ish(JAK2x2)[200]
This test was developed and its performance characteristics
determined by ___ Laboratory.
It has not been cleared or
approved by the US Food and Drug Administration (FDA). The FDA
does not require this test to go through premarket FDA review.
This test is used for
clinical purposes. It should not be regarded as investigational
or for research. This laboratory is certified under the Clinical
Laboratory Improvement
Amendments (CLIA) as qualified to perform high complexity
clinical laboratory testing.
___ ___
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___
Previous biopsies: ___ BLOOD, NEOPLASTIC
___ Immunophenotyping: peripheral blood
___ PERICARDIUM, BIOPSY OR TISSUE
INTERPRETATION:
Non-specific T cell predominant lymphoid profile; diagnostic
immunophenotypic features of involvement by leukemia/lymphoma
are not seen in this specimen. Correlation with clinical,
morphologic (see separate pathology report ___ and other
ancillary findings is recommended. Flow cytometry
immunophenotyping may not detect all abnormal populations due to
topography, sampling or artifacts of sample preparation.
SPECIMEN:
BONE MARROW ASPIRATE AND CORE BIOPSY
DIAGNOSIS:
MILDLY HYPERCELLULAR BONE MARROW FOR AGE WITH MATURING
TRILINEAGE
HEMATOPOIESIS, MARKED EOSINOPHILIA AND NO MORPHOLOGIC EVIDENCE
OF
LEUKEMIA/LYMPHOMA OR A MAST CELL DISORDER; SEE NOTE
The aspirate smears and core biopsy show numerous eosinophils
and eosinophil precursors
with normal granulation. A discrete abnormal blast or lymphoid
infiltrate is not identified nor is an
abnormal mast cell population seen. Corresponding flow cytometry
revealed no diagnostic
immunophenotypic features of involvement by leukemia/lymphoma
(see separate report ___
for full results). Cytogenetics work-up revealed a normal male
karyotype and no evidence of
rearrangement of the PDGFRA, PDGFRB and FGFR1 genes by ___ (see
separate reports
___ and ___). T cell receptor gamma gene
rearrangement PCR performed at ___ was positive indicating the presence of clonal T
cell population (see OMR for full
results). Diagnostic morphologic features of involvement by a
lymphoid or mast cell disorder are not
seen. The failure to demonstrate a clonal chromosomal
abnormality argues against a myeloid
neoplasm. A myeloid sequencing panel is pending. The TCR PCR
result raises the possibility of the
lymphoid variant of hypereosinophilic syndrome. However, a
discrete abnormal T cell population was
not demonstrated by flow cytometry. If all secondary causes for
eosinophilia are excluded, an
idiopathic hypereosinophilic syndrome should be entertained.
Correlation with all available clinical,
laboratory and other ancillary findings is recommended for
further characterization.
CLINICAL HISTORY: Hypereosinophilia
CYTOGENETICS PROCEDURE: Unstimulated and 3 day
DSP30/IL2-stimulated cultures for
Giemsa-banded chromosome analysis.
FINDINGS: An apparently normal 46,XY male chromosome complement
was observed in 20 mitotic
cells examined in detail. Chromosome band resolution was 400. A
karyogram was prepared on 4
cells.
Discharge Labs
==================
___ 05:06AM BLOOD WBC-9.8 RBC-3.70* Hgb-11.3* Hct-34.8*
MCV-94 MCH-30.5 MCHC-32.5 RDW-14.0 RDWSD-47.9* Plt ___
___ 05:06AM BLOOD Neuts-64.0 ___ Monos-11.6 Eos-1.1
Baso-0.2 Im ___ AbsNeut-6.28* AbsLymp-2.13 AbsMono-1.14*
AbsEos-0.11 AbsBaso-0.02
___ 05:06AM BLOOD Glucose-143* UreaN-17 Creat-1.0 Na-141
K-4.7 Cl-105 HCO3-26 AnGap-10
___ 05:06AM BLOOD ALT-220* AST-39 AlkPhos-130 TotBili-0.2
Brief Hospital Course:
Mr. ___ is a ___ yo M with no PMHx who presents as
transfer from ___ with SOB found to have a pericardial
effusion concerning for tamponade physiology s/p pericardial
window on ___. Further workup remarkable for profound
eosinophilia, with evidence of end organ damage (pericarditis,
Transaminitis), meeting criteria for hypereosinophilic syndrome.
Etiology of his eosinophilia unclear at the time of discharge,
see below.
TI
-------
[] Discharged on high dose prednisone, ensure patient is taking
his ppx meds (PPI, Bactrim, vitD, Calcium)
[] Patient does not have a PCP, he was given instructions to set
up with a PCP. Confirm that he has done this, if so, please
ensure PCP gets ___ copy of his discharge summary
[] Patient has expressed symptoms of anhedonia, isolation prior
to admission, started on fluoxetine 20, consider uptitrating
[] F/u lab work ___ ___ 9
[] Recommend repeat CXR within 6 weeks of discharge for interval
change in pleural effusion s/p pericardial window
[] Removal of sutures from left chest tube site at next
appointment
ACUTE ISSUES:
=============
# Hypereosinophilic Syndrome (HES)
Admission labs/diff w/ eosinophil count of 5k which uptrended to
19k prior to initiation of prednisone. He was also found w/ eos
in his pericardial fluid and biopsy, meeting criteria for end
organ damage, meeting criteria for Hypereosinophilic Syndrome.
Briefly, to delineate between a primary process (heme
malignancy) vs a secondary process (parasite/allergy etc) an IgE
was sent which returned wnl, thus making the diagnosis of
secondary eosinophilia less likely. This raised concern for a
myeloid lineage neoplasia such as CEL, or a Tcell leukemia
producing IL-5, however cytology performed on peripheral blood
is negative for PDGFRA, PDGFRB, FGFR1, and JAK2. Furthermore,
the bone marrow biopsy revealed no e/o leukemia or lymphoma.
Flow cytometry also failed to reveal a clonal population of
Tcells. One result that did return positive was the TC receptor
rearrangement. This is associated with T-cell leukemia, but is
non-specific. At the time of discharge, etiology remains
unknown. A summary of the pertinent laboratory/imaging findings
is copied below for completeness.
When the pericardial fluid showed eosinophilia, and the
diagnosis of HES was made, the patient was started on 1mg/kg of
prednisone daily with downtrended to <1.5k at the time of
discharge. We subsequently started the patient on Vit D,
Calcium, ppi, and Bactrim.
============================
Serum IgE: normal
___: negative
ANCA: negative
VitB12: 461
RheuFac: <10
CT A/P: no adenopathy or splenomegaly
Peripheral blood cytogenetics negative for JAK2 and PDGFRA
Tryptase: normal
T-cell rearrangement PCR: positive
Flow cytometry: negative for clonal population of lymphocytes
Bone marrow aspirate and biopsy: MILDLY HYPERCELLULAR BONE
MARROW
FOR AGE WITH MATURING TRILINEAGE HEMATOPOIESIS, MARKED
EOSINOPHILIA AND NO MORPHOLOGIC EVIDENCE OF LEUKEMIA/LYMPHOMA OR
A MAST CELL DISORDER.
================================
# Pericardial Effusion complicated by tamponade
# VATS w/ pericardial window
Patient presented with new pericardial effusion noted on CTA,
elevated pulsus, and TTE finding of increased transmitral
respiratory inflow variation consistent with early tamponade
physiology. Given the anatomic location of the effusion, he
required VATS and window as opposed to subxyphoidal drain.
Etiology of his pericarditis originally presumed viral, however
path results showed numerous eosinophils, leading us to believe
that his pericarditis was a manifestation of end organ damage
from eosinophilia. He was started on colchicine, but
discontinued this given that we started the patient on
prednisone for HES as below.
# Right upper extremity swelling
# B/l UE pruritic rash
Unclear etiology of swelling. Dopplers negative. Improved with
prednisone.Patient first noticed the rash just prior to
admission. The rash was mildly itchy and it was accompanied with
bilateral arm swelling. He last used an antibiotic back in
___ and ___ to treat an abscess in his left axilla.
Derm was consulted, did not recommend biopsy. Rash improved with
steroids.
# ___, resolved
Unknown baseline. Most likely pre-renal ___ hypovolemia in the
setting of acute illness with poor PO intake. Resolved following
IVF.
#CODE: Full (presumed)
#CONTACT: None listed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 800 mg PO DAILY:PRN Pain - Mild
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *acetaminophen 500 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*120 Tablet Refills:*0
2. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate [Antacid Calcium] 215 mg calcium (500 mg)
2 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
3. FLUoxetine 20 mg PO DAILY
RX *fluoxetine 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % apply once daily to shoulder once a day Disp
#*30 Patch Refills:*0
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
6. PredniSONE 100 mg PO DAILY
RX *prednisone 50 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tab-cap by
mouth once a day Disp #*30 Tablet Refills:*0
8. Vitamin D 1000 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Pericarditis
Tamponade
Hypereosinophilic syndrome
hepatitis
acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL?
-You came to the hospital because you had fluid buildup around
your heart.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
-The Thoracic Surgery doctors removed ___ around your heart
through surgery.
-You are found to have an injury to your kidneys. We gave you
IV fluids and this resolved.
-Our rheumatology and hematology doctors saw ___ for rash on
your arms, muscle pain, and an increase in your white blood cell
count.
-We found that your eosinophil levels were dangerously high,
which caused injury to your heart (pericardium) and your liver.
-We performed a bone marrow biopsy and a variety of genetic
studies on your bone marrow to identify the etiology of your
eosinophilia (high eosinophil count)
-We started you on high dose steroid medications to lower your
eosinophil count
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Do not take any more NSAID medications while on prednisone
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below .
- Please see below for more information on your hospitalization.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
19801566-DS-7
| 19,801,566 | 22,118,192 |
DS
| 7 |
2133-10-25 00:00:00
|
2133-10-25 17:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS, Dyspnea
Major Surgical or Invasive Procedure:
G TUBE REPLACEMENT ___
History of Present Illness:
Mr. ___ is a ___ gentleman with advanced ALS
(chronically on BiPAP 24 hours/day), CAD s/p CABG & BMS, NIDDM
who presents with ___ days of chest pain, dyspnea, diaphoresis,
and altered mental status. History was primarily obtained from
patient's two sons and daughter due to patient's limited ability
to communicate.
Patient's family reports that he has had a gradual decline in
both physical mobility and respiratory status over past 6
months, requiring increasing levels of BiPAP support. They
report an acute change over the past ___ days. They report he
has been working slightly harder to breathe and has been
slightly more confused compared to baseline. Per family, he's
had urinary tract infections in the past with similar
presentations. Mr. ___ has not had any fevers, increased
sputum production, vomiting, or diarrhea.
In the ED, initial vitals were T98 HR93 BP111/90 RR20 98% on
BiPAP. Exam notable for lethargy, confusion, abdominal
tenderness, and increased work of breathing. Labs were notable
for WBC 7.5, Hg 14.6, troponin of 0.27 < - 0.19, lactate 2.1 <-
3.2, Cr 0.3, Na 138, K 4.0, proBNP of 148, and D-dimer of 701.
VBG was 7.44/41/63/29. UA was notable for 19 WBC and moderate
bacteria with nitrite positivity. The patient underwent CT A/P
which was notable for diffuse bladder wall thickening concerning
for active cystitis, but otherwise no acute process. CXR
demonstrated low lung volumes with no concern for focal
consolidation. He was given 1g CFTX, 1L NS, 10mg oxycodone 10mg,
1g Tylenol, aspirin, and started on a heparin gtt. In the
setting of troponinemia, Cardiology was consulted and
recommended medical management and treating underlying demand.
While in the ED, DNR/DNI status was confirmed with the patient,
but given requirement for BiPAP he was admitted to the ICU for
further management.
On arrival to the MICU, patient denies ongoing shortness of
breath or chest pain. He does complain of increased secretions
and requests suctioning. Daughter reports he appears somewhat
more uncomfortable than his baseline, but he appears to be back
at his baseline level of alertness and interactivity.
Past Medical History:
ALS, complicated by:
- Chronic respiratory failure requiring 24-hour BiPAP at home
- Neurogenic bladder requiring straight cath ___ times daily
- Dysphagia requiring G-tube
- Chronic pain and dyspnea on standing morphine
CAD s/p CABG (3v LIMA to LAD, SVG to L PDA), PCI OM1 with BMS
___
DM2 on glimepiride
HTN
Social History:
___
Family History:
Mother - DM
Physical ___:
ADMISSION EXAM:
===============
VITALS: Afebrile SBP 200s HR ___ RR ___ SpO2 high ___ on
BiPAP
GENERAL: Thin man lying flat with BiPAP on, appears
uncomfortable but not in distress
HEENT: No icterus or injection. EOMI.
NECK: No meningismus. JVP not elevated
CARDIAC: Tachycardic, regular, no m/r/g
LUNG: Exam limited by BiPAP sounds. No clear crackles or
wheezes.
ABDOMEN: Soft, mild diffuse tenderness, no rebound or guarding.
Hypoactive BS. G-tube with visible yeast or bacterial colonies;
exit site clean, no erythema, warmth, tenderness, or prurulence.
EXTREMITIES: Warm, no edema.
NEURO: Alert, tracks with eyes, reacts to voice and commands,
able to communicate by tracing letters with left index finger.
Marked diffuse muscular weakness and atrophy.
DISCHARGE EXAM:
=================
VITALS: Afebrile. HR ___. SBP 130s-170s. RR ___ on BiPAP, SpO2
96-98%
GENERAL: Thin man lying flat with BiPAP, appears comfortable.
CV: RRR, no m/r/g
RESP: Non-labored breathing on BiPAP
ABD: Soft, NDNT. G-tube CDI.
EXT: Warm, atrophied, trace edema.
NEURO: Alert, tracks with eyes, able to communicate by head nod
and tracing letter with left index finger. Marked diffuse
weakness and atrophy.
Pertinent Results:
ADMISSION LABS:
================
___ 09:50PM BLOOD WBC-9.0 RBC-5.48 Hgb-14.4 Hct-45.2 MCV-83
MCH-26.3 MCHC-31.9* RDW-15.2 RDWSD-45.4 Plt ___
___ 09:50PM BLOOD Neuts-69.5 Lymphs-17.2* Monos-7.0 Eos-5.5
Baso-0.4 Im ___ AbsNeut-6.22* AbsLymp-1.54 AbsMono-0.63
AbsEos-0.49 AbsBaso-0.04
___ 09:50PM BLOOD ___ PTT-29.5 ___
___ 09:50PM BLOOD Glucose-262* UreaN-23* Creat-0.4* Na-135
K-4.0 Cl-95* HCO3-25 AnGap-19
___ 09:50PM BLOOD ALT-35 AST-41* AlkPhos-171* TotBili-0.2
___ 09:50PM BLOOD Lipase-21
___ 09:50PM BLOOD cTropnT-0.19*
___ 09:50PM BLOOD Albumin-3.7 Calcium-9.5 Phos-3.9 Mg-2.2
___ 08:37AM BLOOD D-Dimer-701*
___ 09:50PM BLOOD ___ pO2-63* pCO2-41 pH-7.44
calTCO2-29 Base XS-3
DISCHARGE LABS:
================
___ 03:10AM BLOOD WBC-8.6 RBC-4.96 Hgb-13.0* Hct-41.4
MCV-84 MCH-26.2 MCHC-31.4* RDW-15.1 RDWSD-45.9 Plt ___
___ 03:10AM BLOOD Glucose-289* UreaN-15 Creat-0.3* Na-130*
K-4.3 Cl-95* HCO3-23 AnGap-16
MICRO:
========
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING/STUDIES:
=================
___ CT A/P:
1. Diffuse bladder wall thickening is not fully explained by the
degree of
underdistention. Although some of this may relate to chronic
outflow
obstruction the setting of a mildly enlarged prostate gland,
findingsraise
concern for cystitis. Correlate with urinalysis. Normal CT
appearance
enhancement of the kidneys. Otherwise, no acute process
identified within the abdomen or pelvis.
2. Patchy, regional areas of hypoenhancing hepatic parenchyma
are favored to represent areas of hepatic steatosis.
3. Severe coronary artery calcification. Bibasilar atelectasis.
Other
incidental findings, as above.
ECG ___
Sinus rhythm. Lateral T wave inversions that are non-specific.
Compared to
tracing #2 frequent atrial premature contractions have resolved.
Lateral
T wave inversions persist without significant change. Clinical
correlation is suggested.
___ TTE:
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF = 70%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic arch 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
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
___ LOWER EXTREMITY ULTRASOUND:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ G-TUBE REPLACEMENT
Successful exchange of a Ponsky gastric tube for a new 20 ___
mic gastric tube. The tube is ready to use.
Brief Hospital Course:
___ with advanced ALS (on BiPAP at home), CAD s/p CABG, who
presented with several days of increased work of breathing,
chest pain, and altered mental status and was found to have an
NSTEMI and UTI. He remained hemodynamically stable but was
admitted to the ICU due to need for BiPAP.
================================
ACTIVE ISSUES
================================
#NSTEMI
Patient with known CAD s/p CABG and BMS, presenting with chest
pain, diaphoresis, tachycardia, and dyspnea concerning for ACS
vs. demand ischemia in setting of UTI, hypoxemia, and
hypertension. Troponin/CK-MB peaked at 0.35/13. Serial ECGs
showed non-specific but dynamic changes c/f active ischemia. TTE
was suboptimal quality but found no preserved EF 70% and no
clear focal wall motion abnormality or other pathology.
Cardiology was consulted and recommended medical management
since invasive procedures were not within goals of care per
family. He was treated with heparin gtt x 48 hours, aspirin,
atorvastatin 80mg, metoprolol, nitroglycerin gtt (later
transitioned to isorbide monotritate), and home losartan.
Symptoms and BP control improved and patient was discharged at
baseline.
#HTN
Patient was normotensive in ED but had persistently elevated SBP
to 180s-200s on admission to FICU, likely due to missed meds in
ED but possibly due to inactivation of home metoprolol XL and
nitrate by crushing for administration through G-tube. He was
initially stabilized with nitroglycerin gtt, later transitioned
to isorbide mononitrate, metoprolol tartrate, and previous
losartan 25 mg daily.
#ACUTE ON CHRONIC RESPIRATORY FAILURE
Patient on continuous BiPAP at home for chronic respiratory
muscle weakness ___ ALS. He presented with several days of
worsened dyspnea, likely multifactorial -- NSTEMI, possible
pulmonary edema ___ HTN, increased CO2 production ___ UTI. CT
found significant basilar atelectasis but no pneumonia or
effusions. NSTEMI raised concern for PE given immobility, but
bilateral ___ dopplers were negative for DVT and work of
breathing improved quickly by increasing tidal volume on BiPAP.
#COMPLICATED UTI
Patient presented with AMS similar to prior UTIs. CT
abdomen/pelvis found bladder wall thickening consistent with
cystitis but no evidence for upper tract infection. Urine
culture grew pan-sensitive Klebsiella. He remained
hemodynamically stable with no evidence for sepsis. He was
treated initially with ceftriaxone, later narrowed to PO Bactrim
for 7-day ___.
#DIABETES MELLITUS, TYPE 2, c/b
#HYPERGLYCEMIA
Patient was markedly hyperglycemic on admission but had no
ketonuria to suggest DKA/HHS. He was started on new insulin
regimen this admission, continued at discharge.
#ADVANCED ALS
Family reported progressive decline in mobility and respiratory
function over 6 months prior to admission requiring ___ home
care by family. Code status remained DNR/DNI and efforts were
made to maximize patient's comfort, as well as to connect his
family with home services. Palliative Care was additionally
consulted and recommended initiation of fentanyl patch and NSAID
as well as up-titration of morphine for patient's chronic pain
and dyspnea, and provided contacts for outpatient services.
#NEUROGENIC BLADDER
Continued home straight cath regimen q4-6h and prn
#CHRONIC DYSPHAGIA
G-tube was replaced by ___ without complication and home tube
feeds were continued.
===========================
TRANSITIONAL ISSUES:
===========================
# New medications: Glargine 10u qHS; Humalog 5 qAC; metop
tartrate 25 BID (XL not compatible with G-tube); isorbide
mononitrate BID (ER not compatible with G-tube); increased
losartan from 25 to 50 mg daily; liquid morphine; fentanyl
patch.
# Bactrim DS x 7 days for complicated UTI (last dose ___
# Stopped meds: bisoprolol; metoprolol XL; isorbide mononitrate
ER
# Continue to monitor BG and adjust diabetes regimen as
indicated.
# Continue to monitor BP, consider increasing doses.
# Family would like to reestablish Neurology f/u with Dr.
___.
# Encourage family to call ___ Care clinic for
assistance with symptom management and home care resources.
# Healthcare Proxy: Dr. ___ (son) ___
# Code Status: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO/NG DAILY
2. bisoprolol fumarate 2.5 mg oral DAILY
3. OxyCODONE (Immediate Release) 10 mg PO Q6H
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. Ranitidine 150 mg PO BID
6. Losartan Potassium 25 mg PO DAILY
7. glimepiride 1 mg oral BID
8. Glycopyrrolate 1 mg PO/NG BID
9. Lactulose 30 mL PO DAILY:PRN constipation
10. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
2. Fentanyl Patch 25 mcg/h TD Q72H
RX *fentanyl 25 mcg/hour Place on skin with fatty tissue beneath
(e.g. thigh). Change every 72 hours. change every 72 hours Disp
#*30 Patch Refills:*0
3. Glargine 12 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 12 Units before
BED; Disp #*3 Vial Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL AS DIR 5 units with
meals Disp #*10 Vial Refills:*3
4. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*3
5. OxycoDONE Liquid 10 mg PO Q4H:PRN Pain - Moderate
RX *oxycodone 5 mg/5 mL 10 mg by mouth every 4 hours as needed
Refills:*0
6. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL 20 ml G-tube
twice a day Refills:*0
7. Isosorbide Mononitrate 30 mg PO BID
RX *isosorbide mononitrate 10 mg 3 tablet(s) G-tube twice a day
Disp #*90 Tablet Refills:*3
8. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
9. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
10. Aspirin 81 mg PO DAILY
11. Glycopyrrolate 1 mg PO BID
12. Lactulose 30 mL PO DAILY:PRN constipation
13. Ranitidine 150 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
=======================
Non-ST elevation myocardial infarction
Acute on chronic hypercarbic respiratory failure
Amyotrophic lateral sclerosis
Bibasilar atelectasis
Hypertension
Complicated lower urinary tract infection
SECONDARY DIAGNOSES
==========================
Type 2 diabetes mellitus with hyperglycemia
Chronic dysphagia status post gastric tube placement
Neurogenic bladder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
Why you were admitted:
- shortness of breath
- small heart attack (NSTEMI)
- urinary tract infection
What we did while you were here:
- You were admitted to the ICU for close monitoring and
treatment.
- We adjusted your breathing machine (BiPAP) and your breathing
improved.
- Our Cardiology specialists evaluated you, and we treated your
heart attack with medicines. Your chest pain and blood pressure
got better.
- We gave you antibiotics for your urinary infection.
- We replaced your feeding tube.
- We adjusted your pain medications.
Instruction for when you leave the hospital:
- Follow up with your Primary Care and Neurology doctors.
- We made some changes to your medications. Please review the
detailed instructions in this packet.
- Finish the whole course of antibiotics (Bactrim) for your
urinary infection.
- If you have chest pain or shortness of breath, check your
heart rate, blood pressure, and oxygen level. If these are
normal, you can try nitroglycerin (up to 3 tabs).
- Don't hesitate to call your doctor or return to the ER if you
have any recurrence of symptoms.
We wish you all the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19801812-DS-10
| 19,801,812 | 27,130,921 |
DS
| 10 |
2163-09-23 00:00:00
|
2163-09-23 16:36:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
amoxicillin / Penicillins / Adderall
Attending: ___
Chief Complaint:
gluteal spasms, lower extremity parasthesias
Major Surgical or Invasive Procedure:
Lumbar puncture, ___ guided
History of Present Illness:
The patient is a ___ with hx of L4-5 disc bulge, low back
pain, and sciatica here with ___ months of progressive primarily
sensory symptoms.
Pt reports that several years ago, he had relatively sudden
onset
low back pain and sciatica (radiating down both legs) found to
have L4-L5 disc bulge. The pain was severe to the point where it
would prevent walking. He had severe/significant symptoms for 6
months and then this improved and he only has residual low back
pain from this - no radicular symptoms. He denied any sensory
symptoms at this time.
Over the last ___ months, he has felt progressive onset of the
following symptoms - he cannot remember the exact order in which
they occurred. He has had pulling/pressure around his waist as
if
he is wearing a belt, right around the area where one would lie
-
at his hips. He also endorsed decreased sensation to light touch
"from his hips down" involving both his legs equally. He
particularly notes decreased sensation around his groin and
buttocks bilaterally to the point where he feels that when he is
voiding urine and stool, the sensation is abnormal/different in
that he cannot feel the urine or stool and instead feels a
"pressure". He denies any urinary retention or incontinence,
though he does feel like there may be some rectal leaking. He
has
also noted erectile dysfunction in addition to feeling his
gluteal muscles are spasming. He also feels increased pain in
his
back when sitting up - relieved with lying flat. He also feels
that his left leg/buttock is weaker compared to the right which
he especially notices when he bends over - feeling that he needs
to hold onto something to stabilize himself. Finally, he has
also
noticed tingling in both feet left more than right and his left
whole hand that has been intermittent.
On neurologic review of systems, the patient denies headache,
lightheadedness. Denies difficulty with producing or
comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, denies any recent illness, +tick
bite ___ years ago but was treated and denies any tick exposure
since then. Pt denies recent fever or chills. Denies cough,
runny
nose, sore throat, 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 - has small ecchymosis under right armpit from
"fight" that has not resolved.
Pt is not a vegan and eats meat.
Past Medical History:
L knee surgery - meniscal tear
Recent car accident 6 months ago - s/p recent Nasal septum
surgery
Social History:
___
Family History:
No family history of autoimmune or neurologic disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 97.8F, HR 126---->98--->30s to ___, BP 112/68, RR 17,
96%
on RA, Glu 113
General: Somnolent from ativan, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity
Extremities: No ___ edema.
Skin: Small ecchymosis under R armpit noted. No rashes noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward slowly.
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 several beats
of
end gaze nystagmus b/l. 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 4+
R 5 ___ ___ 5 5 5 5 5 4+
Rectal tone per ED is decreased.
-Sensory: Decreased light touch entire left leg and palm of left
hand. Pt endorses decreased sensation in anterior groin as well
to light touch. Decreased pinprick over right buttock around S3
and medially to perianal area which is S5, and left top of
buttock around S3. Cold sensation intact in ___ and ___. Big toe
joint proprioception intact at toes. Vibration at toes is >20
sec
b/l. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 3 1
Plantar response was flexor bilaterally. No spasticity. No ankle
clonus. b/l crossed adductors. +pectoral jerk on the L
-Coordination: No 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. Endorses feeling that his left leg is weaker on gait.
DISCHARGE PHYSICAL EXAM:
Gen: awake, alert, young man, anxious appearing
HEENT: normocephalic, dried blood in nasal mucosa (per patient
and wife, sequel of septoplasty earlier this week)
CV: warm, well perfused
Abdomen: soft, nontender
Extremities: no edema
Neurologic
-Mental status: awake, alert, oriented to self, place, ___ and
situation. Speech is fluent with no dysarthria. Easily maintains
attention to examiner. Registers and recalls ___ objects at 5
minutes.
-CN: Gaze conjugate, EOMI with no nystagmus, ___ 3>2, face
symmetric, tongue midline, shoulder shrug intact bilaterally
-Motor: normal bulk and tone. No tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 4+
R 5 ___ ___ 5 5 5 5 5 5
- Sensory: decreased sensation to light touch and pinprick in
left lateral leg and patchy areas of anterior foot. No deficits
to temperature throughout this area. Otherwise, normal sensation
to light touch and pinprick in bilateral ___ and lower extremity.
Notably, buttocks and groin area was specifically tested. Great
toe joint proprioception intact at toes. Vibration at toes is
>20 sec
b/l. No extinction to DSS.
- Coordination: No intention tremor, No dysmetria on FNF
bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty.
Pertinent Results:
___ 06:15AM BLOOD WBC-4.2 RBC-5.25 Hgb-15.2 Hct-47.7 MCV-91
MCH-29.0 MCHC-31.9* RDW-12.1 RDWSD-40.0 Plt ___
___ 09:45PM BLOOD Neuts-44.0 ___ Monos-12.1 Eos-2.1
Baso-0.9 Im ___ AbsNeut-2.88 AbsLymp-2.66 AbsMono-0.79
AbsEos-0.14 AbsBaso-0.06
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-92 UreaN-19 Creat-0.8 Na-139
K-4.5 Cl-102 HCO3-27 AnGap-15
___ 06:15AM BLOOD Calcium-9.6 Phos-3.7 Mg-2.0 Cholest-134
___ 06:15AM BLOOD Triglyc-91 HDL-43 CHOL/HD-3.1 LDLcalc-73
___ 09:45PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
#Gluteal spasms and Parasthesias
Patient presented with ___ months of intermittent gluteal spasms
and parasthesias in bilateral ___ (L1 to S5 region), L>R,
associated with erectile dysfunction and subjective changes in
bowel sensation. Exam was notable for significant anxiety,
decreased light touch and pinprick in bilateral ___, moreso below
the knees, and decreased rectal tone in ED. MRI spine with and
without contrast was notable for L5-S1 disk herniation with no
other findings, including no cord signal. Patient underwent LP
attempt at bedside which was not successful (limited attempts
due to patient anxiety). This was therefore completed with ___
under fluoroscopy on ___. Initial studies from the LP were
unremarkable, with notably viral culture, ACE, cytology pending
at time of discharge.
Given relatively unremarkable exam and benign MRI, etiology was
thought to be sequela from disk herniation vs sacroradiculitis
vs infectious radiculopathy.
TRANSITIONAL ISSUES:
- Follow up with Neurology clinic in ___ weeks. Appointment made
for ___.
- When seen in follow up, check cytology, ACE, viral cultures
- Patient and mother educated in detail about warning signs,
notably saddle anesthesia, bowel/bladder incontinence, and
muscle weakness. Educated about when to return to the ED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. clarithromycin 250 mg oral BID
2. Oxymetazoline 1 SPRY NU BID:PRN nasal congestion
Discharge Medications:
1. clarithromycin 250 mg oral BID
2. Oxymetazoline 1 SPRY NU BID:PRN nasal congestion
Discharge Disposition:
Home
Discharge Diagnosis:
Lumbar disk herniation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with sensory changes on your
legs, bowels and toes. On exam, you had signs and symptoms
consistent with a disc herniation. To further evaluate your
symptoms, we sent you for an MRI of your spine, which revealed
an L5-S1 disk herniation, however no other concerning signs. You
also had a lumbar puncture (spinal tap) which did not show any
significant abnormalities on initial results. Moving forward,
it will be important that you follow up with a Neurologist in
___ weeks to follow up on the rest of your CSF results.
It was a pleasure taking care of you.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19802150-DS-10
| 19,802,150 | 23,094,572 |
DS
| 10 |
2153-08-22 00:00:00
|
2153-08-22 17:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cefepime / azithromycin
Attending: ___.
Chief Complaint:
Mid-back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F w/ h/o Ph+ ALL s/p induction tx w/ dasatinib and
high-dose steroids diagnosed, relapse ___ tx w/ hyper-CVAD
___ part A, ___ part B), ponatinib ___, decreased
from 45mg to 30mg given grade 4 hematologic toxicity), and
rituximab and IT methotrexate (___) p/w back pain.
Pt recently admitted for CN VII palsy ___ thought to be
secondary to leptomeningeal involvement and was tx w/ steroids,
intrathecal methotrexate, and was continued on her oral
ponatinib 30mg. CSF studies and head MRI did not show definitive
evidence of new CNS disease, however she was treated as such.
She was also seen by opthalmology on that admission.
Pt reports that since late morning she has had mid back pain
which has been progressive. She denies any trauma. Pain started
suddenly while cooking, is crampy in nature, and ___ at its
worst. She tried taking oxycodone without relief. Denies muscle
weakness or lower extremity numbness, bowel incontinence or
urinary retention. She has not had a bowel movement today. She
denies fevers but is experiencing sweats. Denies nausea,
vomiting or shaking chills. Denies dysuria or increased urinary
frequency.
In the ED, VS: 71 140/100 18 100% ra. On exam, strength &
sensation were intact, she had no vertebral tenderness, + mild
paravertebral tenderness thoracic spine, normal rectal tone and
perirectal sensation intact. She received morphine, dilaudid,
and acyclovir. She had a CXR and plain film of the spine. She
was ordered for MRI T/L spine and CTU.
On arrival to the floor, she c/o ___ back pain.
ROS: Otherwise negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
# ALL diagnosed ___
___ - Noted to have a white count of ~ 75K with immature
lymphocytosis and platelet of ~ 45K at routine examination
___ - PB immunophenotyping consistent with B cell Acute
Lymphoblastic Lymphoma, CD 10 positive; peripheral blood
cytogenetics positive for t(9;22)(q34;q11.2)
___ - Initiated on Dasatinib and prednisone (___ R et al
Blood ___ 118:___) - Initial hospital course complicated
by mild DIC with diffuse alveolar hemorrhage, and a diffuse skin
rash. The latter was likely an allergic reaction to cefepime or
bactrim. During this period dasatinib was held for 3 days.
___ - IT Mtx; csf clear
___ - Discharged
___ - Admitted for acute viral syndrome
___: found to have WBC 70(56% blasts), admitted to
start Hyper-CVAD. treated for possible heel cellulitis ___
(initially vanc/ampicillin, then vanc alone)
___: day 1 cycle 1 hyper-CVAD part A. course complicated by
mucositis
___: day 1 cycle 1 hyper-CVAD part B
___: Rituximab and IT Methotrexate
___: Rituximab
___: Admitted for R facial droop, on ponatinib 30mg
daily, received IT methotrexate, CSF studies inconclusive.
PAST MEDICAL/SURGICAL HISTORY:
- Hyperlipidemia
Social History:
___
Family History:
Father - stomach CA.
Mother - esophageal CA
Sister - throat CA
Children and grandchildren healthy, though daughter with
resolved gestational diabetes.
No history of stroke, MI. No hematologic malignancies reported.
Physical Exam:
ADMISSION
148/82, 90, 16, 100% RA
Gen: in pain
HEENT: OP clear, mmm, sclera anicteric
Neck: no jvd
CV: rr, no murmurs
Pulm: ctab
Abd: soft, nt/nd
Ext: wwp
Neuro: A&Ox3, anxious, strength intact, down going toes,
sensation to LT intact, no spinal tenderness.
DISCHARGE
T 97.9, BP 150/74, HR 60, RR 20, O2 96/RA
GENERAL - ___ yo F who appears comfortable, appropriate and in
NAD
HEENT - Pupils equal and reactive 3 to 2mm, EOMI, sclerae
anicteric, MMM, OP clear
NECK - supple, no lymphadenopathy
LUNGS - clear to ausculatation bilaterally, moving air well and
symmetrically, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, S1-S2 clear and of good quality
without murmurs, rubs or gallops. Port over right chest without
erythema or edema.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs). bilateral heels with large blisters which are non-painful
and with no surrounding erythema or induration
NEURO - awake, A&Ox3, no sensory deficits on face, other CNs
II-XII intact, muscle strength ___ throughout. Decreased
sensation to light tough at fingertips. Otherwise grossly intact
throughout.
Pertinent Results:
ADMISSION
___ 11:30PM PLT SMR-VERY LOW PLT COUNT-44*
___ 11:30PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-OCCASIONAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-OCCASIONAL
___ 11:30PM NEUTS-56 BANDS-10* LYMPHS-13* MONOS-5 EOS-0
BASOS-0 ATYPS-2* ___ MYELOS-1* NUC RBCS-1* OTHER-13*
___ 11:30PM WBC-9.8# RBC-2.79* HGB-9.2* HCT-26.9* MCV-97
MCH-33.0* MCHC-34.1 RDW-21.8*
___ 11:30PM ALBUMIN-4.2 CALCIUM-9.3 PHOSPHATE-5.3*#
MAGNESIUM-2.0
___ 11:30PM ALT(SGPT)-191* AST(SGOT)-66* ALK PHOS-117*
TOT BILI-0.5
___ 11:30PM GLUCOSE-129* UREA N-23* CREAT-0.6 SODIUM-138
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-22 ANION GAP-17
___ 11:36PM LACTATE-1.4
___ 11:36PM ___ COMMENTS-GREEN TOP
___ 02:00AM URINE MUCOUS-RARE
___ 02:00AM URINE RBC-2 WBC-7* BACTERIA-FEW YEAST-NONE
EPI-0
___ 02:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
___ 02:00AM URINE COLOR-Straw APPEAR-Clear SP ___
CSF: ___
FISH: analysis with the ABL1/BCR probe set was attempted,
however, no cells were observed on the 2 slides received.
Therefore, the FISH analysis could not be performed.
IMMUNOPHENOTYPING:
Non-diagnostic study. Cell marker analysis was attempted, but
was nondiagnostic in this case due to insufficient numbers of
cells.
While definitive diagnostic immunophenotypic features of
involvement by leukemia are not seen in specimen, correlation
with clinical findings and morphology is recommended:
Concurrent cytospin reveals occasional atypical lymphoid cells,
raising the suspicion for involvement by ALL.
MRI Head: ___
1. No acute intracranial abnormality, and no significant change
since the study obtained roughly 18 hours earlier.
2. No pathologic focus of enhancement; specifically, there is
no abnormal sulcal FLAIR-hyperintensity or enhancement to
suggest subarachnoid space involvement by ALL.
3. Heterogeneous regional bone marrow signal, which may reflect
either
infiltration by known ALL, response to systemic therapy, or
both.
Echo ___: The left atrium is mildly dilated. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70-75%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Dynamic global and regional biventricular
systolic function, most consistent with a high-catecholamine
state. Mild mitral regurgitation.
CTA CHEST ___:
1. Wedge-shaped consolidation in the right lower lobe
compatible with atelectasis.
2. No evidence of pulmonary embolism or acute aortic syndrome.
MRI T/L-SPINE ___: Somewhat limited evaluation due to
motion. No evidence for discitis, osteomyelitis, abscess or
hematoma. Mild degenerative changes as detailed above.
L/T-SPINE FILM ___:
1. No evidence of compression fracture.
2. Moderate-to-severe S-shaped scoliosis.
Bone Marrow: ___
KARYOTYPE: 46,XX,T(9;22)(Q34;Q11.2)[18]/46,XX[2]
INTERPRETATION: Of 20 cells studied, 18 had a t(9;22)(q34;q11.2)
consistent with relapse of ALL.
DISCHARGE
___ 05:26AM BLOOD WBC-1.7* RBC-2.80* Hgb-9.2* Hct-25.6*
MCV-92 MCH-32.7* MCHC-35.8* RDW-20.6* Plt Ct-66*
___ 05:26AM BLOOD Neuts-34* Bands-0 Lymphs-44* Monos-4
Eos-2 Baso-0 Atyps-5* Metas-1* Myelos-0 Blasts-10* NRBC-5*
___ 05:26AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-1+
Macrocy-2+ Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
MacroOv-1+
___ 05:26AM BLOOD Plt Ct-66*
___ 05:26AM BLOOD Glucose-150* UreaN-17 Creat-0.5 Na-137
K-3.9 Cl-102 HCO3-28 AnGap-11
___ 05:26AM BLOOD ALT-104* AST-31 LD(LDH)-1477*
AlkPhos-256* TotBili-0.6
___ 05:26AM BLOOD Albumin-3.5 Calcium-8.5 Phos-4.0 Mg-2.1
UricAcd-1.9*
___ 08:11AM BLOOD BCR/ABL GENE REARRANGEMENT, QUANTITATIVE
PCR, CELL-BASED-PND
___ 10:20AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test
___ 10:20AM BLOOD B-GLUCAN-Test
Brief Hospital Course:
___ yo F w/ h/o Ph+ ALL w/ relapse ___ tx w/ hyper-CVAD,
ponatinib, and rituximab and IT methotrexate, w/ recent
admission for facial droop and concern for leptomeningeal spread
now p/w back pain.
# Back pain: Likely secondary to ALL progression. Her pain was
mostly paraspinal, however given leptomeningeal involvement on
last admission, there was concern for possible spinal
involvement as well. No evidence of cauda equina syndrome on
exam. Review of CSF studies - cx, HSV pcr, cryptococcal ag were
non-revealing. CTA chest did not show evidence of PE, and MRI T
and L spine did not show evidence of obvious spinal disease. The
pathology report as paucicellular, atypical lymphoid cells,
though FISH unable to be performed. She was treated with IV
dexamethasone 20mg daily, and was transitioned to oral
dexamethasone 20mg daily. She also received oxycontin 10mg twice
daily, lidoderm patch, and dilaudid prn. She also received
valium for pain related to muscle spasms.
# ALL W/ CNS involvement: She has refractory disease despite
receiving IT methotrexate, steroids, and ponatinib on last
admission. Her LDH and blast count was markedly elevated on
admission, and given her refractory disease, she was made
DNR/DNI after a family meeting on ___ with Dr. ___. Her pain
improved with stress dose steroids (dexamethasone 20mg IV daily)
as well as ponatinib 30mg, and her LDH and blast count also
improved. She was continued on acyclovir and started on bactrim
prophlaxis. She received one blood and two platelet transfusions
during this admission. She was discharged to home with bridge to
hospice, and will follow up with Dr. ___ after discharge.
# Anemia, thrombocytopenia: She received one blood and two
platelet transfusions during this admission. Discussions were
held regarding the benefit of transfusions, and it was agreed
that transfusions should continue as long as she feels benefit.
# Hypertension: She had hypertensive urgency during this
admission with SBP 180-190s, especially when on high dose
steroids. She was started on amlodipine 5mg at night, and her
blood pressure improved.
TRANSITIONAL:
# Mrs. ___ has progressive ALL refractory to ponatinib
treatment. She improved with dexamethasone 20mg IV daily, which
was transitioned to 20mg oral daily at discharge. She was
started on oxycontin 10mg BID, lidoderm patch, and dilaudid
___ Q4H prn breakthrough pain. Please follow up on her
symptoms, and adjust these medications as appropriate. She was
continued on ponatinib 30mg daily.
# She has elected to go home with hospice for the time being so
that she may return to see Dr. ___ in clinic and receive
transfusion treatments as needed. Please revisit her need for
inpatient hospice care, and offer this service if appropriate.
# Please check her CBC, and offer transfusions as appropriate.
She received 1 pRBC and 2 platelet transfusions during this
hospitalization.
# She was started on amlodipine 5mg QHS because she had
hypertensive urgency (SBP 180-190s), likely a result of stress
dose steroids. Please follow up on her blood pressure, and
adjust this medication as appropriate (taper if steroids are
tapered).
# Contact: ___ (husband) ___
# CODE: DNR/DNI but not CMO, discharged with bridge to hospice
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Atovaquone Suspension 1500 mg PO DAILY
3. ponatinib *NF* 30 mg Oral daily
4. Potassium Chloride 20 mEq PO DAILY
5. Ranitidine 150 mg PO DAILY
6. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
7. PredniSONE 40 mg PO DAILY
8. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
9. Lidocaine-Prilocaine 1 Appl TP ASDIR
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Atovaquone Suspension 1500 mg PO DAILY
4. Lidocaine-Prilocaine 1 Appl TP ASDIR
5. ponatinib *NF* 30 mg Oral daily
6. Dexamethasone 20 mg PO DAILY
RX *dexamethasone 4 mg 5 tablet(s) by mouth daily Disp #*50
Tablet Refills:*1
7. Diazepam 2 mg PO Q6H pain, anxiety, sleep
RX *diazepam 2 mg 1 tablet(s) by mouth every 6 hrs Disp #*15
Tablet Refills:*1
8. HYDROmorphone (Dilaudid) 4 mg PO Q4H pain
Use this medication only if you have pain that is not controlled
with oxycontin and lidoderm patch
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 4
hours Disp #*20 Tablet Refills:*1
9. Lidocaine 5% Patch 2 PTCH TD DAILY
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) Apply ___ patches
daily Disp #*20 Each Refills:*1
10. Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Take every 12 hours whether you have pain or not.
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every 12
hours Disp #*30 Tablet Refills:*1
11. Docusate Sodium 100 mg PO BID constipation
This is for constipation that may be caused by narcotics
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*30 Capsule Refills:*1
12. Senna 1 TAB PO BID:PRN constipation
This is for constipation that may be caused by narcotics
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*30 Capsule Refills:*1
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
This medication helps prevent infections while you are on high
dose steroids
RX *sulfamethoxazole-trimethoprim [Bactrim] 400 mg-80 mg 1
tablet(s) by mouth daily Disp #*15 Tablet Refills:*1
14. Potassium Chloride 20 mEq PO DAILY
15. Ranitidine 150 mg PO DAILY
16. Amlodipine 5 mg PO HS
RX *amlodipine 5 mg 1 tablet(s) by mouth every evening Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Acute Lymphoblastic Leukemia
Secondary:
- Back pain
- Anemia
- Thrombocytopenia (low platelet count)
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 at the ___. You were
admitted for back pain, and were found to have progression of
your leukemia. You were treated with high dose steroids
(dexamethasone), as well as pain medications, and your pain
improved. We had extensive discussion about your refractory and
progressive leukemia, and reached the conclusion that you wanted
to go home with ___ to hospice. You will return to clinic to
follow up with Dr. ___ as needed.
You were started on a number of medications to treat your pain,
including dexamethasone 20mg daily, oxycontin 10mg twice daily,
and lidoderm patch daily as needed. You may use valium
(diazepam) 2mg if you have pain from muscle spasms, or anxiety
or difficulty sleeping. You should use dilaudid ___ only if
you have pain despite these other medications.
You were started on amlodipine 5mg every evening for high blood
pressure.
Followup Instructions:
___
|
19802201-DS-11
| 19,802,201 | 27,711,305 |
DS
| 11 |
2154-09-28 00:00:00
|
2154-09-28 14:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with 5 day history of diffuse, intermittent abdominal pain.
First noticed it on ___. Continued to come and go throughout
the week. Pain is diffuse, but worst in the lower quadrants.
Denies nausea/vomiting. Does endorse chills, but no objective
fever. Has been able to eat throughout this week, but
has less appetite than usual. Denies changes in his stools or
bloody stools. Has never had abdominal pain like this before.
Past Medical History:
Possible HNPCC (patient not aware, but per GI note, family
history suspicious for HNPCC per father before he passed away),
h/o arm lipomas
Social History:
___
Family History:
per note from gastroenterologist, possible family history of
HNPCC, but patient not aware of this. Does endorse multiple
family members have had colon cancer.
Physical Exam:
Physical Exam On Admission:
Vitals: 99.0, HR 75, BP 103/62, RR 18, 99% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended, tender to palpation diffusely, worst in
LLQ, no rebound or guarding,
Ext: No ___ edema, ___ warm and well perfused
Physical Exam On Discharge:
Vitals:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, non-distended, mildly improved tenderness to
palpation
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 10:25PM BLOOD WBC-11.0* RBC-4.04* Hgb-13.1* Hct-39.2*
MCV-97 MCH-32.4* MCHC-33.4 RDW-13.4 RDWSD-48.1* Plt ___
___ 07:55AM BLOOD WBC-11.9* RBC-4.06* Hgb-13.0* Hct-39.6*
MCV-98 MCH-32.0 MCHC-32.8 RDW-13.0 RDWSD-46.8* Plt ___
___ 05:00AM BLOOD WBC-10.7* RBC-3.65* Hgb-11.8* Hct-35.9*
MCV-98 MCH-32.3* MCHC-32.9 RDW-12.7 RDWSD-45.8 Plt ___
___ 06:20AM BLOOD WBC-10.5* RBC-3.84* Hgb-12.4* Hct-37.1*
MCV-97 MCH-32.3* MCHC-33.4 RDW-12.7 RDWSD-45.1 Plt ___
___ 10:25PM BLOOD Glucose-105* UreaN-12 Creat-0.9 Na-134
K-6.6* Cl-103 HCO3-21* AnGap-17
___ 07:55AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-138
K-4.0 Cl-104 HCO3-21* AnGap-17
___ 05:00AM BLOOD Glucose-76 UreaN-12 Creat-0.9 Na-136
K-3.7 Cl-101 HCO3-22 AnGap-17
IMAGING:
---------
IMPRESSION:
New opacities in both lower lobes may be reflective of
pneumonia/atelectasis.
Small bilateral pleural effusions.
Brief Hospital Course:
Mr. ___ was admitted to the hospital for treatment of
perforated diverticulitis. He was placed on IV Antibiotics
(Ciprofloxacin and Flagyl) and kept NPO with IVF. His pain
improved on HD1 and on HD2 he was started on a regular diet and
tolerated well and passed flatus.
On HD3 he is tolerating a regular diet, states improved
abdominal pain and was switched to PO antibiotics.
During the hospital course, it was noted he had persistent
oxygen requirement up to 3L where he is asymptomatic. He was
weaned off O2 prior to discharge, maintaining a saturation in
the 90's. He is to follow up with his PCP ___ 1 week of
discharge to for check up of his oxygen saturation.
He is ready for discharge on HD3. At the time of discharge he is
afebrile, VS stable, tolerating a regular diet and is to be
discharged on high fiber diet and continue 2 week PO antibiotic
course with ciprofloxacin and flagyl. He is ambulating
independently, pain well controlled. He is scheduled to follow
up with ___ clinic in 2 weeks.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
NO strenuous exercise while taking this medication
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*27 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO TID
do NOT drink alcohol while taking this medication
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*41 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Perforated Diverticulitis
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 due to
perforated diverticulitis. You were treated with IV antibiotics
and bowel rest and you have recovered well. You are now ready to
continue your recovery at home and will be discharged on a
course of oral antibiotics. Please schedule an outpatient
colonoscopy for 6 weeks from discharge. Please follow the
instructions below to ensure a safe recovery:
Your oxygen level was low upon this admission and required O2.
At the time of discharge you were off oxygen. Please follow up
with your primary care within 1 week of discharge for check up
of your oxygen status.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
19802210-DS-8
| 19,802,210 | 20,378,488 |
DS
| 8 |
2182-12-29 00:00:00
|
2182-12-29 16:32:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / NSAIDS
Attending: ___.
Chief Complaint:
___ ADMISSION NOTE
time pt seen & examined: 7:15pm
CC: abdominal pain, F/C
PCP: ___
___ Surgical or Invasive Procedure:
ERCP with stent placement
History of Present Illness:
Mr. ___ is an ___ year old male with a history of afib on
warfarin (TIA, CHADS of 3), colon CA s/p resection and ostomy,
who presented to the ED with RUQ abd pain.
Over the past 3 days he developed right flank pain that radiated
to the mid back and through the back to his abdomen. This
evolved over the past three days into RUQ. He has also had fever
to 101.2 and rigors over the past two nights. He has had
intermittent RUQ pain over the past several months, each episode
resolving spontaneously. He has been lightheaded with abdominal
distension - to the point that his ostomy bag came off. He
feels lightheaded and very weak, though lightheadedness has been
chronic for years. Urine was very dark yesterday, and he
increased his intake to four 8 oz glasses of water overnight.
Ostomy output also been decreased. No appetite for the past day,
unsure if he lost weight. Also with exertional SOB last few mos,
worse in last few days, no associated CP. He presented to ___
___ today, and he was referred to ED for further
evaluation.
In the ED, vital signs were 98.5 82 131/71 18 97% on RA. Initial
labs notable for WBC 32.8 (95.5% N), Hct 36.9, INR 4.8, PTT
46.8, ALT 226, AST 234, Alk Phos 705, Tbili 5.8, lactate 2.3. He
was started empirically on Unasyn, and ACS was consulted. He was
given 2U FFP and went for ERCP, which showed: "Moderate amount
of pus was draining from the ampulla. Cannulation of the biliary
duct was successful and deep after a guidewire was placed.
Contrast medium was injected resulting in partial opacification
due to cholangitis. Scout film was normal. The CBD was 12 mm in
diameter. Large amount of debris and 12 mm impacted stone in the
distal CBD consistent with a large ___ shaped stone were
identified. Cystic duct was patrially opacified and the
gallbladder was not seen. The left and right hepatic ducts were
normal. IHD were not opacified due to cholangitis. A
sphincterotomy was NOT performed due to INR of > 5, therefore no
stones were removed. A 7cm by ___ biliary stent was placed
successfully traversing the impacted stone to ensure drainage of
bile and resolution of cholangitis."
In the ERCP suite, pt reports feeling much better and denies any
abdominal pain, N/V, F/C. He denies current SOB but confirms he
has had intermittent exertional SOB. No cough or other URI sx,
no myalgias. ROS otherwise negative.
Past Medical History:
-rectal cancer s/p resection & end colostomy, chemotherapy ___
-asbestosis
-atrial fibrillation
-hyperlipidemia
-TIA
-macular degeneration
-remote duodenal ulcer, evaluated at ___, resolved without tx
-osteoarthritis
-anxiety
-___ esophagus (___)
-Meniere's disease
-Pseudogout
Social History:
___
Family History:
Father - COPD
Physical ___:
VS: afeb 134/74 ___ 98% 2L
GEN: NAD, well-appearing
EYES: conjunctiva clear, icteric
ENT: dry mucous membranes
NECK: supple
CV: irreg irreg s1s2 soft II/VI SEM
PULM: CTA, decreased BS
GI: decreased BS, mildly distended, soft, nontender, ostomy
in place with opaque bag
EXT: warm, no edema
SKIN: no rashes, icteric
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands
PSYCH: appropriate
ACCESS: PIV
FOLEY: none
Pertinent Results:
Admission Labs:
___ 10:15AM BLOOD WBC-32.8*# RBC-4.12* Hgb-11.9* Hct-36.9*
MCV-90 MCH-28.8 MCHC-32.2 RDW-16.8* Plt ___
___ 10:15AM BLOOD Neuts-95.5* Lymphs-1.4* Monos-2.8 Eos-0.1
Baso-0.2
___ 10:15AM BLOOD ___ PTT-46.8* ___
___ 10:15AM BLOOD Glucose-160* UreaN-11 Creat-0.8 Na-135
K-3.7 Cl-96 HCO3-25 AnGap-18
___ 10:15AM BLOOD ALT-226* AST-243* AlkPhos-705*
TotBili-5.8*
___ 10:25AM BLOOD Lactate-2.3*
___ 10:15 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Ultrasound:
**Wet Read**
Distended gallbladder with wall edema and small amount of
pericholecystic fluid as well as stones and sludge seen
concerning for acute cholecystitis. The common bile duct is
prominent but no choledocholithiasis is identified.
CXR: (prelim report)
Extensive bilateral pleural plaques suggest prior asbestos
exposure and partially obscure the lung fields making it
difficult to accurately discern whether there is
underlying new underlying opacities, though no definite
new focal consolidation. Blunting of the right
costophrenic angle may be due to a small pleural
effusion.
Brief Hospital Course:
___ year old male with a history of rectal cancer s/p resection
and colostomy, a-fib on warfarin, and anxiety who presents with
biliary sepsis secondary to acute cholecystitis/cholangitis
complicated by supratherapeutic INR.
# ESBL E. Coli sepsis:
# Cholangitis:
He presented with abdominal pain and fever and was found to have
obstructive jaundice and ESBL E. coli bacteremia. Met ___ SIRS
criteria with WBC of 32.8, fever to 101.2 at home, and
tachycardia (100s) while on rate controlling agents.
ERCP showed bile duct stone. He underwent ERCP with placement of
a plastic stent around the stone to facilitate drainage. A
sphincterotomy was not performed due to supratherapeutic INR.
His symptoms improved following the prodedure. His liver
function tests are improving but not yet normalized. He was
initially treated with Unasyn but after blood cultures returned
growing ESBL E.coli this was changed to meropenem (___) with
plan to complete a 14 day course (ending ___. He was evaluated
by surgery with recommendation for interval cholecystectomy in
the next several weeks. He will follow up with surgery to
schedule cholecystectomy. Ideally the day prior he would
undergo repeat ERCP for stent removal, sphincterotomy, stone
removal with possible mechanical lithotripsy vs. Spy ___. He
will need to go off coumadin in the days preceding this
procedure in order to let INR drift down to a safe value to
perform invasive procedures.
# Atrial fibrillation: He was continued on rate control. He has
a CHADS2 score of at least 3, on warfarin with supratherapeutic
INR on admission likely due to acute illness and liver injury.
His INR trended down and his coumadin was restarted at home dose
of 3mg daily. Would recommend monitiring INR closely while on
antibiotics.
# hyperlipidemia: holding statin in setting of hepatic
inflammation
# depression/anxiety: continue outpatient sertraline, alprazolam
& clonazepam
Medications on Admission:
alprazolam 0.25 mg tablet twice a day as needed for anxiety
brimonidine [Alphagan P] Dosage uncertain
clonazepam 0.5 mg tablet half tablet by mouth twice a day as
needed for anxiety
fluticasone 50 mcg/actuation nasal spray,suspension 1 puff NAS
twice a day (Not Taking as Prescribed)
omeprazole 20 mg capsule,delayed release 1 capsule,delayed
___ by mouth qam
pravastatin 20 mg tablet 1 Tablet(s) by mouth once a day in the
evening
sertraline 25 mg tablet one tablet by mouth twice a day
tramadol 50 mg tablet ___ Tablet(s) by mouth every four (4) -
six (6) hours as needed for pain
verapamil ER 180 mg 24 hr capsule,extended release 1 capsule,ext
rel. pellets 24 hr(s) by mouth qd for heart rate
warfarin 2 mg tablet Take up to 2 (two) tablets by mouth once a
day or as directed by ___ clinic
acetaminophen 500 mg tablet 1 tablet by mouth three times a day
as needed for pain
aspirin 81 mg tablet,delayed release 1 Tablet(s) by mouth daily
multivitamin tablet 1 tablet by mouth qam
Discharge Medications:
1. ertapenem 1 gram injection daily
contine through ___
RX *ertapenem [Invanz] 1 gram 1 gram daily Disp #*10 Vial
Refills:*0
2. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
RX *sodium chloride 0.9 % 0.9 % 10 mL IV daily Disp #*10 Syringe
Refills:*0
3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
RX *heparin lock flush (porcine) [heparin lock flush] 10 unit/mL
2 mL IV daily Disp #*10 Syringe Refills:*0
4. Pravastatin 20 mg PO HS
5. Aspirin 81 mg PO DAILY
6. Warfarin 3 mg PO HS
7. Verapamil SR 180 mg PO DAILY
8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
9. Acetaminophen 500 mg PO TID:PRN pain
10. ALPRAZolam 0.25 mg PO BID:PRN anxiety
11. ClonazePAM 0.25 mg PO BID:PRN anxiety
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Sertraline 25 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cholangitis
sepsis
E. coli bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care. You were admitted
with abdominal pain and fever and were found to have a
gallstone causing obstruction in your bile duct system. This
caused an infection (cholangitis) and spread of bacteria to your
blood stream (sepsis). You had a procedure (ERCP) to place a
stent across the stone and relieve the obstruction. You were
treated with antibiotics and will continue this through ___. You were seen by the surgery team. The plan is for you
to return to the hospital in several weeks to have the stone
removed by the ERCP doctors and to have the surgeon's remove
your gallbladder.
Followup Instructions:
___
|
19802296-DS-14
| 19,802,296 | 23,683,536 |
DS
| 14 |
2176-09-29 00:00:00
|
2176-10-01 20:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
small bowel obstruction
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ y o M w/ hx of lap gastric band ___ yrs
ago at ___ who is ___'ed from OSH for c/f SBO and
presenting
w/ ~1 day hx of acute onset diarrhea, abd pain, distension and
dry heaving. He notes the diarrhea to be primarily watery brown
with some solid material, having ~1 BM per hour. After the
diarrhea started he had rapid abd distension and started dry
heaving as well. He presented to OSH for these sx and an NG was
placed w/ relief. A CT was done showing c/f SBO and was
transferred here to the ED. In the ED his labs were notable for
WBC 20, Cr 1.2, and lactate 2.2. A KUB showed an NG coiled in
the
esophagus and was thus readjusted, w/ repeat KUB showing tip
placement in the stomach. He currently feels much better, with
no
pain, and mild distension. He continues to pass gas and have
BMs.
He endorsed some sweats, and denies f/c, recent illness, sick
contacts. ROS is o/w negative except as noted above.
Past Medical History:
PMHx/PSHx: lap gastric band ___ yrs ago as noted above
Social History:
___
Family History:
non-contributory
Physical Exam:
Discharge physical exam:
VS: 99.0 126/82 71 18 98Ra
Gen: NAD
CV: normal S1, S2, no murmur
Pulm: non-labored breathing, no resp distress
Abd: soft, non- distended, non-tender
Pertinent Results:
___ 02:30AM PLT COUNT-341
___ 02:30AM NEUTS-89.0* LYMPHS-4.4* MONOS-5.3 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-18.56* AbsLymp-0.91*
AbsMono-1.10* AbsEos-0.00* AbsBaso-0.07
___ 02:30AM WBC-20.8* RBC-5.54 HGB-17.0 HCT-49.1 MCV-89
MCH-30.7 MCHC-34.6 RDW-12.4 RDWSD-40.1
___ 02:30AM estGFR-Using this
___ 02:30AM GLUCOSE-152* UREA N-26* CREAT-1.2 SODIUM-136
POTASSIUM-5.2* CHLORIDE-102 TOTAL CO2-20* ANION GAP-19
___ 02:48AM LACTATE-2.2* K+-5.0
___ 02:48AM ___ COMMENTS-GREEN TOP
___ 01:32PM PLT COUNT-257
___ 01:32PM WBC-12.3* RBC-4.47* HGB-14.1 HCT-39.9* MCV-89
MCH-31.5 MCHC-35.3 RDW-12.5 RDWSD-40.6
___ 01:32PM CALCIUM-8.3* PHOSPHATE-2.9 MAGNESIUM-1.7
___ 01:32PM estGFR-Using this
___ 01:32PM GLUCOSE-91 UREA N-20 CREAT-1.0 SODIUM-140
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-20* ANION GAP-15
___ 01:36PM LACTATE-1.1
___ 01:36PM ___ COMMENTS-GREEN TOP
Brief Hospital Course:
The patient transferred form OSH to the ED on ___ after
being diagnosed with SBO. He has been evaluated in the ED and
admitted to the regular floor for conservative management of
SBO.
Neurology: The patient was alert and oriented throughout
hospitalization; Pain was very well controlled. The patient was
then transitioned to oral pain medication once tolerating a
regular diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored.
GI/GU/FEN: The patient was initially kept NPO with NGT in place.
Eventually, NGT taken off once he started passing gas and moving
his bowel. Diet has advance to clears and subsequently, the
patient was advanced to regular diet which the patient was
tolerating on day of discharge.
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.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest and intravenous fluids and a
nasogastric tube was placed in your stomach to decompress your
bowels. Your obstruction has subsequently resolved after
conservative management. 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.
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.
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:
___
|
19802326-DS-9
| 19,802,326 | 21,368,813 |
DS
| 9 |
2191-03-03 00:00:00
|
2191-03-03 16:07:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / tamsulosin
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ y/o male with HCV cirrhosis followed by ___
liver clinic, afib, COPD, chronic pain and bipolar disorder who
presented with confusion. According to the patient's wife, he
was ___ admitted to ___ for 4 days for confusion
and was found to have a UTI. He was discharged on ___ to his
home and was doing relatively well. Overnight his wife found him
in the bathroom holding on to the wall and not responding to
her. He retunred to ___ where he was noted to have an
ammonia level was 53 and a creatinine of 1.8. His wife called
Dr. ___ and he was referred to ___.
According to his wife, he was discharged on antibiotics however
they were unable to fill the script. He was also taking
lactulose but was not having bowel movements. She states that he
was not having any fevers, vomiting, abdominal pain, diarrhea or
rashes.
Of note, patient has had multiple admissions to ___
___ for encephalopathy. It appears that there
are multiple etiologies for his decline in mental status.
In the ED, initial vs were: 97 40 ___ 97% RA. Patient
reportedly had SBP's in the 70's which came up with stimulation
to 85. He was given 25g of albumin and 1L of NS. Vitals upon
transfer 98.8 50 irreg 107/38 13 100% RA. They checked his
abdomen with ultrasound for fluid but there was not enough for
tap.
On arrival to the ICU, patient was lethargic and unable to
follow commands. He was noted ot have a blood pressure of
106/51.
Review of systems:
(+) Per HPI
(-) unable to obtain from patient
Past Medical History:
# Chronic hepatitis C infection -- Genotype 2
-- Pegylated interferon/ribivarin started ___
-- Discontinued after 8 weeks of planned ___ week course
-- Admission on ___ for possible interferon induced psychosis
--HCV VIRAL LOAD (Final ___: 15,600,000 IU/mL
# Atrial fibrillation
-- Previously on Coumadin
-- No Coumadin since ___hronic obstructive pulmonary disease
# Chronic musculoskeletal pain of unknown etiology
# Status post cholecystectomy
# History of substance abuse
# Possible myelodysplasia on recent bone marrow biopsy
# Bipolar disorder
# History of peptic ulcer disease
# Left lung empyema in ___
# Pilonidal cyst removal in ___
Social History:
___
Family History:
No family history of liver disease.
Father died from MI at age ___.
Physical Exam:
ADMISSION EXAM:
VS: 98.2 °F HR: 60 BP: 105/51 RR: 15 SpO2: 100%
___: patient was lethargic but in NAD, not following
commands
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregular, S1/S2 appreciated no m/r/g
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
DISCHARGE EXAM:
VS: 98.3 ___ 18 100%RA
___: Disheveled appearing, attentive
HEART: Irregular, normal rate, S1/S2 heard. No
murmurs/gallops/rubs.
LUNGS: CTAB no crackles or wheezes, non labored
ABDOMEN: Soft, nondistended non-tender to palpation. No guarding
or rebound
EXT: no edema b/l
SKIN: dry, coccyx wound bandaged
NEURO: no asterix
Pertinent Results:
ADMISSION LABS:
___ 06:57PM BLOOD WBC-10.4 RBC-3.13* Hgb-9.8* Hct-30.5*
MCV-98 MCH-31.2 MCHC-32.0 RDW-15.2 Plt ___
___ 06:57PM BLOOD Neuts-69.9 ___ Monos-5.6 Eos-1.9
Baso-0.6
___ 06:57PM BLOOD ___ PTT-30.8 ___
___ 06:57PM BLOOD Glucose-103* UreaN-28* Creat-1.5* Na-144
K-4.0 Cl-120* HCO3-23 AnGap-5*
___ 06:57PM BLOOD ALT-16 AST-38 AlkPhos-74 TotBili-0.2
___ 06:57PM BLOOD Lipase-58
___ 06:57PM BLOOD Albumin-3.5 Calcium-9.5 Phos-3.1 Mg-1.9
___ 06:57PM BLOOD Ammonia-52
___ 06:57PM BLOOD Lithium-0.4*
___ 06:57PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:04PM BLOOD Lactate-0.7
PERTINENT LABS:
___ 06:10AM BLOOD PTH-23
___ 06:10AM BLOOD 25VitD-28*
___ 06:10AM BLOOD CRP-80.8*
___ 04:45PM BLOOD b2micro-17.8*
___ 06:10AM BLOOD PEP-ABNORMAL B IgG-1550 IgA-180 IgM-111
IFE-MONOCLONAL
___ 06:00AM BLOOD Lithium-0.6
___ 05:45AM BLOOD Lithium-0.5
___ 06:57PM BLOOD Lithium-0.4*
___ 11:10PM BLOOD Lactate-1.2
___ 06:42AM BLOOD freeCa-1.35*
___ 08:01AM BLOOD freeCa-1.51*
___ 01:53PM BLOOD freeCa-1.54*
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-19.5* RBC-2.97* Hgb-9.4* Hct-30.5*
MCV-103* MCH-31.6 MCHC-30.7* RDW-16.2* Plt ___
___ 06:30AM BLOOD ___ PTT-27.7 ___
___ 06:30AM BLOOD Glucose-88 UreaN-42* Creat-1.9* Na-141
K-4.3 Cl-114* HCO3-18* AnGap-13
___ 06:30AM BLOOD ALT-20 AST-21 AlkPhos-72 TotBili-0.3
___ 06:30AM BLOOD Calcium-10.1 Phos-3.1 Mg-2.6
IMAGING:
___ CXR: Mild bibasilar atelectasis.
___ Abdominal U/S:
1. No focal liver lesion and no ascites.
2. Patent hepatic vasculature.
3. Minimal central biliary ductal dilatation with dilated common
hepatic duct (1.2cm), the etiology of which is unapparent. The
pancreatic duct is also noted to be mildly dilated (0.4cm). An
MRCP could further characterize.
4. Splenomegaly.
5. Simple bilateral renal cysts.
___ CXR:
There is unchanged evidence of mild-to-moderate pulmonary edema.
An area of atelectasis at the right lung base is slightly more
extensive than before. A linear lucency along the left chest
wall corresponds to a skinfold. Moderate cardiomegaly and
tortuosity of the thoracic aorta. No new parenchymal opacities.
No larger pleural effusions.
___ Sacral x-ray: No radiographic evidence of osteomyelitis.
However, MRI is more sensitive.
___: MRI pelvis:
No definitive evidence of osteomyelitis on this extremely
suboptimal examination which was terminated prematurely.
Followup MR examination with sedation or CT examination of the
pelvis would provide further imaging evaluation if clinically
warranted.
___ Skeletal survey:
1. Tiny 5-mm lucency in the right humeral head which is
equivocal for small myelomatous deposits. There is slight
mottling throughout the calvarium and the pelvis and the right
humerus.
2. Enchondroma within the left proximal humeral shaft.
3. Intact hardware, bilateral proximal femurs.
4. Degenerative changes of bilateral knees, predominantly
involving the medial compartment.
5. DISH involving the thoracic spine.
6. Degenerative changes of the thoracic and lumbar spines.
Brief Hospital Course:
___ gentleman with HCV cirrhosis, afib, COPD, chronic pain and
bipolar disorder who presented with confusion, due to hepatic
encephalopathy. Course complicated by ___, due to ATN, and
leukocytosis of unclear etiology but possibly due to MGUS vs
myelodysplastic disorder.
# Encephalopathy: Patient has a history of encephalopathy
however not ever attributed to hepatic encephalopathy. His wife
noted that when he develops an infection, his ammonia level goes
up and he becomes confused. She also noted that when he is not
consistent with his lactulose he becomes confused. Patient did
not have BM x2 days prior to admission. CT head at ___
negative for acute process. During this hospital stay the
patient's mental status/solmnolence improved with lactulose.
Methadone, ativan and seroquel initially held in the MICU, but
restarted once the patient was transfered to the floor.
On the floor the patient's mental status was stable on lactulose
until the morning of the ___ the patient was found to be
minimally responsive. Additionally, he developed a new O2
requirement, was diaphoretic on exam, and had elevated HR's to
150s. Given the patient's change in mental status he was given
naloxone. EKG showed afib with RVR, so he was given IV
metoprolol. Given his acute decompensation the patient was
transfered back to the MICU for further managment.
In the MICU the patient was found to have a retrocardiac opacity
on CXR and with rising leukocytosis and for this reason was
started on vanc + cefepime for possible HCAP vs. aspiration.
Oxygen was weaned. An NGT was placed and lactulose given Q 2
hours until the patient had a large amount of stool output. His
mental status cleared and patient was noted to be breathing well
on RA. He was transferred back to the floor on ___. On the
floor lactulose was continued and was titrated down to ___ bowel
movements per day and the patient's mental status returned to
his baseline. He should be continued on the lactulose at least
TID -- if the patient fails to have ___ bowel movements per day,
an extra dose of lactulose should be given.
# Monoclonal gammopathy, likely MGUS: The patient has a history
of myelodysplasia. Due to hypercalcemia he had a SPEP and UPEP
sent. His SPEP was notable for a monoclonal spike. The UPEP and
skeletal survey were equivocal. Heme/Onc was consulted and
believes this is most likely MGUS, rather than multiple myeloma.
He will need Heme/Onc follow up as a patient within in the next
few weeks to clarify his diagnosis.
[ ] f/u ___ 16:45 FREE KAPPA AND LAMBDA, WITH K/L RATIO
Results light chains which is Pending
# Leukocytosis: Patient was started on vanco/cefepime
empirically at time of transfer to MICU on ___. Subsequent
infectious work up was negative including CXR, UA & urine
cultures, blood cultures and MRI to r/o osteomyelitis. He was
empirically broaded to daptomycin and cefepime based on ID's
recommendations on ___. LDH was not elevated and differential
was not suggestive of blast crisis. After 8 days of antibiotics
ID consults recommended stopping all antibiotics as there was no
clear source of infection identified. In the following days he
continued to have a leukocytosis (WBC ___ but was afebrile
and had no focal complaints. Given no clear source of infection
it was thought that the leukocytosis was due to primary marrow
problem given concern for myedysplasia. The patient will be seen
by Heme/Onc as an outpatient to ensure MGUS/Leukocytosis follow
up.
# Acute Renal Failure: Patient was noted to have a creatinine of
1.8 at the OSH and 1.5 at ___. Based on the BUN creatining
ratio, is likely a prerenal etiology. HRS was unlikely based on
high urine Na. Cr trended upward and on ___ on the day the
patient was transfered back to the MICU a renal consult was
called. Renal Consult found that the etiology of his renal
failure was most likely due to ATN. Although HRS was less likley
the patient was given a 2 day albumin challenge and his
creatinine did not improve. Creat increased on ___ -- given
concurrent increase in BUN and large volume dirrhea this may
have been prerenal again. Urine lytes rechecked on ___ showed
FeNa of 2.06% c/w intristic renal process. Renal consult on ___
believe worsening ___ is still due to ATN with some component of
dehydration/prerenal azotemia. In the days prior to discharge
the patient's creatinine was downtrending/stable from 1.9-2.2.
# Hypotension: Patient reportedly had pressures in the 70's
while in the ED when he was admitted. Patient recieved 25g of
albumin and 1L of NS with good response. Unclear etiology of
hypotension but infection is of concern based on hitory. U/A was
notably within normal limits making UTI unlikely despite being
recently treated. Received one dose cefepime, then abx
discontinued after mental status improved (see above). Patient
did not require pressor support at any time during his stay in
the ICU. On the floor all blood pressures were stable.
# Cirrhosis: Patient has a history of cirrhosis secondary to
HCV. Based on his labs synthetic function appears to be
maintained with a normal albumin and near normal INR.
# Bipolar Disorder: Patient has a significant history of bipolar
disorder which appears to be controlled on his current regimen.
Continued home dose 300mg qHS. Continued lexapro.
# Chronic Pain: Patient has a history of chronic pain and is on
methadone for pain relief. On a specific regimen. Initially held
methadone which he gets QID 15mg in the morning, afternoon,
evening and 25mg at night, then restarted once the patient was
transfered to the floor on ___. Methadone was held upon
acute mental status change on transfer to the MICU. However, was
restarted the next day at a lower dose of 15 mg TID to prevent
withdrawl.
# Atrial Fibrillation: Patient is rate controlled. Not being
anticoagulated due to risk of falls. Initially held metoprolol
due to hypotension, then given IV metoprolol on ___ for RVR. On
transfer to the MICU initially he was started on diltiazem,
however this was discontinued prior to transfer to the floor
given rate control and soft SBPs.
# Sacral decubitus ulcer: The patient was seen by Wound Care who
made recommendations for dressing changes. Given a new
leukocytosis on which developed on ___ (while the patient was
on antibiotics for presumed aspiration PNA) and with all other
infectious work up being negative there was concern for
osteomyelitis. On ___ he had a xray of sacrum which was
difficult to interpret given degenerative changes seen on
imaging. Subsequent MRI was not suggestive of osteomyelitis. In
the days prior to discharge the wound seemed to be improving.
Daily wound care will need to be continued while the patient is
at rehab.
TRANSITIONAL ISSUES:
#Patient will need Heme/Onc follow up as an outpatient for MGUS
vs multiple myeloma.
#Patient will need Chem 10 labs checked the week of ___ to ensure that creatinine is downtrending and bicarbonate
is stable, if the bicarbonate level is normal sodium bicarbonate
supplement can be discontinued.
#PENDING RESULTS: f/u ___ FREE KAPPA AND LAMBDA, WITH
K/L RATIO Results light chains which is pending at the time of
discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 10 mg PO DAILY
2. Lactulose 30 mL PO TID
3. Allopurinol ___ mg PO DAILY
4. Lithium Carbonate 300 mg PO QHS
5. Lidocaine 5% Patch ___ PTCH TD DAILY:PRN Pain
6. Quetiapine Fumarate 50 mg PO QHS
7. Lorazepam 0.5-1 mg PO Q8H:PRN Anxiety
8. Methadone 30 mg PO QAM
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Naproxen 500 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Aspirin 81 mg PO DAILY
13. Escitalopram Oxalate 10 mg PO QHS
14. Rifaximin 550 mg PO BID
15. Methadone 20 mg PO BID
at 12pm and 4pm
16. Methadone 35 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Escitalopram Oxalate 10 mg PO QHS
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Lactulose 30 mL PO TID
5. Lidocaine 5% Patch ___ PTCH TD DAILY:PRN Pain
6. Lithium Carbonate 300 mg PO QHS
7. Methadone 15 mg PO QID
8. Quetiapine Fumarate 50 mg PO QHS
9. Rifaximin 550 mg PO BID
10. Collagenase Ointment 1 Appl TP DAILY
11. Metoprolol Tartrate 25 mg PO BID
12. Sodium Bicarbonate 1300 mg PO QID
13. Vitamin D 800 UNIT PO DAILY
14. Finasteride 10 mg PO DAILY
15. Lorazepam 0.5-1 mg PO Q8H:PRN Anxiety
16. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hepatic encephalopathy
Acute on chronic renal failure
MGUS vs multiple myeloma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to participate in your care at ___. You came
to the hospital because of increased confusion. We gave you
lactulose and your confusion improved. We were concerned that
you had an infection so you were given antibiotics. You were
seen by the Infectious Disease team who believes that you were
not infected, so your antibiotics were stopped. You were seen by
the Renal team because your kidney function was poor during this
hospital stay. You were seen by the Oncology team due to your
abnormal labs -- you will need to be seen by the Oncology team
after you leave the hospital for further management.
Please keep all follow up appointments. Please take all
medications as prescribed.
Followup Instructions:
___
|
19802576-DS-11
| 19,802,576 | 21,256,497 |
DS
| 11 |
2193-03-21 00:00:00
|
2193-03-21 16:19:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / strawberry / shellfish derived
Attending: ___.
Chief Complaint:
mouth pain, poor po intake
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ personal care assistant with a ___
pertinent for anxiety/depression, fibroids, anemia, asthma,
allergic rhinitis, and tobacco-marijuana smoking (20+ years,
often 10 blunts daily) who presents with several weeks of
worsening oral pain leading to poor oral intake and dehydration
who was sent from her PCP's office ___ for further evaluation
of
these issues.
Patient presented to primary care clinician at ___ on ___ with concern for sore throat that made
swallowing painful. She had been taking acetaminophen without
relief. Initial concern was for pharyngitis and throat cultures
were sent but negative. Because of lack of relief of her
symptoms, she went to ___ and they gave her
ibuprofen
and vicious lidocaine, and did blood work, and sent her home
from
the ED. Patient again presented to ___ ___ and
reported continued severe pain that was making it difficulty to
eat. She also reported that ___ had contacted her to let her
know her lab work showed she was positive for HSV (later
confirmed: HSV1 and HSV IgG positivity,
Monospot negative). She reported she was taking acetaminophen
and
even took some oxycodone left over from a prior surgery that
partially helped. She was still eating and drinking little, had
minimal urine output, and was feeling weak. In the clinic she
was
noted to have BP 78/52 (lying) with HR of 127. Given the
persistent difficulty with oral intake and low blood pressure
she
was sent to the ___ ED for further evaluation.
Arriving at the ED she was noted to be afebrile with normal
vitals including low-normal BP (about 100/70). Exam was notable
for a large lesion in the mid-soft palate. Labs were notable for
Cr 1.4 (improved to 1 with fluids) and low potassium and
magnesium for which she got repletion. CMV serologies were sent.
She was started on acyclovir 250mg IV q8 and got several doses.
She was given several liters of IVF. She received medications
for her pain including magic mouth wash, cepacol lozenges, and
acetaminophen. Initially NPO, she by midday ___ she was feeling
better and switched from NPO to regular diet, which she
tolerated
well. ___ was consulted and evaluated her mouth lesion and
initial assessment was suspicion for tumor or malignancy and
very
low suspicion for infectious process. ___ requested maxillary
facial CT with contrast and planned to likely pursue setting up
outpatient follow-up when they would perform a biopsy.
ROS:
Pertinent positives and negatives as noted in the HPI. All
other
systems were reviewed and are negative. Negative or CP, SOB,
fevers/chills, vomiting, diarrhea, abdominal pain.
Past Medical History:
PAST PSYCHIATRIC HISTORY:
-Sx/Dx: bipolar disorder, PTSD
.
PAST MEDICAL HISTORY:
ALLERGIC RHINITIS
ASTHMA
HEMORRHOIDS
TOBACCO ABUSE
ECZEMATOUS DERMATITIS
HEARING LOSS
ANEMIA
DYSMENORRHEA
FIBROIDS
CANNABINOID HYPEREMESIS SYMDROME
PCP: ___, NP at ___
Social History:
SUBSTANCE ABUSE HISTORY:
Tobacco: remote history, denies current use
EtOH: denies
Marijuana: reports ___ blunts daily on weekdays and more on
weekend days.
Other substances: denies
.
FORENSIC HISTORY:
___
SOCIAL HISTORY:
___
Family History:
FAMILY PSYCHIATRIC HISTORY:
Per chart review, grandmother has bipolar disorder and that
there is substance use and depression in other family members.
Physical Exam:
VITALS: Afebrile and vital signs stable
T 98.3, BP 99/65, HR 85, RR 18, O2 sat 100% on RA.
GENERAL: Anxious thing woman in hospital bed, in no apparent
distress
EYES: PERRL. EOMI. Anicteric sclerae.
ENT: Ears and nose without visible erythema, masses, or trauma.
No mucosal lesions noted. Eroding lesion of the soft palate
observed, about midline, without bleeding. No cervical
lymphadenopathy or gland tenderness noted.
CV: Regular rate and rhythm. Normal S1 S2, no S3, no S4. No
murmur. No JVD.
PULM: Breathing comfortably on room air. Lungs clear to
auscultation. No wheezes or crackles. Good air movement
bilaterally.
GI: Bowel sounds present. Abdomen non-distended, soft,
non-tender
to palpation.
GU: No suprapubic fullness or tenderness to palpation.
EXTR: No lower extremity edema. Distal extremity pulses palpable
throughout.
SKIN: No rashes or scars noted.
NEURO: Alert. Oriented to person/place/time/situation. Face
symmetric. Gaze conjugate with EOMI. Speech fluent. Moves all
limbs spontaneously. No tremors or other involuntary movements
observed.
PSYCH: Anxious but pleasant, cooperative. Follows commands,
answer questions appropriately. Appropriate affect.
Pertinent Results:
___ 04:55AM BLOOD WBC-6.3 RBC-3.88* Hgb-9.9* Hct-30.5*
MCV-79* MCH-25.5* MCHC-32.5 RDW-16.5* RDWSD-47.7* Plt ___
___ 01:31PM BLOOD WBC-7.6 RBC-5.32* Hgb-13.6 Hct-42.1
MCV-79* MCH-25.6* MCHC-32.3 RDW-17.5* RDWSD-46.3 Plt ___
___ 01:31PM BLOOD Neuts-56.9 ___ Monos-14.2*
Eos-0.7* Baso-0.5 Im ___ AbsNeut-4.33 AbsLymp-2.08
AbsMono-1.08* AbsEos-0.05 AbsBaso-0.04
___ 04:55AM BLOOD ___
___ 01:31PM BLOOD Plt ___
___ 04:55AM BLOOD Glucose-93 UreaN-10 Creat-0.7 Na-135
K-3.2* Cl-91* HCO3-32 AnGap-12
___ 10:00PM BLOOD Glucose-110* UreaN-13 Creat-0.8 Na-136
K-3.4* Cl-92* HCO3-35* AnGap-9*
___ 02:58PM BLOOD ALT-9 AST-18 AlkPhos-61 TotBili-0.4
___ 04:55AM BLOOD Calcium-8.8 Phos-2.2* Mg-2.4
___ 04:55AM BLOOD Trep Ab-PND
___ 02:58PM BLOOD CMV IgG-PND CMV IgM-PND CMVI-PND
___ 10:00PM BLOOD HIV Ab-NEG
___ 01:40PM BLOOD Lactate-1.9
___ 01:31PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-PND
___ 02:58PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-PND
___ 8:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT
INDICATION: ___ year old woman with oral ulcer, c/f malignancy,
unable to
tolerate MRI// ?malignancy
TECHNIQUE: MDCT acquired helical axial images were obtained
from the thoracic
inlet through the skull base.
Coronal and sagittal multiplanar reformats were then produced
and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.7 s, 24.2 cm; CTDIvol = 8.1 mGy
(Body) DLP = 191.8
mGy-cm.
2) Spiral Acquisition 3.7 s, 24.2 cm; CTDIvol = 23.1 mGy
(Body) DLP = 543.5
mGy-cm.
Total DLP (Body) = 735 mGy-cm.
COMPARISON: MRI nasopharynx dated ___.
FINDINGS:
Imaging was initially attempted with intravenous contrast
material. However,
due to technical error, the contrast was not administered in the
appropriate
amount or at the appropriate time of the study.
The study is limited in the absence of intravenous contrast.
Dental amalgam
artifact further limits evaluation of the oral cavity.
Aero digestive tract: 3.6 cm x 2.9 cm x 1.1 cm soft palate soft
tissue
fullness is better assessed on MRI ___.. No bone
destruction. No
other abnormalities. No evidence of perineural tumor.
Neck lymph nodes: There are multiple bilateral scattered
subcentimeter level
I-VI cervical lymph nodes, not pathologically enlarged based on
CT size
criteria. There is no retropharyngeal adenopathy.
Extra nodal tumor spread: There are no findings suggestive of
extra nodal
extension.
Deep neck muscles, masticator space: There is no muscle
invasion.
Bones, skull base:
There is no bone involvement.
There are no findings suggestive of perineural tumor extension.
Jugular
foramen, carotid canal, pterygopalatine fossa, infraorbital
foramen, other
skull base foramina are not involved.
Vessels: There is no vascular invasion.
Brachial Plexus: There is no brachial plexus contact or
invasion.
Thyroid, salivary glands: There is no mass.
Other findings: There are no lung nodules.
IMPRESSION:
1. Technical failure of IV contrast administration. Essentially
noncontrast scan.
2. Stable appearance of the hard/soft palate soft tissue
abnormality.
3. No definite adenopathy.
EXAMINATION: MRI NASOPHARYNX W/O CONTRAST
INDICATION: ___ year old woman with oral leision// Oral lesion,
rule out
malignancy
TECHNIQUE: Study is limited due to patient inability to
complete the exam.
Sagittal T1 imaging of the brain was obtained. Axial T1 and T2
fat sat of the
nasopharynx were obtained. Coronal STIR and T1 fat-sat
precontrast of the
nasopharynx were obtained. After which, the patient was unable
to complete
exam.
FINDINGS:
Limited study due to patient inability to complete the exam. No
post-contrast
imaging was obtained.
Lobulated T2 hyperintense submucosal lesions are seen involving
the midline
hard palate. The lesion appears confined to the hard palate
without soft
palate involvement.
Otherwise, the visualized aerodigestive tract is unremarkable.
There is no
lymphadenopathy. The parotid and submandibular glands carotid
remarkable.
The visualized brain and orbits are unremarkable. The mastoid
air cells are
clear.
IMPRESSION:
1. Limited study due to patient inability to complete the exam.
No
postcontrast imaging was obtained.
2. Lobulated mucosal lesions involving the midline hard palate,
differential
considerations include necrotizing sialometaplasia. Direct
visualization is
recommended.
3. No lymphadenopathy.
4. 5-mm descent of the cerebellar tonsils likely secondary to
tonsillar
ectopia.
Brief Hospital Course:
Ms. ___ is a ___ personal care assistant with a PMH
including anxiety/depression and tobacco-marijuana smoking (20+
years, often 10 blunts daily) who presents with several weeks of
worsening oral pain leading to poor oral intake and dehydration
who was sent from her PCP's office ___ for further evaluation
of
these issues. Admitted for management of painful soft palate
lesion likely contributing to poor po intake as well as ___ and
hypokalemia.
# Soft palate lesion
Per ___ Consult service,
"Given that she reports having it for several weeks, it would be
unlikely to be infectious or developmental in nature. Given the
bilateral nature of it, trauma seems less likely, though
necrotizing sialometaplasia is in the differential. Systemic
conditions with oral manifestations, such as granulomatosis with
polyangiiitis, SLE, immunocompromised state, Behcet's disease,
or
syphilis may also be in the differential. It is somewhat
concerning for benign or malignant tumor of the minor salivary
glands, and as a result, biopsy and imaging would be indicated."
She received CT of the area as well as an MRI, though the latter
was not completely diagnostic secondary to motion artifact. In
my discussion with ___ they think that the relatively rapid
onset was consistent with reactive injury. She will follow-up
in clinic on ___. She was given Tylenol, Lidocaine, and
Tramadol for pain. She understands that the pain will not go
away completely, but the medicine will allow her to have
acceptable oral intake.
# Recent poor po intake
Although history suggested throat issues, assessment since
arriving at ___ suggests that the oral lesion is the cause of
her pain and difficulty eating. Now that she's gotten pain
treatment she is eating well without obvious swallowing issues.
Low suspicion for infection at this point. CMV esophagitis would
be unusual in an immunocompetent individual and wouldn't explain
oral lesion so there was no need for acyclovir. Her HIV was
negative. Final tests for different infections were pending at
the time of discharge, but she can follow up with her PCP to go
over results.
# Hypokalemia
Presumably related to recent poor oral intake. She received oral
supplementation of this and phosphorous, and was encouraged to
have high potassium foods on discharge with recheck with her PCP
next week.
# s/p ___ due to dehydration
Initial Cr 1.4 with elevated BUN. S/p fluids, now normalized to
0.7. She was able to eat all of her breakfast and lunch without
any difficulty prior to discharge.
#Anxiety - she was upset and also tearful with many aspects of
her hospital stay. She was given Klonopin 0.5 and Xanax 0.5 in
order to go through with the CT scan. I was very firm that
these were intended for one-time uses, and not intended to be
continued on an outpatient basis.
Pending Results at discharge that PCP ___ need to follow:
Labs
___ 14:58 CMV IgG Ab
___ 14:58 CMV IgM Ab
___ 04:55 Treponema pallidum (Syphilis) Antibodies
Send Outs
___ 14:58 HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM
___ 13:31 HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY IGM
Microbiology
___ 18:04 THROAT CULTURE VIRAL CULTURE: R/O HERPES SIMPLEX
VIRUS
I spent > 30 min in discharge planning and coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN throat pain
2. ProAir HFA (albuterol sulfate) 2 puffs inhalation Q4H:PRN
wheezes
3. Fluticasone Propionate NASAL ___ SPRY NU DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. norgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-35 mcg (28)
oral 1 tablet daily
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
7. Docusate Sodium 100 mg PO BID
8. Ferrous Sulfate 325 mg PO BID
9. Senna 17.2 mg PO BID
10. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
Discharge Medications:
1. Lidocaine Viscous 2% 15 mL PO TID
RX *lidocaine HCl [Lidocaine Viscous] 2 % 10 ml three times a
day Refills:*2
2. Polyethylene Glycol 17 g PO TID:PRN Constipation - First
Line
RX *polyethylene glycol 3350 17 gram 1 packet(s) by mouth twice
a day Disp #*30 Packet Refills:*0
3. TraMADol 50 mg PO TID:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth three times a day Disp
#*12 Tablet Refills:*0
4. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN throat pain
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
7. Docusate Sodium 100 mg PO BID
8. Ferrous Sulfate 325 mg PO BID
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. Fluticasone Propionate NASAL ___ SPRY NU DAILY
11. norgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-35 mcg
(28) oral 1 tablet daily
12. ProAir HFA (albuterol sulfate) 2 puffs inhalation Q4H:PRN
wheezes
13. Senna 17.2 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Soft palate mass
Acute Kidney injury
Hypokalemia
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 both to understand the reason
there is a mass on the roof of your mouth, and to give medicine
to make it more comfortable. You had scans that will help the
oral surgeons determine what next steps you will need in order
to get a diagnosis, which may include a biopsy in the future.
You will continue to experience some mouth swelling and
soreness, which is normal, but the medicines should make it
easier. As long as you are able to eat some food and drink
fluids, there is no need to come to the hospital. If you have
concerns, we encourage you to check with your primary care
providers as the first step.
We wish you the best in your recovery,
Your ___ team
Followup Instructions:
___
|
19802576-DS-6
| 19,802,576 | 22,187,976 |
DS
| 6 |
2186-05-11 00:00:00
|
2186-05-20 23:37:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
n/v since ___
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
___ F with bipolar disorder, anxiety not on medications, on
disability for these psychiatric disorders with multiple ED
visits for N/V (improved with IVF and no other interventions),
vaginitis/UTI, and myriad of other nonspecific joint complaints
presents with continued n/v, inability to tolerate PO since
___. Patient was very vague and did not offer any
details as to how recent episode started. From what I could
gather, patient was otherwise well until ___ or ___ when
all of a sudden, patient began to have nausea, vomiting leading
to epigastric abdominal discomfort, inability to tolerate PO.
Patient came to the ED, was given compazine, IVF, and
instructions to ease diet to liquids/popsicles until symptoms
improve. Patient reported to PCP that she remembers being in her
brother's home on ___ and woke up ___ at a stranger's house.
When she woke up, patient noticed a broken front tooth and cuts
on her hand. She believes that she was drugged. She states that
she drinks regularly on weekends, about ___ drinks/night, and
has been smoking marijuana regularly since age ___, last smoked
on ___. States that she does not have any drug use or h/o
IVDU. Patient states that she does not take any psychiatric
drugs nor is she followed by a psychiatrist/psychologist b/c she
does not like how the medications make her feel. Pt has had no
hx of any GI bleeding or gastritis in past.
In the ED, VS: 98.3 67 113/73 18 98%RA. Patient was given 2L NS,
PO/PR compazine and IV ativan without immediate resolution of
sx. KUB without obstruction/free air. Patient was then admitted
to medicine for further evaluation.
Upon arrival, VSS and patient feels much better, without n/v.
Patient also describes passing gas and occasionally having
diarrhea, a couple of BM/day. No fevers/chills, weight loss.
Abdominal pain c/w strain from mult emesis. Patient denies any
blood in vomit, says that she's not sure if it has been liquid,
food, or bilious. Patiet with weakness and malaise. Currently on
period. No cough, SOB, CP, wheeze.
Past Medical History:
bipolar disorder
asthma
UTI
___ vaginitis
Neck spasm
N/V with no etiology found in past
Social History:
___
Family History:
Father passed away of cancer, unsure what kind or at what age.
Mother currently alive, in good health.
Physical Exam:
Physical Exam on Admission:
VS: 98.0 74 126/81 18 100%
NAD, A+Ox3, annoyed at having to answer questions, under bed
covers, feeling cold. No obvious signs of trauma except L front
tooth broke in half
Neck: supple w/o LAD
Chest: clear w/o wheeze
Cardiac: RRR, normal S1/S2
abdomen: soft, NT/ND, slight epigastric tenderness on palp.
Skin: clear w/o rash
Physical Exam on Discharge:
NAD, A+Ox3
Neck: supple w/o LAD
Chest: clear w/o wheeze
Cardiac: RRR, normal S1/S2
abdomen: soft, NT/ND
Skin: clear w/o rash
Pertinent Results:
Labs on Admission:
___ 08:57AM BLOOD WBC-6.8 RBC-4.00* Hgb-11.8* Hct-35.7*
MCV-89 MCH-29.6 MCHC-33.1 RDW-12.4 Plt ___
___ 08:57AM BLOOD Glucose-107* UreaN-7 Creat-0.7 Na-143
K-3.2* Cl-104 HCO3-25 AnGap-17
___ 08:57AM BLOOD ALT-14 AST-15 LD(LDH)-170 AlkPhos-46
TotBili-0.6
___ 08:57AM BLOOD Neuts-69.8 ___ Monos-4.9 Eos-1.5
Baso-0.4
___ 08:57AM BLOOD Lipase-15
___ 08:57AM BLOOD Albumin-4.7
___ 05:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:00AM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:00AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-4* pH-8.0 Leuks-NEG
___ 10:00AM URINE RBC-102* WBC-2 Bacteri-MOD Yeast-NONE
Epi-3
___ 10:00AM URINE AmorphX-OCC
___ 10:00AM URINE Mucous-MANY
___ 10:00AM URINE UCG-NEGATIVE
Labs on Discharge:
___ 07:30AM BLOOD WBC-6.0 RBC-3.26* Hgb-9.8* Hct-29.5*
MCV-91 MCH-30.1 MCHC-33.2 RDW-12.7 Plt ___
___ 07:30AM BLOOD Glucose-72 UreaN-5* Creat-0.7 Na-142
K-3.3 Cl-108 HCO3-23 AnGap-14
___ 07:30AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.9
Micro: None
Imaging:
KUB
1. Paucity of bowel gas, but no definite signs of obstruction.
2. No evidence of free air.
Brief Hospital Course:
___ F with bipolar disorder/anxiety not on medications, on
disability for these psychiatric disorders with multiple ED
visits for N/V (improved with IVF and no other interventions),
vaginitis/UTI, and myriad of other nonspecific joint complaints
presents with continued n/v likely ___ cyclic vomiting syndrome,
perhaps induced by regular marjiuana usage.
# N/V: Patient has repeated ED visits for similar complaint,
which generally resolves with IVF and anti-emetics. Patient had
recent ETOH/marjiuana usage and symptoms subsided by the time
the patient arrived the floor. Likely ___ EtOH, marijuana, or
other drug ingestion. Other ddx include gastritis, GERD, or PUD.
Patient was given zofran as needed, as well as intravenous
fluids initially. LFTs WNL as was KUB. We explained to the
patient that we think this may be cyclic vomiting ___ marjiuana
usage and advised for her to stop. Should her symptoms continue,
patient may need an EGD as outpatient to f/u for gastritis/PUD.
Medications on Admission:
ALBUTEROL NEBULIZER EVERY 4 TO 6 HOURS AS NEEDED FOR ASTHMA
ALBUTEROL SULFATE 2 (Two) puff(s)q ___ h prn
FLUTICASONE 50 mcg 2 puff daily
IBUPROFEN - 600 mg q 8 h prn fever or pain
TRIAMCINOLONE affected areas BID
MINERAL OIL BID
Discharge Medications:
1. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puffs Inhalation every ___ hours as needed for shortness of
breath or wheezing.
3. triamcinolone acetonide 0.025 % Ointment Sig: One (1) Appl
Topical twice a day.
4. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea for
5 days.
Disp:*15 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
cyclic vomiting syndrome, likely ___ marijuana use
.
UTI, vaginitis
neck spasm
non-specific joint pain
bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for nausea and vomiting, likely secondary to a
phenomenon called cyclic vomiting from chronic marijuana use.
You were treated with medications to help curb your nausea but
in order to prevent this from happening in the future, you will
need to stop using marijuana.
Please follow up with your PCP, ___.
We have sent you home with zofran, for you to take as needed for
nausea.
Followup Instructions:
___
|
19802576-DS-7
| 19,802,576 | 28,362,473 |
DS
| 7 |
2188-08-05 00:00:00
|
2188-08-05 18:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Cannabinoid Hyperemesis Syndrome
Post-Operative Nausea and Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p hemorrhoid surgery presents with persistent nausea,
vomiting and abdominal pain. Patient said she had her surgery 2
days ago by Dr. ___ at ___ and developed nausea and
vomiting immediately following surgery. Reports that she
developed periumbilical abdominal pain soon after. Some lower
abdominal pain. Says she actually does not have pain at the site
itself. No fevers or chills. No urinary symptoms. Passing gas.
Has had multiple bowel movements, but denies diarrhea. First
bowel movement had some bright red blood coating it, subsequent
bowel movements were brown. She is currently having her period.
Denies any urinary symptoms. She denies having any prior issues
with nausea/vomiting in the past, although on review of records,
she was hospitalized with similar symptoms in ___ and had
multiple ED visits for similar symptoms prior to that time. On
this occasion, she reports that symptoms improved transiently
with hot showers. Tried mylanta and procholperazine from her PCP
at home without relief.
In the ED, initial vitals were ___ pain, T 98.5, HR 60, BP
113/67, RR 16, SaO2 100% on RA. Labs notable for Was given
ondansetron 4mg x3, APAP 500mg, lorazepam 2mg, metoclopramide
10mg, and a scopolamine patch. ED felt that, as patient was
unable to tolerate any PO and immediately vomits, she was not
safe to go home; colorectal surgery team was FYId and patient
was admitted to general medicine.
On the floor, patient complaining of nausea and abdominal
discomfort, requesting to take a hot shower.
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 diarrhea, constipation. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
Cannabinoid Hyperemesis Syndrome
Prolapsing bleeding internal anal hemorrhoids status-post
operative hemorrhoidectomy and elastic band ligation
Mood Disorder (records mention Bipolar Disorder, Depression,
Anxiety, and/or Agoraphobia)
Nausea/Vomiting with no clear past etiology
Allergic Rhinitis
Asthma
Multiparity (>5 pregnancies)
Current 0.5 Pack/Day Smoker
Eczematous Dermatitis
Iron Deficiency Anemia
Urinary Tract Infection
Vulvovaginal Candidiasis
Neck Spasm
Social History:
___
Family History:
Significant for breast cancer ___ yo sister with invasive ductal
carcinoma), unknown malignancy in father.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 99.7, 120/58, 56, 20, 99%/RA
General: Alert, oriented, appears anxious and uncomfortable
HEENT/NECK: Sclera anicteric, MMM, oropharynx clear, EOMI,
PERRL, neck supple
CV: mild bradycardia, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, mild diffuse tenderness to deep
palpation without rebound/guarding, normal BS
Rectal: external suture noted, no surrounding swelling/erythema,
no visible drainage or bleeding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, strength and sensation grossly intact
DISCHARGE PHYSICAL EXAM:
Vitals: 99.5, 48-57, 122-135/62-81, 18, 100% on RA
General: Alert, oriented, fatigued, easily and without pain
flexing abdomen
HEENT/NECK: Sclera anicteric, MMM, oropharynx clear, EOMI,
PERRL, neck supple
CV: Mild bradycardia, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-distended, mild tenderness in epigastrium, no
guarding/rebound, normal BS
Rectal: external suture noted, no surrounding swelling/erythema,
no visible drainage or bleeding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, strength and sensation grossly intact
Pertinent Results:
___ 10:00AM BLOOD WBC-11.4* RBC-3.68* Hgb-11.1* Hct-33.2*
MCV-90 MCH-30.3 MCHC-33.5 RDW-14.3 Plt ___
___ 10:00AM BLOOD Neuts-80.6* Lymphs-12.6* Monos-6.1
Eos-0.6 Baso-0.1
___ 10:00AM BLOOD ___ PTT-24.4* ___
___ 10:00AM BLOOD Glucose-135* UreaN-15 Creat-0.7 Na-142
K-3.3 Cl-98 HCO3-26 AnGap-21*
___ 05:40AM BLOOD Glucose-117* UreaN-8 Creat-0.7 Na-141
K-2.8* Cl-100 HCO3-30 AnGap-14
___ 10:00AM BLOOD ALT-21 AST-23 AlkPhos-45 TotBili-0.5
___ 10:00AM BLOOD Lipase-14
___ 10:00AM BLOOD Albumin-5.1
___ 10:07AM BLOOD Lactate-2.8*
___ 06:27AM BLOOD Lactate-1.3
___ 11:25AM URINE Blood-TR Nitrite-NEG Protein-300
Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-2* pH-8.5* Leuks-NEG
___ 11:25AM URINE RBC-23* WBC-2 Bacteri-NONE Yeast-NONE
Epi-1
___ 11:25AM URINE UCG-NEGATIVE
AXR ___ = No evidence of obstruction noting limited
evaluation due to paucity of bowel gas.
EKG ___ = HR 48, sinus, QTc 457, no electrolyte disturbance
changes
HEMORRHOID SURGERY OPERATIVE NOTE ___ =
DATE OF OPERATION: ___
PREOPERATIVE DIAGNOSIS: Prolapsing bleeding internal anal
hemorrhoids.
POSTOPERATIVE DIAGNOSIS: Prolapsing bleeding internal anal
hemorrhoids.
NAME OF PROCEDURE: ___ hemorrhoidectomy and elastic band
ligation.
SURGEON: Dr. ___.
ANESTHESIA: Local with sedation.
INDICATIONS: The patient is a ___ female who had
previously been treated conservatively with elastic band
ligation for her internal hemorrhoids without success. She
understands the risks and benefits of the procedure and agrees
to proceed.
DESCRIPTION OF PROCEDURE: The patient is brought to the
operating room and Properly identified as the patient. Placed
on the operating room table in the prone position after
obtaining adequate sedation. She was placed in the jackknife
position and her buttocks were tapped apart. Skin overlying the
perianal region was prepped with Betadine solution and draped
sterilely after an appropriate surgical timeout. Bilateral
anal nerve block was created with a combination of Marcaine and
lidocaine bicarbonate and epinephrine. Following this using a
Sawyer anal retractor the left lateral hemorrhoid column was
identified. A ligating stitch of ___ Vicryl was placed
proximally at the pedicle of the hemorrhoid and after this was
tied and tightened the hemorrhoid was excised from distal to
proximal by removing the external and internal hemorrhoids in a
column. Hemostasis was obtained and the incisions then closed
in a continuous running locked fashion out to the dentate line
and then in a nonlocked fashion out to the distal aspect.
Again hemostasis was assured. Attention was turned to the right
anterior position. A significantly enlarged hemorrhoid was
similarly identified in this location. A ligating
figure-of-eight stitch was placed in the proximal aspect of the
hemorrhoid column and the hemorrhoid was excised from distal to
proximally and amputated, sent off as a separate specimen.
Again hemostasis was assured with direct pressure and the
incision was closed in a continuous running locked fashion.
Completing this attention was turned to the right posterior
position. The internal hemorrhoid in this location was only
slightly enlarged or modestly enlarged. The external
hemorrhoid was not _____ there was no evidence of bleeding and
so we opted for elastic band ligation in this location.
Completing this a dry bulky dressing was placed externally.
The patient was rotated back in a supine position and sent to
recovery stable And extubated. All needle, sponge and
instrument counts are correct. Estimated blood loss was less
than 10 mL. Drains were none. Specimens were left lateral and
right anterior hemorrhoid separately to pathology. I was
present, scrubbed and performed the entire procedure.
DISCHARGE LABS
___ 03:40PM BLOOD Na-139 K-3.5 Cl-102
Brief Hospital Course:
___, a ___ yo F PMHx chronic daily marijuana use and
hemorrhoids s/p hemorrhoidectomy ___ presents with persistent
nausea/vomiting with abdominal pain and inability to tolerate PO
and refractory to numerous anti-emetics. On ___ AM, she was
able to tolerate clears diet and crackers and was willing to go
home.
# Cannabinoid Hyperemesis Syndrome / PONV: Persistent
post-operative nausea with inability to take PO. Has elevated
lactate with leukocytosis and ketonuria but has normal
BMP/LFTs/Lipase/hCG/AXR. Most likely post-op nausea and vomiting
given time course, although marijuana-induced hyperemesis also
in ddx given daily marijuana use and relief with hot showers.
Patient previously had recurrent episodes of nausea and vomiting
attributed to cyclic vomiting vs marijuana hyperemesis. Also
with significant psychiatric history, which may be contributing
to symptoms. eosinophilic esophagitis also a possibility given
hx of ectopy but less likely. EKG in AM showed bradycardia to
48, sinus, QTc 457. She was initially treated with ondansetron,
prochlorperazine, and lorazepam IV along with scopolamine patch
and famotidine for symptomatic relief. She went home with PO/PR
anti-emetics and instructions to avoid marijuana as it was
causing her nausea/vomiting.
# Hypokalemia: K 2.8 on AM labs from 3.3 in ED, likely related
to repeated emesis. She was given several IV K+ repletions as
part of maintenance IV fluids and as an initial bolus. Final K+
was 3.5 on discharge.
# Bradycardia: HR ___ without clear lightheadedness,
dizziness, pre-syncope, or chest pain. Possibly constitutional
(otherwise healthy patient) and parasympathetic tone from
repeated Valsalva maneuvers. She remained hemodynamically
stable in sinus throughout her hospital stay.
# Abdominal Pain: Epigastric likely related to vomiting,
improved with PR acetaminophen and famotidine. Patient
requested avoidance of opioids as this may increase her nausea.
Substantially improved on discharge.
# Status-Post Hemorrhoidectomy ___: Post-operative
nausea/vomiting was at least a component but hard to define
feature of her presentation. She was continued on a
Senna/Docusate bowel regimen to avoid constipation.
# Mood Disorder: Variable but stable history of depression,
anxiety and agorophobia continued on home olanzapine 10mg qHS.
# Atopy: Chronic stable issues, but eosinophilic esophagitis is
a potential cause of nausea/vomiting in this patient (less
likely with prompt improvement). Continued on home albuterol
inhaler, fluticasone nasal spray
# Iron-Deficiency Anemia: Patient has had chronic issues with
anemia, attributed to bleeding from her hemorrhoids. Home
ferrous sulfate held during hospital stay given risk of
constipation but restarted on discharge.
# Code Status: Full Code, no health care proxy documented.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea, wheeze
2. Clobetasol Propionate 0.05% Cream 1 Appl TP BID:PRN itch
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Hydrocortisone Acetate Suppository 1 SUPP PR QHS:PRN
hemorrhoids
6. Ibuprofen 800 mg PO Q8H:PRN pain
7. OLANZapine 10 mg PO HS
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Docusate Sodium 100 mg PO BID
10. loratadine-pseudoephedrine ___ mg oral daily
11. Mineral Oil ___ mL PO BID:PRN affected area
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea, wheeze
2. Docusate Sodium 100 mg PO BID
3. Fluticasone Propionate 110mcg 2 PUFF IH BID
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. OLANZapine 10 mg PO HS
6. Clobetasol Propionate 0.05% Cream 1 Appl TP BID:PRN itch
7. Hydrocortisone Acetate Suppository 1 SUPP PR QHS:PRN
hemorrhoids
8. Ibuprofen 800 mg PO Q8H:PRN pain
9. loratadine-pseudoephedrine ___ mg oral daily
10. Mineral Oil ___ mL PO BID:PRN affected area
11. Famotidine 20 mg PO BID:PRN Abdominal Pain
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
13. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*12 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cannabinoid Hyperemesis Syndrome / Post-Operative Nausea and
Vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted because you were having
nausea/vomiting and couldn't eat anything. We gave you fluids,
made sure your electrolytes stay normal, and discharged you once
you were eating some food. Best of luck to you in your future
health.
Please stop consuming marijuana, as we think this is
contributing to your nausea. Please take all medications as
prescribed, attend all physician appointments as directed, and
call a physician with any questions or concerns.
Followup Instructions:
___
|
19803372-DS-20
| 19,803,372 | 22,190,767 |
DS
| 20 |
2128-11-25 00:00:00
|
2128-11-25 16:18:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
thrombocytopenia, headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y.o female with h.o ITP? who had recent bruising and
presented to ___ and she has been having
platelet transfusions reportedly almost every other day. She
first received IVIG ___ and ___ and was on prednisone
starting at 40mg then up to 60mg then down to 10mg per day with
plans to stop in 2 days. Pt also reportedly started promacta
yesterday. Per report she last saw Dr. ___ ___ and was
still having bruising, petechiae and epistaxis. Last plt
transfusion ___.
Of note, She drinks about ___ beers/day, quit about 24 hours ago
since she read about an interaction between promacta and
alcohol. Today she continues to have a headache ___ pressure on
the top of her head that has been off/on for 1 month and
relieved by Tylenol. She denies any paresthesias, weakness, n/v,
neck stiffness, visual changes. No change in the character of
her headaches. She was given romiplostim in clinic before
transfer to the ED.
.
10 pt ROS reviewed and otherwise negative for CP, sob, st,
cough, palpitations, abdominal pain, nausea, vomiting, diarrhea,
constipation, melena, brbpr, dysuria, joint pain. +spontaneous
bruising and occasional epistaxis.
Past Medical History:
thrombocytopenia, ITP?
ETOH misuse
has had elevated BP lately to ___, no diagnosis of HTN
PAST SURGICAL HISTORY:
Ovarian cystectomy about ___ years ago
tonsillectomy
Social History:
___
Family History:
Mom is ___ healthy. Dad died MI age ___. One sister died of lung
cancer age ___, another sister had laryngeal cancer age ___,
brother had a MI age ___. Sister with diabetes. Has 4 boys
age
___, ___, ___ all healthy.
Physical Exam:
GEN: well appearing, NAD
vitals:T 98.5 BP 123/60 HR 92 RR 16 sat 98% on RA
HEENT: ncat eomi anicteric MMM
neck: supple
chest: b/l ae no w/c/r
heart: s1s2 rr no m/r/g
abd: +bs, soft, NT, ND, no guarding or rebound
ext: no c/c/e 2+pulses
neuro: face symmetric, speech fluent
psych: calm, cooperative
skin: various ecchymoses on the b/l flanks/sides of ribs, L.arm,
legs
Discharge PE:
T 97.7 HR 79 BP 167/63 RR 16 100% RA
Gen: NAD, resting comfortably
Lung: CTA B
CV: RRR
Abd: Nabs, soft
Ext NO edema
skin: old echymosses, no petechia
Pertinent Results:
___ 05:30PM URINE ___
___ 05:30PM URINE ___
___ 05:30PM URINE ___ SP ___
___ 05:30PM URINE ___
___
___
___ 05:30PM URINE ___
___
___ 11:35AM ALT(SGPT)-126* AST(SGOT)-47* ALK ___ TOT
___
___ 11:35AM ___
___ 11:35AM ___
___ 11:35AM HIV ___
___ 11:35AM ___
___
___ 11:35AM ___
___
___
___ 11:35AM ___
___ 11:35AM ___
___
___ 11:35AM PLT ___ PLT ___
___ 11:35AM ___ ___
___ 10:45AM ___
___ 10:45AM UREA ___
___ TOTAL ___ ANION ___
___ 10:45AM ___ this
___ 10:45AM ___
.___ 06:35AM BLOOD ___
___ Plt ___
___ 07:10AM BLOOD ___
___ Plt ___
___ 11:35AM BLOOD HCV ___
Head CT:
1. No acute intracranial abnormality.
2. Several subcortical areas of ___ matter hypodensity may
reflect sequela of chronic microvascular disease. However, these
appears somewhat focal and are more extensive than typical for a
patient of this age. Further evaluation with MRI is recommended
non urgently.
RECOMMENDATION(S): Nonurgent brain MR.
___ PYLORI ANTIBODY TEST (Final ___:
POSITIVE BY EIA.
(Reference ___.
___ VIRUS ___ AB (Final ___: POSITIVE BY
EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS ___ AB (Final ___:
NEGATIVE <1:10 BY IFA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
Brief Hospital Course:
___ y.o woman with h.o thrombocytopenia s/p steroids, IVIG and
plt transfusions, ETOH use who presents with thrombocytopenia
and headache.
.
#thrombocytopenia, refractory with recent steroids, IVIG,
romiplostim and plt tranfusions. DDx includes ITP, liver
disease/splenomegaly. Reportedly flow at ___ did not show a
clonal disorder. She was seen by hematology service who felt
that she had ITP; she received two doses of IVIG and also was
started on IV dexamethasone. She needs PJP prophylaxis as well
as calcium and vitamin D. She did not have any signs of
bleeding during her hospitalization. She required premedication
with pepcid, benedryl and tylenol when getting IVIG. Discharged
on prednisone 60 mg daily with close ___.
#Transaminitis. Mild and downtrending. Could be due to alcohol
use. Hepatitis serologies showed she was hepatitis C negative
and had previously been exposed to hepatitis B and had cleared
it.
#Tobacco/alcohol use: Patient endorsed drinking six drinks a
night so that she could fall asleep. She works ___ at her job
and ___ works as primary caretaker of her blind ___ y/o mom
with whom she lives. She feels very unhappy with this
arrangement, and feels she does the bulk of the care taking
because she happens to live with her mother. She spoke with SW.
She did not have any signs of alcohol withdrawal. She would
benefit greatly from outpatient counseling. Counselled on the
importance of alcohol cessation.
.
___ CT showing no acute abnormalities. Radiology
suggests ___ MRI head for further evaluation of multiple
areas of ___ matter hypodensities.
.
___ diet
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Promacta (eltrombopag) unknown oral unknown
Discharge Medications:
1. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
2. Calcium 600 + D(3) (calcium ___ D3) 600 mg
calcium- 200 unit oral DAILY
RX *calcium ___ D3 600 mg calcium (1,500 mg)-200
unit 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX ___ [Bactrim DS] 800 ___ mg 1
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. ITP
2. Alcohol use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because your platelets are low due to having
ITP. You were treated by Dr ___ the rest of his
hematology team and they advised that you have steroids as well
as two doses of IVIG. You should be on calcium and vitamin D to
strengthen your bones while on steroids. You met with your
social worker to discuss your long term stressors and alcohol
use. Please completely avoid alcohol use. Please discuss this
further with your PCP - with therapy and medication you will
feel much better emotionally.
Followup Instructions:
___
|
19803391-DS-3
| 19,803,391 | 25,447,793 |
DS
| 3 |
2195-10-19 00:00:00
|
2195-10-20 13:05:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tegaderm / adhesive
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with recurrent metastatic anal
cancer in the setting of HIV status post definitive
chemoradiotherapy with ___ and mitomycin C with recurrent
disease, status post eight cycles of cisplatin and ___ therapy
with subsequent ___ disease progression along with
___ evidence of further progression, now status post two
cycles of palliative carboplatin with further ___ evidence of
disease progression.
Patient reported 2 weeks of exertional dyspnea and some chest
discomfort. CTA chest ordered on the day of admission in clinic
ruled out PE but showed pericardial effusion and interstitial
findings suspicious for lymphangitic spread. So the patient was
referred to the ED.
He denied any recent fevers, nausea, diarrhea, dysuria, or
rashes. He did have a cold with some nasal and sinus congestion
a couple of weeks ago but this has improved. He had an
occasional nonproductive cough that has been going on for months
and is unchanged.
Past Medical History:
PAST ONCOLOGIC HISTORY
Anal cancer stage III (T3N2M0) with progressive metastatic
disease
- ___: anal pap revealed HGSIL
- ___: anal pap showed LGSIL
- ___: Dr. ___ a nodular lesion on anoscopy. She was
able to appreciate regional lymphadenopathy on exam.
- ___: MRI of the pelvis showed a large enhancing anal mass
measuring up to 3.6 cm in craniocaudal dimension. Pathological
right external iliac and right inguinal nodes and a single left
inguinal lymph node were enlarged. This was consistant with a
T2N3 tumor. That same day, the patient underwent a needle biopsy
of the right inguinal node. This showed invasive squamous cell
carcinoma that was focally keratinizing and moderately
differentiated.
- ___ CT of the abdomen and pelvis again showed the right
inguinal and external iliac adenopathy as well as a borderline
enlarged left inguinal node. There were small number of mildly
prominent nodes noted along the retroperitoneum. The chest CT
showed three small lung nodules measuring ___ mm.
- ___ Started concurrent XRT and ___
- ___ Cycle 2, day 1 of ___ (mitomycin held secondary to
counts).
- ___ Completion of radiation therapy.
- ___ CT torso showed mixed response to treatment with
new
___ and paracaval nodes as well as more prominent left
pelvic side wall nodes. The right external iliac nodes are
decreased in size.
- ___ C1D1 Cisplatin 75 mg/m2 D1 + ___ 1000 mg/m2 ___
- ___ C2D1 Cisplatin 75 mg/m2 D1 + ___ 750 mg/m2 ___,
reduced for mucositis in C1
- ___ C3D1 Cisplatin 75 mg/m2 D1 + ___ 750 mg/m2 ___
- ___ CT torso showed decreased size of ___
hypodensity posterior to anus. Stable or decreased size of
multiple lymph nodes, including right inguinal, left pelvic
wall,
aortocaval, and periaortic nodes.
- ___ PET showed numerous FDG avid lymph nodes along the
retroperitoneum, mediastinum, bilateral pulmonary hilae and the
left supraclavicular region are concerning for metastatic
disease. Some of these nodes show disproprotionate FDG uptake in
relation with their size, suggestive of similar biological root
of the increased metabolic activity. Diffuse increased FDG
avidity throughout the esophagus is compatible with esophagitis.
Although a focal region of relatively higher tracer uptake in
the
distal esophagus may be related to the same inflammatory
process,
a neoplasm cannot be excluded. FDG avidity in the lower
rectum/anal region may be physiologic although it could be
related to disease recurrence.
- ___ C4D1 Cisplatin 75 mg/m2 D1 + ___ 750 mg/m2 ___
- ___ C5D1 Cisplatin 75 mg/m2 D1 + ___ 750 mg/m2 ___
- ___ C6D1 Cisplatin 75 mg/m2 D1 + ___ 750 mg/m2 ___
- ___ C7D1 Cisplatin 75 mg/m2 D1 + ___ 500 mg/m2 ___
- ___ C8D1 Cisplatin 75 mg/m2 D1 + ___ 500 mg/m2 ___
- ___ PET CT showed increasing mediastinal and
retroperitoneal lymphadenopathy compatible with disease
progression.
- ___ Lung biopsy revealed metastatic SCC. SNaPShot testing
showed a mutation in PI3KCA.
- ___ Referred for clinical trial of a PI3KCA active small
molecule at ___
- ___ - Dr. ___ - pt would potentially be a good
candidate for CLR457 though would need some adjustments of HIV
medications for interactions and uncertain about slot
availability, will look into this
- ___ PET CT showed progressive disease.
- ___ Labs showed new ___, Renal consulted who felt this
is due to ARVs
- ___ Carboplatin 5 x AUC
- ___ Carboplatin 5 x AUC
- ___ - held C3D1 carboplatin due to significant fatigue
along with UTI
PAST MEDICAL HISTORY:
- HIV
- CKD
- Renal cysts
- Nephrolithiasis,
- Hyperlipidemia.
Social History:
___
Family History:
His brother and paternal grandmother both had kidney stones.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
==================================
VS: T 98.2 BP 148/84 HR 101 RR 21 O2 97%RA
GENERAL: NAD
HEENT: EOMI, Neck Supple, MMM
CARDIAC: RRR
LUNG: CTA
ABD: Nondistended, nontender.
EXT: No edema.
NEURO: Alert and oriented, no focal deficits.
PHYSICAL EXAMINATION ON ADMISSION:
==================================
VS: T 98.5 BP 130/76 HR 92 RR 18 O2 97%RA
GENERAL: NAD
HEENT: EOMI, Neck Supple, MMM
CARDIAC: RRR
LUNG: Scant anterior wheezes, clear posteriorly
ABD: ___.
EXT: No edema.
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 10:30AM BLOOD ___
___ Plt ___
___ 10:30AM BLOOD ___
___ 10:30AM BLOOD Plt ___
___ 10:30AM BLOOD ___
___ 10:30AM BLOOD ___
___ 09:00PM BLOOD cTropnT-<0.01
___ 06:17AM BLOOD cTropnT-<0.01
___ 10:30AM BLOOD ___
LABS ON DISCHARGE:
==================
___ 05:07AM BLOOD ___
___ Plt ___
___ 05:07AM BLOOD ___
___ Im ___
___
___ 05:07AM BLOOD Plt ___
___ 05:07AM BLOOD ___
___
___ 05:07AM BLOOD ___
IAMGING:
========
___ CTA CHEST
1. No evidence of pulmonary embolism or aortic abnormality.
2. Interval progression of disease with new pulmonary nodules
and increase in size of prior pulmonary nodules involving all
lobes. New lymphangitic carcinomatosis, particularly in the
right
lower lobe. Interval worsening of mediastinal and hilar
lymphadenopathy.
3. Increased multifocal areas of bronchial wall thickening,
with
some areas of ___ opacities, concerning for superimposed
infection.
4. New small simple pericardial effusion.
Brief Hospital Course:
___ man with recurrent metastatic anal cancer in the
setting of HIV who presented with several weeks of progressive
exertional chest pain and dyspnea on exertion, found to have
progressive metastatic pulmonary disease including increasing
nodules and lymphangitic carcinomatosis and new small
pericardial effusion.
# Exertional chest pain: Patient presented with several weeks of
shortness of breath. CTA was negative for PE and notable for
markedly worsened pulmonary disease and new lymphangitic
carcinomatosis. CTA was notable for small pericardial effusion,
but TTE was within normal limits. Troponins were negative. He
was started on levofloxacin (Day ___ for empiric
treatment of infection. Symptoms were thought to be likely
secondary to progressive metastatic disease in the lungs. He was
started on prednisone 60 mg on ___, with course to be
determined by Dr. ___.
# Progressive, recurrent, metastatic anal cancer with
progressive disease: Patient was noted to have increased disease
on PET from ___. CTA was notable for markedly worsened
pulmonary disease and new lymphangitic carcinomatosis,
particularly in the right lower lobe.
# Renal insufficiency: Patient has a stable CKD with Cr of 1.7.
We monitored creatinine, and it remained stable.
# HIV: We continued home ART.
***TRANSITIONAL ISSUES:***
- Continue levofloxacin for a total of 7 days (Day ___
last ___
- Patient was started on prednisone 60 mg with course to be
determined by Dr. ___
- ___ short duration of steroids, was not provided with PCP
ppx
- ___ up appointment with primary oncologist pending at
discharge
#CODE STATUS: Full
#CONTACT: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of Breath
2. Darunavir 800 mg PO DAILY
3. Doxazosin 4 mg PO HS
4. Dolutegravir 50 mg PO DAILY
5. LaMIVudine 300 mg PO DAILY
6. RiTONAvir 100 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Fish Oil (Omega 3) Dose is Unknown PO Frequency is Unknown
9. Vitamin D Dose is Unknown PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Shortness of Breath
2. Darunavir 800 mg PO DAILY
3. Dolutegravir 50 mg PO DAILY
4. Doxazosin 4 mg PO HS
5. LaMIVudine 300 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. RiTONAvir 100 mg PO DAILY
8. Levofloxacin 750 mg PO DAILY
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth once a
day Disp #*5 Tablet Refills:*0
9. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*12
Tablet Refills:*0
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*21 Tablet
Refills:*0
10. Fish Oil (Omega 3) Unkown mg PO DAILY
11. Vitamin D Dose is Unknown PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Lymphangitic carcinomatosis
Pneumonia
SECONDARY DIAGNOSES:
Metastatic anal cancer
Chronic kidney disease
HIV infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___. You came to the hospital because you were
experiencing shortness of breath on exertion. CT chest did not
show any infection or clots, but it was notable for progression
of the cancer in the lungs. We treated you with antibiotics for
a possible infection, and also started you on steroids
(prednisone) to treat the inflammation in the lungs.
Please continue taking the steroids until instructed otherwise
by Dr. ___. Take your antibiotics for a total of 7 days,
with the final day being ___. Make sure to take all your
medications on time and follow up with your doctors as
___.
Best regards,
-Your ___ team
Followup Instructions:
___
|
19803391-DS-4
| 19,803,391 | 20,484,183 |
DS
| 4 |
2196-01-15 00:00:00
|
2196-01-15 13:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tegaderm / adhesive
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with metastatic anal cancer
in the setting of HIV status with progression of disease despite
both definitive and palliative chemotherapy now with PE and
lymphangitis carcinomatosis and pulmonary mets on 2L home O2)
i.s.o. HIV currently on home hospice (MOLST states DNR/DNI, OK
to
transfer to hospital) who presents with acute on chronic dyspnea
on exertion. He has been short of breath for some time but it
worsened in the last week. He also has severe chest tightness
and
a strong sense of air hunger. He has lost at most 10 lbs and is
able to eat well. He denies fevers, chills or significant cough.
He had an episode of brown urine that has since resolved. He is
currently on anticoagulation with enoxaparin. Reports that he
was
going down the stairs when he started feeling more short of
breath. He took CombiVent x2 and PO morphine x1 from his ___
increased his oxygen to 4L, and was brought in. He denies chest
pain, fevers, chills, nausea, vomiting or diarrhea. Endorses R
leg swelling, but this is improved from prior. He denies
constipation or dysuria.
ED Course:
- Vitals: T 98.4F P ___ BP 121/86 RR 20 O2 99% 4L O2
- EKG: sinus tachycardia, normal axis
- Exam: On 4L O2, end-expiratory wheezes b/l, no crackles, RRR,
abd soft, no peripheral edema
Labs were notable for: Cr = 1.7 - stable since ___.
Pt
hydrated for CTA
Imaging included: CTA
Significant interval increase in the size and number of
metastatic lesions within the pulmonary parenchyma as well as
bilateral juxta hilar masses. The juxta hilar masses result in
compression of bilateral bronchovascular structures, without
definite distinct filling defect seen to suggest the presence of
acute pulmonary embolism.
Past Medical History:
PAST ONCOLOGIC HISTORY
Anal cancer stage III (T3N2M0) with progressive metastatic
disease
- ___: anal pap revealed HGSIL
- ___: anal pap showed LGSIL
- ___: Dr. ___ a nodular lesion on anoscopy. She was
able to appreciate regional lymphadenopathy on exam.
- ___: MRI of the pelvis showed a large enhancing anal mass
measuring up to 3.6 cm in craniocaudal dimension. Pathological
right external iliac and right inguinal nodes and a single left
inguinal lymph node were enlarged. This was consistant with a
T2N3 tumor. That same day, the patient underwent a needle biopsy
of the right inguinal node. This showed invasive squamous cell
carcinoma that was focally keratinizing and moderately
differentiated.
- ___ CT of the abdomen and pelvis again showed the right
inguinal and external iliac adenopathy as well as a borderline
enlarged left inguinal node. There were small number of mildly
prominent nodes noted along the retroperitoneum. The chest CT
showed three small lung nodules measuring 2-3 mm.
- ___ Started concurrent XRT and ___
- ___ Cycle 2, day 1 of ___ (mitomycin held secondary to
counts).
- ___ Completion of radiation therapy.
- ___ CT torso showed mixed response to treatment with
new
para-aortic and paracaval nodes as well as more prominent left
pelvic side wall nodes. The right external iliac nodes are
decreased in size.
- ___ C1D1 Cisplatin 75 mg/m2 D1 + ___ 1000 mg/m2 D1-4
- ___ C2D1 Cisplatin 75 mg/m2 D1 + ___ 750 mg/m2 D1-4,
reduced for mucositis in ___
- ___ C3D1 Cisplatin 75 mg/m2 D1 + ___ 750 mg/m2 D1-4
- ___ CT torso showed decreased size of ill-defined
hypodensity posterior to anus. Stable or decreased size of
multiple lymph nodes, including right inguinal, left pelvic
wall,
aortocaval, and periaortic nodes.
- ___ PET showed numerous FDG avid lymph nodes along the
retroperitoneum, mediastinum, bilateral pulmonary hilae and the
left supraclavicular region are concerning for metastatic
disease. Some of these nodes show disproprotionate FDG uptake in
relation with their size, suggestive of similar biological root
of the increased metabolic activity. Diffuse increased FDG
avidity throughout the esophagus is compatible with esophagitis.
Although a focal region of relatively higher tracer uptake in
the
distal esophagus may be related to the same inflammatory
process,
a neoplasm cannot be excluded. FDG avidity in the lower
rectum/anal region may be physiologic although it could be
related to disease recurrence.
- ___ C4D1 Cisplatin 75 mg/m2 D1 + ___ 750 mg/m2 D1-___ C5D1 Cisplatin 75 mg/m2 D1 + ___ 750 mg/m2 D1-___ C6D1 Cisplatin 75 mg/m2 D1 + ___ 750 mg/m2 D1-___
- ___ C7D1 Cisplatin 75 mg/m2 D1 + ___ 500 mg/m2 D1-___
- ___ C8D1 Cisplatin 75 mg/m2 D1 + ___ 500 mg/m2 D1-___
- ___ PET CT showed increasing mediastinal and
retroperitoneal lymphadenopathy compatible with disease
progression.
- ___ Lung biopsy revealed metastatic SCC. SNaPShot testing
showed a mutation in PI3KCA.
- ___ Referred for clinical trial of a PI3KCA active small
molecule at ___
- ___ - Dr. ___ - pt would potentially be a good
candidate for CLR457 though would need some adjustments of HIV
medications for interactions and uncertain about slot
availability, will look into this
- ___ PET CT showed progressive disease.
- ___ Labs showed new ___, Renal consulted who felt this
is due to ARVs
- ___ Carboplatin 5 x AUC
- ___ Carboplatin 5 x AUC
- ___ - held C3D1 carboplatin due to significant fatigue
along with UTI
PAST MEDICAL HISTORY:
- HIV
- CKD
- Renal cysts
- Nephrolithiasis,
- Hyperlipidemia.
Social History:
___
Family History:
His brother and paternal grandmother both had kidney stones.
Physical Exam:
VS: VSS, satting well on 4L NC
GENERAL: Pleasant male, visibly dyspneic, taking deep breaths,
HEENT: No scleral icterus
CARDIAC: Tachy, Regular rate no murmurs, rubs, or gallops
LUNG: Appears in respiratory distress. Diffuse wheezes
throughout.
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES:2+ ___ pulses b/l
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
Pertinent Results:
___ 05:32AM BLOOD WBC-6.9 RBC-3.91* Hgb-12.1* Hct-37.8*
MCV-97 MCH-30.9 MCHC-32.0 RDW-13.7 RDWSD-48.7* Plt ___
___ 05:32AM BLOOD WBC-6.9 RBC-3.91* Hgb-12.1* Hct-37.8*
MCV-97 MCH-30.9 MCHC-32.0 RDW-13.7 RDWSD-48.7* Plt ___
___ 05:32AM BLOOD Glucose-92 UreaN-30* Creat-1.5* Na-141
K-4.3 Cl-102 HCO3-30 AnGap-13
Brief Hospital Course:
The patient is a ___ year old male with metastatic anal cancer
progressing despite palliative and definitive therapy now on
hospice who presents with acute on chronic dyspnea.
# DYSPNEA - Ddx includes CHF/ACS/PE/increasing pulmonary tumor
burden and
lymphangetic spread, COPD exacerbation, treated with five day
course of Prednisone, held off on diuresis given hypovolemia to
euvolemia. Palliative care evaluated patient and changed
morphine to oxycodone for dyspnea given poor renal function
- Held Lasix on discharge. Please continue to reassess at
___ facility.
HIV On HAART:
- Continued home meds
HLD:
- Stopped Lipitor
POSSIBLE REFLUX ESOPHAGITIS
- Started acid suppression
PE: continue lovenox. Adjusted dose based on renal function
BPH: continued tamsulosin
PPX: MVT/Fish oil/vitamin D/Stool softener
CONSTIPATION: Added Senna, Colace, Miralax, and Bisacodyl
suppository PRN for opioid-induced constipation
CODE: DNR/DNI but would like to return to the hospital, agrees
to non-invasive ventilation if needed
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 10 mg PO QPM
2. Furosemide 40 mg PO DAILY
3. Tamsulosin 0.4 mg PO QHS
4. Dolutegravir 50 mg PO DAILY
5. Darunavir 800 mg PO DAILY
6. RiTONAvir 100 mg PO DAILY
7. LaMIVudine 300 mg PO DAILY
8. LORazepam 0.5 mg PO QHS
9. Enoxaparin Sodium 120 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
10. Multivitamins 1 TAB PO DAILY
11. Fish Oil (Omega 3) 1000 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
14. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Darunavir 800 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Dolutegravir 50 mg PO DAILY
4. Enoxaparin Sodium 80 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
5. LaMIVudine 300 mg PO DAILY
6. LORazepam 0.5 mg PO QHS
7. Multivitamins 1 TAB PO DAILY
8. RiTONAvir 100 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN Bronchospasm
11. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q2H:PRN Severe dyspnea
12. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. OxycoDONE (Concentrated Oral Soln) ___ mg PO Q2H:PRN
dyspnea
15. OxycoDONE (Concentrated Oral Soln) 15 mg PO Q6H
16. Polyethylene Glycol 17 g PO DAILY
17. PredniSONE 60 mg PO DAILY Duration: 1 Day
18. Ranitidine 75 mg PO BID:PRN heartburn
19. Senna 8.6 mg PO BID
20. Fish Oil (Omega 3) 1000 mg PO BID
21. Vitamin D 1000 UNIT PO DAILY
22. Bisacodyl ___ID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Metastatic anal cancer
PE and lymphangitis carcinomatosis and pulmonary metastatic
disease
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
You presented to the hospital with shortness of breath, though
to be due to a combination of your cancer as well as COPD
exacerbation.
Followup Instructions:
___
|
19803635-DS-12
| 19,803,635 | 29,863,370 |
DS
| 12 |
2154-03-17 00:00:00
|
2154-03-17 15:02:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
"I couldn't feel my hand"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness:
___ is an ___ year-old ___ woman with
poorly-controlled hypertension and untreated hyperlipidemia who
was BIBA late this morning many hours after she awakened earlier
(around 4am) with new neurologic symptoms. She was in her USOH
yesterday, and neither ill nor taking any new medications in the
recent past. This morning, she awoke around 4am and says "I
couldn't feel my hand." Also, she noticed "my tongue was not
normal" -- clarified to mean it felt "big" and "wrong." She was
slurring her words slightly. Her right hand seemed weak and less
coordinated. She did not alert anyone to these symptoms; she
says
she did not want to bother her children that early in the
morning. She did not eat breakfast, but denies feeling ill. She
took her normal dose of verapamil (120 ext rel), and found her
BP
afterwards to be elevated at 200/100, so she took an additional
verapamil 80mg as instructed by her physician; yesterday, she
did
not measure her BP, but says it is usually 140-160/50-60. She
called her son at work to tell him she thought she had a stroke.
He and her daughter talked her into calling an ambulance. EMS
brought her to our ED, where she arrived hypertensive with exam
as below. Initial ED impression was ataxic-hemiparesis (they
thought the RUE was ataxic). NCHCT and Neurology consult were
ordered in addition to routine lab studies.
Review of Systems:
On neuro ROS, the pt denies headache, change in vision,
diplopia,
dysphagia, odynophagia, lightheadedness, vertigo, tinnitus or
change in hearing. Denies difficulties producing or
comprehending
language or reading. No numbness or tingling currently. No leg
symptoms sensory or motor. No bowel or bladder incontinence or
retention. Denies difficulty with gait or balance, but thinks
she
is walking slower today than usual.
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. No current or recent palpitations, but
she has experienced palpitations in the past (denies afib or
Coumadin use in the past). 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:
Past Medical History:
1. Denies any history of stroke, MI, or other vascular disease
2. Denies any neurologic history
3. hypertension (variable on CCB + PRN-CCB + low-dose ACE)
4. hyperlipidemia, unmedicated (LDL 139 in ___ previously as
high as 200 in ___
5. iron-deficiency anemia, on FeSO4
6. mild, chronic LBP
7. mild anxiety
8. h/o vertigo Tx with PRN meclizine
Social History:
___
Family History:
noncontributory at this time
Physical Exam:
Exam on admission:
General Physical Examination:
Vital signs:
HR ___ and regular on monitor
BP 180/74 --> ranging 118 to 180 systolic here
RR ___, SaO2 99% RA
General: Very short, friendly ___ woman speaking
reasonably good ___, with son/daughter there to help
translate occasional words. Awake, cooperative, NAD.
HEENT: Normocephalic and atraumatic. Receding hairline. No
scleral icterus. Mucous membranes are moist. No lesions noted in
oropharynx.
Neck: Supple. No LAD. No carotid bruits.
Pulmonary: Lungs CTA. Non-labored breathing.
Cardiac: RRR, systolic ___ murmur rad to carotids.
Abdomen: Soft, non-tender, and non-distended, + normoactive
bowel
sounds.
Extremities: Warm and well-perfused, no clubbing, cyanosis, or
edema. 2+ radial, DP pulses bilaterally.
Skin: no gross rashes or lesions noted.
*****************
Neurologic examination:
Mental Status: Awake and alert; MSE is grossly normal to
conversation. Further, she is oriented to ___, no,
___. She relates her medical history without difficulty.
She is attentive and follows commands quickly and reliably.
Speech was mildly dysarthric. Language is fluent with intact
repetition and comprehension, normal prosody, and normal affect.
Appears happy. There were no paraphasic errors. Able to read
___ without difficulty. Naming is intact to all NIHSS
objects, in ___ (initially cactus was "plant," but on
prompting, she remembered "cactus;" initially glove was "hand,"
but again, correct on prompting). Memory - registers 3 objects
and recalls ___ at 10 minutes. Good knowledge of recent and
current events, including ___ v. ___ POTUS race; ___ VPs. Calculation intact - seven quarters in $1.75. No e/o
L/R confusion, apraxia, or neglect.
-Cranial Nerves:
II: PERRL, 3.5 to 2mm and brisk. Visual fields are FTC. No
papilledema or hemorrhages on fundoscopic examination.
III, IV, VI: EOMs full and conjugate; no nystagmus. No saccadic
intrusion during smooth pursuits. Normal saccades.
V: Facial sensation intact and subjectively symmetric to light
touch and pinprick V1-V2-V3.
VII: Prominently flattened Right nasolabial fold. Lag and
incomplete elevation of the right cheek with smile. Brow
elevation is symmetric. Eye closure is strong and symmetric.
VIII: Hearing intact and subjectively equal to bed-scratch.
IX, X: Palate elevates symmetrically with phonation. She
pronounces all consonant sounds ___, ga, ba/pa, ta, ca"), but
lingual (___) and labial ("ba/pa") sounds are slightly slurred.
XI: ___ equal strength in trapezii bilaterally.
XII: Tongue protrusion is midline.
-Motor:
Right hand/forearm cups and pronates slightly (does not drift
down). No asterixis. No tremor. Normal muscle bulk and tone
except in the Right hand/fingers, which are slightly hypotonic
at
rest.
Delt Bic Tri WE FF FE IO | IP Q Ham TA ___
L 4+ ___ ___ 5 5 5 5 5 5
R 4+ 5 4+ 5 4+ 4 4+ 5- 5 5 5 5 5
-Sensory:
No gross deficits to light touch or pinprickin any extremity.
Joint position sense is excellent in both thumbs and both great
toes. Eyes-closed Finger-to-nose testing revealed no gross
proprioceptive deficit (did not miss nose).
- Cortical sensory testing: No agraphesthesia in either palm. No
astereoagnosia in the Right hand. No extinction to DSS.
-Reflexes (left; right): symmetric
Biceps (++;++)
Triceps (++;++)
Brachioradialis (++;++)
Quadriceps / patellar (++;++)
___ / achilles (0/+;0/+)
Plantar response was flexor on the left and mute-to-flexor on
the
right.
-Coordination:
Finger-nose-finger testing and heel-knee-shin testing with no
dysmetria or intention tremor. Mirroring arm behavior was
normal,
with minimal-to-no overshoot. Moderate slowing of Right
hand/finger movements.
-Gait:
Stands without difficulty. Slightly stooped. Slightly wide base,
slightly slow, but smooth and well-coordinated gait. Turns
normally. Able to walk on heels, toes. Cannot tandem. Romber
absent (excellent balance with eyes open and closed).
Exam on discharge:
T 98.2 BP 158/65 HR 65 RR 18 O2sat 97%RA
Gen: NAD, comfortable
CV: carotids with brisk upstroke, ___ SEM loudest at RUSB that
becomes louder with standing, ___ SRM at apex
MS: alert & fully oriented, conversing appropriately with intact
speech production, comprehension, prosody and articulation
CN: EOM intact, smile symmetric
Motor: the previously observed deficits on pronator drift, RAM
and finger tapping are essentially no longer noticeable
Pertinent Results:
___ 01:20PM ___ PTT-30.3 ___
CT head ___:
FINDINGS: There is focal hypodensity identified in the white
matter of the
precentral gyrus on the left, which could potentially explain
right upper
extremity weakness. Scattered periventricular and subcortical
white matter
hypodensities are also seen, non-specific, but commonly due to
chronic small
vessel disease. The ventricles and sulci are symmetric and
unremarkable,
appropriate for patient's age. There is no acute intra-axial or
extra-axial
hemorrhage, mass, midline shift, or territorial infarct.
Basilar cisterns are
patent.
Included portion of the orbits is symmetric and unremarkable.
Included
paranasal sinuses and mastoids are clear. Skull and
extracranial soft tissues
are unremarkable.
IMPRESSION: Focal hypodensity in the precentral gyrus on the
left in a
location that could explain patient's upper extremity and facial
symptoms.
MRI may offer additional detail regarding acuity or other
findings to suggest
acute stroke. Scattered periventricular white matter
hypodensities,
non-specific but often due to chronic small vessel disease.
MRI brain, MRA head & neck ___:
FINDINGS: There is slow diffusion along the left precentral
gyrus in the
motor area compatible with acute or subacute ischemia. There is
corresponding
increased T2 and increased FLAIR signal in this region. There
is no evidence
of acute hemorrhage. Small focus of susceptibility artifact in
the left
parietal lobe may reflect area of prior hemorrhage or a small
cavernoma or may
reflect a calcification seen on the prior head CT. A small
focus of
susceptibility artifact in the right frontal lobe may also
reflect prior
hemorrhage, cavernoma, or mineralization. Additional similar
findings in the
pons have the same diagnostic possibilities. Elsewhere, there
are scattered
foci of increased FLAIR signal in the periventricular and deep
white matter
bilaterally, likely reflecting sequela of chronic small vessel
ischemia. The
ventricles, sulci, and subarachnoid spaces are globally
prominent, likely
reflecting age-related volume loss. Chiari I malformation
incidentally noted.
Visualized paranasal sinuses, mastoids, and orbits are
unremarkable.
HEAD MRA FINDINGS: The vertebral and basilar arteries and the
posterior
circulation are normal without evidence of stenosis, dissection,
or aneurysm.
The posterior cerebral arteries are normal bilaterally. The
bilateral middle
cerebral and anterior cerebral arteries are normal in course and
caliber
without evidence of stenosis, dissection or of aneurysm. There
is no
occlusion in the middle cerebral arteries bilaterally.
NECK MRA FINDINGS: There is a normal three-vessel aortic arch.
The origins
of the great vessels are unremarkable. Origins of the vertebral
arteries are
normal. The bilateral vertebral arteries are normal in course
and caliber
without evidence of stenosis, dissection, or occlusion. The
bilateral carotid
arteries are normal in appearance without evidence of stenosis,
dissection, or
occlusion. The images are slightly limited by motion artifact.
The distal
left internal carotid artery measures 4 mm and the distal right
internal
carotid artery measures 3 mm.
IMPRESSION:
1. Slow diffusion in the left motor area along the central
sulcus involving
the precentral gyrus. This is compatible with acute/subacute
ischemia and
corresponds to the area of concern identified on CT.
2. No stenosis or occlusion involving the head or neck
vasculature.
3. Chiari I malformation incidentally noted.
TTE ___:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.3 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 75% >= 55%
Left Ventricle - Peak Resting LVOT gradient: *140 mm Hg <= 10
mm Hg
Left Ventricle - Lateral Peak E': *0.04 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.04 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': *28 < 15
Aorta - Sinus Level: 3.0 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 1.4 m/sec
Mitral Valve - E/A ratio: 0.79
Mitral Valve - E Wave deceleration time: *129 ms 140-250 ms
TR Gradient (+ RA = PASP): *48 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Mild ___. Mass in the body of the ___.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Hyperdynamic LVEF >75%.
TDI E/e' >15, suggesting PCWP>18mmHg. Severe resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Complex (>4mm) atheroma in the
ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Cannot
exclude AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. ___ of mitral valve leaflets.
Physiologic MR ___ normal limits). Trivial MR. ___ to
moderate (___) MR.
___ VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Very small pericardial effusion. Effusion
circumferential.
GENERAL COMMENTS: Echocardiographic results were reviewed by
telephone with the houseofficer caring for the patient.
Conclusions
The left atrium is mildly dilated. A small, highly mobile mass
(0.6 x .05 cm) is seen in the body of the left atrium and
appears to be attached to the mitral annular calcification, c/w
friable MAC vs. thrombus vs. tumor. This is best seen in the
parasternal views but also seen in the apical views. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is a severe resting left ventricular outflow tract obstruction.
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the ascending aorta. The
aortic valve leaflets (3) are mildly thickened. The study is
inadequate to exclude significant aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is systolic anterior motion of the
mitral valve leaflets. Physiologic mitral regurgitation is seen
(within normal limits). Trivial mitral regurgitation is seen.
Mild to moderate (___) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a very
small pericardial effusion. The effusion appears
circumferential.
IMPRESSION: Small, mobile mass consistent with tumor, thrombus
vs. less likely vegetation in the body of left atrium which
appears to be attached to the mitral annular calcification.
Moderate symmetric left ventricular hypertrophy with valvular
systolic anterior motion of the mitral valve and severe outflow
tract gradient at rest. Hyperdynamic left ventricular systolic
function. At least moderate pulmonary hypertension. No
intracardiac shunt identfied.
Compared with the prior study (images reviewed) of ___,
resting outflow tract gradient has increased. The mobile mass is
new. There is more mitral regurgitation. Pulmonary hypertension
is now present.
Brief Hospital Course:
ASSESSMENT:
___ yo. WF w/ poorly controlled HTN and untreated dyslipidemia,
with complaints of new right hand deficits, facial droop, mild
dysarthria.
MRI demonstrates the clinically suspected stroke in the left-mid
precentral gyrus.
Her deficits on exam were lower facial weakness (UMN), mild
dysarthria, and mild clumsiness and slowing of FFM as well as
orbiting deficit, and these have improved and are barely
noticeable now.
TTE demonstrated HOCM, MAC, a small mobile mass (differential
thrombus vs tumor), and new pulmonary hypertension.
In light of these TTE findings, have started warfarin, and pt
will be discharged on 5 mg daily. She has been set up for outpt
ATC f/u.
Ms. ___ was maintained on continuous cardiac telemetery.
During this admission she had one episode 20-beat of
asymptomatic monomorphic VTach and other shorter runs. Pt has
HOCM and is thus predisposed to cardiac arrhythmias. This was
discussed with cardiology, no further recs.
Ms. ___ blood pressure was difficult to control during this
admission. She had a predictable am spike in SBP to approx. 200
with good control afterwards on a regimen of metoprolol 12.5 mg
q6h and amlodipine 5 mg daily. Per cardiology recommendations,
pt will be discharged on metoprolol succinate 100 mg qhs and
amlodipine 5 mg daily.
She was also started on atorvastatin 40 mg daily in light of LDL
134 (previously untreated dyslipidemia)
Medications on Admission:
Medications:
1. verapamil 120 ER qAM
2. verapamil additional 80mg if BP > 140/90 (says ~1-2/mo.)
3. lisinopril 2.5mg daily
4. lorazepam 0.25-0.5mg PRN for anxiety (says ___
5. lidocaine patch PRN for LBP (says not used recently)
6. FeSO4 325mg daily
7. meclizine 12.5-25mg PRN for vertigo (says not used in 6mos)
Discharge Medications:
1. Lorazepam 0.25 mg PO Q12H:PRN anxiety
home dose is 0.25-0.5mg PRN for anxiety
2. Warfarin 5 mg PO DAILY16
RX *warfarin 1 mg three and half tablet(s) by mouth every day
Disp #*120 Tablet Refills:*2
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
3. Ferrous Sulfate 325 mg PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN low back pain
5. Meclizine 12.5-25 mg PO Q8H:PRN vertigo
6. Outpatient Lab Work
Please check INR on ___ and send the result to ___
___ clinic at ___.
ICD-9: 434.9
7. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Atorvastatin 40 mg PO DAILY stroke secondary prophylaxis
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
9. Metoprolol Succinate XL 100 mg PO HS
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth every
evening Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Stroke, intracardiac mass, likely cardiac
thrombus
Secondary Diagnosis: Hypertrophic obstructive cardiomyopathy,
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure to take care of you at ___
___. You were admitted with symptoms of weakness and
clumsiness in your right hand, a facial droop, and difficulty
pronouncing words. Based on this history and your neurological
exam, we obtained an MRI of your brain, which confirmed that you
had a stroke.
We obtained an echo (ultrasound) of your heart to look for a
possible cause of a stroke. This showed a mass in your heart.
This is likely a blood clot but it is possible that it is a
tumor in your heart. Because of this, we started you on a blood
thinner medication called warfarin (Coumadin). You will need to
take this medication every day, and have blood levels checked on
a number called INR. We have arranged follow-up in the
___ clinic for you.
You will need to have another echo in one month to assess what
has happened to the blood clot.
Over the course of this hospitalization your weakness and other
difficulties improved. We expect your deficits from your stroke
to continue to improve over the next months.
The echo of your heart also showed that you have a condition
called HOCM (hypertrophic obstructive cardiomyopathy). This
means that there is an obstruction to the blood flow out of the
heart. I believe your cardiologist was already aware of this.
Because the outflow tract gradient was high, and because your
blood pressure was high during this hospitalization, we made
some changes to your blood pressure medications, and we will
discharge you on metoprolol 100 mg every evening and amlodipine
5 mg daily. This plan was discussed with your cardiologist, Dr.
___. Please monitor your blood pressure at home and call
your primary care physician if it is higher than 160. Your
visiting nurse ___ also check your blood pressure.
These CHANGES were made to your medications:
NEW MEDICATIONS:
- pravastatin 40 mg daily for high cholesterol
- metoprolol succinate 100 mg every evening for high blood
pressure
- amlodipine 5 mg daily for high blood pressure
- warfarin (coumadin) 5 mg daily as a "blood thinner". It is
important that you get your blood checked by visiting nurses and
to adjust this medication depending on your INR level.
CHANGES in MEDICATIONS:
- verapamil was STOPPED
- STOP taking verapamil as needed. If your blood pressure is
high at home, please call your primary care physician or your
cardiologist, Dr. ___.
Followup Instructions:
___
|
19803858-DS-9
| 19,803,858 | 24,662,172 |
DS
| 9 |
2116-07-20 00:00:00
|
2116-07-20 15:48:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Cath
History of Present Illness:
___ with no PMH presents with acute chest pain, code STEMI
activated, found to have clean coronaries.
He was in usual state of health until this morning, he suddenly
developed acute onset chest pain after taking some Mucinex for
sore throat. Pain continued unchanged in substernal chest area,
associated with nausea and vomiting. He was seen in Urgent Care
at ___ ___. There was concern for symptomatic bradycardia
with HR 48, and he was sent to ___ ED.
In the ED initial vitals were: 99.7 60 ___ 100% RA. Labs
notable for normal CBC, ___, troponin. Lactate 3.7. CXR
clear. EKG was concerning for ST elevations vs ___
elevations in V3. No prior EKG in ___ or Atrius system. Code
STEMI was activated. He was given morphine 5mg IV, aspirin 324mg
PO, lorazepam 0.5mg IV. He was taken to cath lab which showed
normal coronaries, right radial access.
On the floor, he has no complaints. His symptoms have resolved
and he is watching football. Recent URI several weeks ago. No
recent long travel or sick contacts.
ROS:
Positive for cough, sore throat, chest pain, recent chills,
nausea, vomiting. No dyspnea at rest or with exertion or
inspiration, abdominal pain, diarrhea, constipation, dysuria,
frequency, palpitations, presyncope, syncope.
Past Medical History:
None
Social History:
___
Family History:
FAMILY HISTORY:
Grandmother with diabetes. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T99.0 114/59 80 18 100RA
GEN: Young adult male sitting comfortable, no distress
HEENT: Sclera anicteric, MMM, no neck adenopathy
HEART: RRR, normal S1 S2, no murmurs, no rubs, CP not
reproducible to palpation
LUNGS: Clear, no wheezes or rales
ABD: Soft, NT ND, normal BS
EXT: No ___ edema. 2+ pulses. Right radial access with TR band.
DISCHARGE PHYSICAL EXAM
VS: T98.8 ___ 18 100RA
GEN: Young adult male lying comfortable, NAD
HEENT: Sclera anicteric, MMM, no neck adenopathy, no JVP
HEART: RRR, normal S1 S2, no murmurs, no rubs, CP not
reproducible to palpation
LUNGS: Clear, no wheezes or rales
ABD: Soft, NT ND, normal BS
EXT: No ___ edema. 2+ pulses. Right radial access with TR band.
Non tender to palpation. No hematoma
Pertinent Results:
ADMISSION LABS
___ 05:51PM ___
___
___ 05:51PM ___
___ IM ___
___
___ 05:51PM cTropnT-<0.01
___ 05:51PM ALT(SGPT)-26 AST(SGOT)-36 ALK ___ TOT
___
___ 05:51PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 06:06PM ___
___ 11:38PM ___
DISCHARGE LABS
___ 07:20AM BLOOD ___
___ Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD ___
___
___ 07:20AM BLOOD ___
RESULTS
Cardiac Catheritization ___
-Dominance: R
LMCA is normal
LAD is normal
Circumflex is normal
RCA is normal
Impression
Normal coronary arteries
Normal LVEDP and cineangiography
Brief Hospital Course:
___ with no PMH presents with acute chest pain, code STEMI
activated, found to have clean coronaries.
# Chest Pain and EKG Changes. Chest pain on admission was
relieved with morphine. EKG showed potential STE in leads V2/V3,
which appears likely to be ___ elevation or normal changes
in the heart of a young healthy athlete. Cardiac Cath was
performed which showed normal coronary arteries. He was not
started on any new medications. Potassium and Magnesium were
repleted. He was sent home with follow up in primary care.
# Lactate elevation. Lactate was elevated to 3.7 on admission
and trended down to 1.2 after 1L NS.
***Transitional Issues***
PCP
- ___ repeat CBC at follow up to trend Hgb given mild
anemia post catheterization.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Atypical Chest Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you during your hospitalization
at ___. Briefly, you were hospitalized with chest pain and
concern that you were having a heart attack. Your EKG showed
some concerning findings so you underwent a cardiac
catheterization. This test looked at the blood vessels that
supply blood to the heart muscle. This test was normal. It was
determined that you did *not* have a heart attack.
Please follow up with your primary care provider as listed
below.
We wish you the best,
Your ___ Treatment Team
Followup Instructions:
___
|
19804034-DS-17
| 19,804,034 | 20,803,534 |
DS
| 17 |
2177-10-27 00:00:00
|
2177-10-27 15:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Bile Duct Obstruction due to Pancreatic mass
Major Surgical or Invasive Procedure:
EUS with FNA ___
ERCP with sphincterotomy ___
History of Present Illness:
___ year old Female transferred from ___ after
presenting there with abdominal pain and jaundice. SHe notes for
about a week prior to admission she noted white stools. she
notes some nausea and vomiting, and dark urine. At ___
___ she had a CT of the abdomen which noted a pancreatic
head mass and labs AST 57, AST 174, LIP 473. INR was 1 and WBC
of 9.3. She is transferred for ERCP evaluation and HBP surgical
consultation. She notes her pain was in a band like patter
around the epigastric region around to the back.
In the ___ ED her initial vitals were 98.1, 104/52, 20, 97%.
She was given IV Fluids with 80meq potassium along with 2g of
magnesium IV. She was noted with elevated anion gap which was
assumed to be starvation ketosis. Of note she had an elevated
HCG on ED labs, although per report has no uterus. She notes an
8lb weight loss.
Past Medical History:
Type 2 Diabetes
Cholecystectomy
TAHBSO
Social History:
___
Family History:
Mother: DM, ___, Cholelithiasis
Father: ___ in one eye
Identical Twin sister: ___ Cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VSS: 98.1, 105/79, 89, 18, 97%
GEN: NAD, Jaundice
Pain: ___
Eyes: Icteric, EOMI
Mouth: Dry MM, sublingual icterus, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
DISCHARGE PHYSICAL EXAM:
VITALS: 98.1PO 151 / 73 79 18 99 RA
GENERAL: laying in bed, in NAD
EYES: + scleral icterus, no conjunctival injection
ENT: MMM, clear OP, normal hearing
NECK: Supple, no appreciable LAD
RESP: CTA b/l, no w/r/r, non-labored breathing
CV: RRR, no m/r/g
GI: Soft, TTP in mid-epigastrum, ND, normoactive BS
GU: no foley
EXT: wwp, no edema
SKIN: jaundiced, no rashes
NEURO: AOx3, moving all extremities purposefully
PSYCH: normal mood and affect
Pertinent Results:
ADMISSION LABS:
===============
___ 10:10AM BLOOD WBC-8.4 RBC-4.51 Hgb-12.3 Hct-37.4 MCV-83
MCH-27.3 MCHC-32.9 RDW-14.1 RDWSD-42.9 Plt ___
___ 10:10AM BLOOD Neuts-69.8 ___ Monos-8.1 Eos-0.5*
Baso-1.2* Im ___ AbsNeut-5.85 AbsLymp-1.65 AbsMono-0.68
AbsEos-0.04 AbsBaso-0.10*
___ 10:24AM BLOOD ___ PTT-29.2 ___
___ 02:20PM BLOOD Glucose-214* UreaN-9 Creat-0.4 Na-141
K-3.5 Cl-101 HCO3-20* AnGap-20*
___ 10:10AM BLOOD Glucose-233* UreaN-9 Creat-0.4 Na-140
K-3.6 Cl-100 HCO3-19* AnGap-21*
___ 10:10AM BLOOD ALT-338* AST-192* AlkPhos-461*
TotBili-7.2* DirBili-5.3* IndBili-1.9
___ 10:10AM BLOOD Lipase-90*
___ 02:20PM BLOOD Calcium-9.2 Phos-3.2 Mg-1.6
___ 10:10AM BLOOD Albumin-3.7 Calcium-9.3 Phos-3.3 Mg-1.5*
___ 02:33PM BLOOD ___ pO2-44* pCO2-38 pH-7.38
calTCO2-23 Base XS--1 Intubat-NOT INTUBA Comment-PERIPHERAL
___ 02:33PM BLOOD Lactate-1.1
___ 10:29AM BLOOD Lactate-1.2
DISCHARGE LABS:
===============
___ 07:35AM BLOOD WBC-8.7 RBC-4.13 Hgb-11.4 Hct-34.7 MCV-84
MCH-27.6 MCHC-32.9 RDW-14.6 RDWSD-44.2 Plt ___
___ 07:35AM BLOOD Glucose-211* UreaN-8 Creat-0.5 Na-137
K-4.5 Cl-97 HCO3-19* AnGap-21*
___ 07:35AM BLOOD Glucose-211* UreaN-8 Creat-0.5 Na-137
K-4.5 Cl-97 HCO3-19* AnGap-21*
___ 07:35AM BLOOD ALT-259* AST-85* AlkPhos-416*
TotBili-6.6*
___ 07:35AM BLOOD Albumin-3.5 Calcium-9.0 Mg-1.6
IMAGING:
========
CTA pancreatic protocol ___:
Improved biliary obstruction post CBD stent. Redemonstration of
pancreatic malignancy with vascular involvement, retroperitoneal
adenopathy and findings concerning for hepatic metastatic
disease.
Mild proximal colitis and pneumatosis in the splenic flexure.
PROCEDURES:
==========
EUS with FNA ___:
EUS was performed using a linear echoendoscope at ___ MHz
frequency: The head and uncinate pancreas were imaged from the
duodenal bulb and the second / third duodenum. The body and tail
[partially] were imaged from the gastric body and fundus.
Mass: A 2.6cm X 3.1cm ill-defined mass was noted in the head of
the pancreas. The mass was hypoechoic and heterogenous in
echotexture. The borders of the mass were irregular and poorly
defined. The mass was closely related to the portal vein.
However, there was no evidence of portal vein invasion seen on
EUS. The mass encroached the CBD and the proximal CBD was
dilated at 9mm in diameter.
FNB was performed of the mass. Color doppler was used to
determine an avascular path for needle biopsy. A 22-gauge
SharkCore needle with a stylet was used to perform biopsy. Three
needle passes were made into the mass.
Bile duct: The bile duct was imaged at the level of the
porta-hepatis, head of the pancreas and ampulla. The CBD was
dilated at 9mm in diameter.
A lymph node was noted in the porta-hepatis. The lymph node was
hypoechoic and homogenous in echotexture. The borders were
well-defined. No central intra-nodal vessels were seen.
ERCP with Spincterotomy ___:
The scout film showed surgical clips in the RUQ. The major
papilla was normal.
The PD was cannulated using a Rx sphincterotome preloaded with
0.035in guidewire. Partial opacification showed normal PD.
Multiple trials to cannulate the CBD were unsuccessful.
The decision was made to place a PD stent to help with biliary
cannulation. A ___ x 3cm plastic PD stent was successfully
placed in the PD.
The CBD was then successfully cannulated using a Rx
sphincterotome preloaded with 0.035in guidewire.
Contrast injection revealed a 2cm mid-CBD stricture.
A biliary sphincterotomy was successfully performed at the 12
o'clock position. There was no post-sphincterotomy bleeding.
Multiple brushings were obtained from the CBD stricture and
sent for cytology.
A ___ x 7cm plastic CBD stent was successfully placed in the
CBD.
There was excellent contrast and bile drainage at the end of
the procedure.
The PD stent was successfully removed at the end of the
procedure using a snare.
Brief Hospital Course:
___ F with history of DM2, prior cholecystectomy p/w epigastric
pain, jaundice, found to have new pancreatic mass.
# Obstructive Jaundice
# Pancreatic Mass
Pt had CT a/p done prior to admission showing new pancreatic
head mass. Underwent EUS with FNA today, appearance c/f likely
adenocarcinoma. Biopsy result pending. Pt also underwent ERCP
with sphincterotomy which she tolerated well. Diet was advanced
to regular which pt was tolerating on day of discharge and LFT's
downtrended post-procedure. She was treated with Cirpo x5 days
post-procedure. She also underwent CTA pancreatic protocol
which showed known pancreatic mass with likely vascular invasion
and liver mets. Her case will be discussed in multidisciplinary
meeting and pt will be called with f/u appointment.
# Type 2 Diabetes
Held metformin and glipizide while inpatient and placed on ISS.
Pt will continue to hold metformin post-discharge until 48 hours
after CTA.
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 5 mg PO BID
2. MetFORMIN (Glucophage) 500 mg PO BID
3. biotin 10 mg oral DAILY
4. Cetirizine 10 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*8 Tablet Refills:*0
2. biotin 10 mg oral DAILY
3. Cetirizine 10 mg PO DAILY
4. GlipiZIDE 5 mg PO BID
5. HELD- MetFORMIN (Glucophage) 500 mg PO BID This medication
was held. Do not restart MetFORMIN (Glucophage) until 48 hours
after your CT scan, and then resume as normal
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatic mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came in with abdominal pain and jaundice. We found that you
have a new pancreatic mass on CT scan. This was biopsied and
you had a procedure called an ERCP to stent the duct open. You
tolerated this procedure well.
The multidisciplinary team of liver specialists, surgeons, and
oncologist will meet later today to discuss your imaging and
pathology. You will get called with a follow-up appointment.
Followup Instructions:
___
|
19804510-DS-15
| 19,804,510 | 20,907,769 |
DS
| 15 |
2157-11-22 00:00:00
|
2157-11-24 20:39:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / amoxicillin
Attending: ___.
Chief Complaint:
flank pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ male with no significant past medical
history who presents with flank pain and hematuria.
The patient was seen at ___ yesterday after
experiencing 6 days of flank pain with hematuria. A CT scan
without contrast there showed 1 mm non-obstructing stone. He was
sent home to follow up with urology.
The patient saw urology (Dr. ___ at ___ in ___ this morning in the office, who told him he
did not think the stone was contributing to his pain and
hematuria. He had a prostate exam and the urologist didn't think
prostatitis was ongoing to explain the pain otherwise. He was
prescribed Bactrim. Urology had plan to consult nephrology and
do
a cystoscopy in a few weeks if his symptoms persisted.
Here, CTU imaging shows mild hydronephrosis of the left kidney
with mild surrounding perinephric stranding and delayed
excretion
consistent with obstruction of uncertain
etiology. However, punctate densities within the left kidney may
represent tiny stones. Additional density within the left
collecting system as well as at the left ureteral vesicular
junction may represent areas of blood clotting, which is
likely the etiology of patient's obstruction.
At this time, the patient describes persistent 'twisting'
constant nonradiating flank pain in the left side, although
yesterday it did radiate halfway to the midabdomen. He has some
nausea still. No fever. He reports continued blood clots in his
urine this morning. No dysuria.
He does note a traumatic injury to left kidney at age ___ causing
significant hematuria and hospitalization at ___.
ED: given dilaudid, NS, Zofran, CTX, morphine, reglan
Past Medical History:
Migraines
Traumatic injury to left kidney at age ___ causing significant
hematuria and hospitalization at ___.
Social History:
___
Family History:
Mother and uncle had kidney stones. Provoked trauma related DVT
in mother. DVT in father for unknown etiology
Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
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. There is +CVAT to left flank.
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
.
.
DISCHARGE EXAM:
Gen: comfortable sitting up in bed
HEENT: anicteric sclera, EOMI, pupils 4 mm b/l, OP clear
Neck: no LAD
Cards: RR, no m/r/g
Chest: CTAB, normal WOB
Abd: soft, not tender to palpation, not distended, BS+
GU: no CVA tenderness today b/l
Ext: no peripheral edema, 2+ distal pulses
Skin: pale, warm, not diaphoretic
Neuro: AAOx3, clear speech
Psych: calm, cooperative
Pertinent Results:
ADMISSION LABS:
==================
.
___ 12:30AM BLOOD WBC-14.0* RBC-3.88* Hgb-12.2* Hct-35.4*
MCV-91 MCH-31.4 MCHC-34.5 RDW-11.9 RDWSD-39.3 Plt ___
___ 12:30AM BLOOD ___ PTT-26.8 ___
___ 12:30AM BLOOD Glucose-98 UreaN-13 Creat-1.2 Na-141
K-3.9 Cl-106 HCO3-20* AnGap-15
___ 06:40AM BLOOD ALT-10 AST-16 AlkPhos-53 TotBili-0.7
.
.
NOTABLE LABS DURING HOSPITALIZATION:
===================
.
___ 06:29AM BLOOD ___
___ 06:55AM BLOOD calTIBC-209* Ferritn-243 TRF-161*
___ 06:55AM BLOOD Ret Aut-1.4 Abs Ret-0.05
___ 06:55AM BLOOD TSH-2.0
___ 06:29AM BLOOD Triglyc-77 HDL-40* CHOL/HD-2.7 LDLcalc-51
.
___ 11:28AM URINE Color-Straw Appear-Clear Sp ___
___ 11:28AM URINE Blood-LG* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-10* Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 11:28AM URINE RBC-88* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
___ 11:28AM URINE Hours-RANDOM Creat-34 TotProt-25
Prot/Cr-0.7*
.
.
MICRO:
==================
-___ UCx: no growth (final)
-___ BCx: NGTD
-___ BCx: NGTD
-___ UCx: no growth (final)
.
.
IMAGING:
==================
-___ Renal u/s
IMPRESSION:
1. Possible 6 mm left superior renal calculus. Mild left
hydronephrosis.
2. Decompressed urinary bladder, limiting its evaluation
-___ CTU abd/pelvis
IMPRESSION:
New mild left hydronephrosis with delayed nephrogram consistent
with left renal obstruction, likely secondary to blood clots
within the left renal pelvis and at the left ureterovesical
junction. No urolithiasis demonstrated.
.
.
DISCHARGE LABS:
==================
___ 06:55AM BLOOD WBC-4.8 RBC-3.68* Hgb-11.2* Hct-32.8*
MCV-89 MCH-30.4 MCHC-34.1 RDW-11.7 RDWSD-37.5 Plt ___
___ 06:55AM BLOOD ___ PTT-27.2 ___
___ 06:55AM BLOOD Glucose-83 UreaN-4* Creat-0.6 Na-144
K-3.5 Cl-105 HCO3-26 AnGap-13
___ 06:55AM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.2 Mg-1.8
Iron-60
___ 06:55AM BLOOD ALT-7 AST-8 AlkPhos-44 TotBili-0.5
Brief Hospital Course:
# Gross Hematuria
# Severe intermittent left flank pain
# Left hydronephrosis: due to obstructing blood clots
# Left nephrolithiasis
*Treated with aggressive IVF and pain control w/ IV morphine
PRN. Renal consulted, no concerning findings on urine
microscopy, and urine Pr/Cr not consistent with nephrotic
syndrome. Urology consulted, advised continued aggressive
hydration and initiation of tamsulosin. Flank pain has nearly
resolved, with no significant episodes of pain, only some mild
discomfort with movement. Gross hematuria has resolved, still
has some sediment in otherwise clear urine output. Ultimately
the etiology of the hematuria is not definitive, possibly due to
nephrolithiasis in setting of chronic aspirin use (Excedrin
migraine).
*Discharged on tamsulosin (Flomax) to continue until left flank
pain has completely resolved.
*Advised maintaining good oral hydration (2 L per day oral
fluids) per Urology recs.
*Advised patient to avoid aspirin (a component of Excedrin) and
all NSAIDs at least until he has follow-up lab testing with his
PCP.
[]Please refer for Urology ___ for hematuria
[]Please refer for Nephrology ___ for recurrent kidney stones
and 24-hour urine testing for "litholink"
# ___ due to obstruction +/- intravenous contrast: resolved (Cr
1.2 at admission, down to 0.6 on day of discharge)
# Anemia: normocytic, likely from acute blood loss, iron studies
not suggestive of iron deficiency, but retic ct. inappropriately
low.
[]Please repeat CBC at upcoming PCP ___ visit to ensure
improving.
# Coagulopathy: mild (INR 1.3), s/p vitamin K 10 mg IV on ___,
INR 1.2 on ___.
[]Please repeat coags at upcoming PCP ___ visit to ensure
normalized.
# ? of UTI: was initiated on abx prior to transfer to ___ ED
and continued initially. Ultimately the ___ UCx
(obtained prior to abx) was no growth (final), and both UCx
obtained here at ___ were no growth (final), so empiric abx
(ceftriaxone) were discontinued.
.
.
.
Time in care:
[x] Greater than 30 minutes in discharge-related activities
today.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Excedrin Extra Strength (aspirin-acetaminophen-caffeine)
250-250-65 mg oral DAILY:PRN
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Moderate
2. Tamsulosin 0.4 mg PO DAILY
Stop taking this medication once you have had no flank pain for
48 hours.
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*1
3. Excedrin Extra Strength (aspirin-acetaminophen-caffeine)
250-250-65 mg oral DAILY:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
# Gross Hematuria
# Left hydronephrosis: due to obstructing blood clots
# ___ due to obstruction +/- intravenous contrast: resolved
# Left nephrolithiasis
# Anemia
# Coagulopathy
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 worsening left flank pain
and blood in your urine ("hematuria"). Based on the imaging
studies, we think that you had a kidney stone that *may* have
been the cause of bleeding from the left kidney or collecting
ducts. The blood that accumulated in your left kidney
collecting ducts caused intermittent obstruction that cause your
severe episodes of left flank pain. This ultimately resolved
with administration of lots of IV fluids and initiation of
tamsulosin ("Flomax").
For your hematuria and recurrent left-sided kidney stones, we
recommend that you see a Urologist in clinic for further
evaluation. In the meanwhile, please continue to drink plenty
of fluids (goal of 2 L of fluid intake per day, primarily water
or other non-sweetened, non-carbonated beverages). Our Urology
team instructed that you should continue taking the tamsulosin
(Flomax) until you are having absolutely no more flank pain, at
which time you can stop taking it.
You were also found to have a slight elevation in your INR, a
measure of your body's ability to clot blood. We gave you a
dose of intravenous vitamin K and your INR went from 1.3 on ___
to 1.2 on ___. A normal INR is 0.9-1.1. We would ask that you
have your primary care physician, ___ your INR
when you see him in clinic. If it remains elevated, it may
warrant additional work-up with a hematologist (blood
specialist).
You were also found to have anemia. We suspect that this was
likely the result of the blood loss you suffered as a result
from hematuria. Your blood counts have been stable for several
days, so we do not think you are losing significant amounts of
blood any longer. As with your INR, we would ask that your
primary care physician, ___ your blood counts
when you see him in clinic to ensure that your anemia is
improving/resolving. If it is not improving, it would
definitely warrant additional work-up with a hematologist.
It was a pleasure caring for you and we wish you all the best.
Sincerely,
The ___ Medicine Team
Followup Instructions:
___
|
19804556-DS-10
| 19,804,556 | 24,275,260 |
DS
| 10 |
2175-01-14 00:00:00
|
2175-01-14 16:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
RUE pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ yo woman with metastatic lung adenocarcinoma
(mets to bone, soft tissue), s/p RT to lower T ___, scapula, R
buttock, on ___ (last given ___, who
presented after PET scan today demonstrated near total
destruction of C6-C7 and weeks of worsening R arm paresthesia
and
neuropathic pain.
Mrs. ___ called her oncologist 4 days prior to admission
complaining of weeks of R arm neuropathic pain that was severe
and acutely worsening. She described waking up with R arm
burning
pain and "pins and needles" sensation over the dorsum of her
thumb. She states the pain is worst at night and improves with
ambulation and gentle exercise. Given the nature of her pain,
she
was advised to increase her nightly gabapentin dose from 600 mg
to 900 mg and continue to monitor her symptoms. Initially she
reported that this pain seemed similar to pain she had had ___
years ago in the setting of spinal stenosis, but on interview
today she says this pain feels different in its severity and
location.
Today, Mrs ___ presented for routine f/u PET scan and was
called into ED after it demonstrated near total destruction of
C6-C7. She was advised to obtain stat MRI C ___ and
neurosurgical evaluation especially in light of her R arm
symptoms.
She denied any preceding trauma or falls. No headache, visual
changes, nausea, vomiting. No confusion. No bowel or bladder
incontinence. No lower extremity numbness/tingling. She has had
some bilateral lower extremity weakness that has been improving
with home ___.
In the ED: 98.2 F | 96 | 140/78 | 18 | 98% RA. An MRI total
___
was obtained. The C6 metastatic lesion (4.2 x 2.5 x 4.6 cm) was
noted to involve the entire vertebra but not compromising the
cord. However, a T11 lesion (3.3 x 2.3 x 5.4 cm) had
significantly increased from prior imaging ___ and now
showed
extension into the epidural space with severe compression of the
spinal cord without definite cord signal abnormality. Additional
___ mets were noted at C5, C7, T1, T12.
Neurosurgery was consulted. They did not find any neurologic
deficits on exam to correlate with the T11 finding. Therefore,
she was recommended for high dose steroids, continued
observation, continued chemoRT, and outpatient follow up.
She received 10 mg IV dexamethasone prior to transfer to the
floor.
Past Medical History:
CERVICAL RADICULITIS
DEPRESSION
HYPERPROLACTINEMIA
OSTEOPENIA
ASTHMA
LUNG MASS
LEFT SHOULDER MASS
Social History:
___
Family History:
Mother with melanoma, RA. Maternal aunt with lung
cancer. Otherwise no malignancy history in the family
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: T 98.9 F | 148/82 | 90 | 96% RA
General: Tired appearing, pleasant, older Caucasian woman
resting
in bed in no acute distress
Neuro:
- Cranial nerves: PERRL, EOMI, Facial sensation equal
bilaterally, resists eye opening ___, hearing intact to finger
rub b/l, palate elevates symmetrically, tongue midline, shoulder
shrug ___
- Motor:
___ deltoid, bicep, tricep, handgrip bilaterally
___ hip flexion, knee extension, plantar and dorsiflexion
4+/5 knee flexion bilaterally
- Sensation intact to light touch and pinprick over UE and ___
including the dorsum of right thumb
- Alert and oriented, provides clear and cogent hx
HEENT: Sclera anicteric. oropharynx clear, MMM. Hard C collar in
place
Cardiovascular: RRR no murmurs
Chest/Pulmonary: Clear to auscultation bilaterally
Back: Tenderness to palpation over the T11 area. Tender, tight
trapezius muscles on the right
Abdomen: Soft, nontender, nondistended. normal bowel sounds
Extr/MSK: No peripheral edema, WWP
Skin: Hyperpigmented post radiation changes over the left
scapula
and T11 area
Access: PIV
DISCHARGE PHYSICAL EXAM
========================
VS: ___ 0416 Temp: 98.4 PO BP: 130/72 HR: 70 RR: 18 O2 sat:
98% O2 delivery: RA
General: Pleasant, older Caucasian woman resting in bed in no
acute distress
Neuro:
- Cranial nerves: CN II-XII grossly intact
- Motor:
___ deltoid, bicep, tricep, handgrip bilaterally
___ hip flexion, knee extension, plantar and dorsiflexion
4+/5 knee flexion bilaterally
- Mildly decreased sensation over the R dorsal thumb
(long-standing); otherwise intact to light touch in upper
extremities
- Alert and oriented, provides clear and cogent hx
HEENT: Sclera anicteric. oropharynx clear, MMM. Hard C collar in
place
Cardiovascular: RRR, nl s1/s2, no murmurs, rubs, gallops
Chest/Pulmonary: Clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Back: Tenderness to palpation over the T11 area. Tender, tight
trapezius muscles on the right.
Abdomen: Soft, nontender, nondistended. normal bowel sounds
Extr/MSK: No peripheral edema, WWP
Skin: Hyper-pigmented post radiation changes over the left
scapula and T11 area
Access: PIV
Pertinent Results:
ADMISSION LABS
==============
___ 01:00PM BLOOD WBC-1.6* RBC-2.78* Hgb-9.3* Hct-27.6*
MCV-99* MCH-33.5* MCHC-33.7 RDW-14.3 RDWSD-50.5* Plt Ct-55*
___ 01:00PM BLOOD Neuts-43.2 ___ Monos-12.9
Eos-0.0* Baso-0.0 AbsNeut-0.67* AbsLymp-0.68* AbsMono-0.20
AbsEos-0.00* AbsBaso-0.00*
___ 04:35PM BLOOD ___ PTT-29.9 ___
___ 01:00PM BLOOD Glucose-134* UreaN-9 Creat-0.6 Na-139
K-5.7* Cl-102 HCO3-27 AnGap-10
___ 07:00AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.7
___ 04:17PM BLOOD K-5.4*
___ 05:04PM BLOOD K-3.7
DISCHARGE LABS
==============
___ 06:27AM BLOOD WBC-2.1* RBC-2.44* Hgb-8.1* Hct-24.8*
MCV-102* MCH-33.2* MCHC-32.7 RDW-15.0 RDWSD-52.1* Plt ___
___ 07:50AM BLOOD Neuts-60.7 ___ Monos-7.4 Eos-0.0*
Baso-0.0 AbsNeut-0.99* AbsLymp-0.52* AbsMono-0.12* AbsEos-0.00*
AbsBaso-0.00*
___ 07:50AM BLOOD Glucose-96 UreaN-13 Creat-0.6 Na-143
K-4.5 Cl-104 HCO3-26 AnGap-13
___ 07:50AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
IMAGING
=======
MRI Cervical, Thoracic ___
1. Enhancing soft tissue mass centered at C6 with a prevertebral
soft tissue
component measuring 4.2 x 2.5 x 4.6 cm and a tiny intratumoral
necrotic
component in the left posterolateral vertebral body, consistent
with
metastasis. At the level of C6, moderate to severe spinal canal
stenosis is
seen with possible subtle increased T2/stir signal abnormality
of the cord
which may be secondary to artifact however cord edema cannot be
excluded at
this level.
2. Additional tumoral involvement is seen involving C5 and C7
vertebral bodies
as well as spinous processes of C5 and C6.
3. Additional metastatic involvement is seen involving the T1
vertebral body
with anterior wedging of T1 consistent with metastases and an
associated
pathologic compression fracture.
4. 3.3 x 2.3 x 5.4 cm enhancing mass centered at the left T11
spinous process,
lamina and pedicle consistent with metastasis extending into the
epidural
space causing severe compression of the spinal cord at the same
level with
subtle increased cord signal abnormality concerning for cord
edema, worse
compared to PET-CT from ___.
5. There is additional tumoral involvement of the spinous
process and left
pedicle of T12.
6. 3.5 x 3.2 cm left lower lobe enhancing mass. Small left
pleural effusion
with atelectasis.
7. Additional mild degenerative changes as described in the body
of the
report.
Brief Hospital Course:
___ with metastatic lung adenocarcinoma (mets to bone, soft
tissue), s/p radiation therapy to lower T ___, scapula, R
buttock, on ___ (last given ___, who
presented after
PET scan on admission demonstrated near total destruction of
C6-C7 and MRI ___ showed new large C6 and previously known T11
lesion with weeks of worsening R arm neuropathic pain. She was
started on radiation therapy for C6 lesion.
#Spinal metastases
Patient had an old T11 metastatic lesion with recent PET scan
showing extension into epidural space, severe compression of
spinal cord, but no definite cord signal abnormality. Also noted
new C6 metastatic lesion with PET scan showing destruction of
C6-C7 vertebral bodies and MRI on admission showing replacement
of vertebra w/ metastatic lesion, no evidence of associated cord
compromise. On stat evaluation by neurosurgery for T11 lesion,
they noted there were no neurologic findings to accord with the
radiographic images. They recommended outpatient follow up with
them, starting steroids, staying in a hard C-collar. Additional
spinal mets were noted at T1 and associated pathologic fractures
at C5, C7. Following admission, dexamethasone was changed from
4mg Q6h to 4mg BID. The patient was continued on omeprazole 20mg
daily. She received radiation therapy for the C6 lesion per
radiation oncology. Palliative care was consulted to help with
pain control. Pain control was achieved with: standing Tylenol
___ q6h, ibuprofen 600 BID, Flexeril 10 mg BID, oxycontin
___ from home dose), PRN oxycodone and 0.5-1 mg
IV dilaudid q6 prn for breakthrough pain.
# Right arm paresthesia, neuropathic pain
No high grade neural foraminal stenosis seen on MRI. No clear
impingement on cord seen on MRI. Given significant cervical
metastatic burden and tight tender trapezius on exam, suspect
peripheral nerve impingement from muscular tightness causing
intermittent pain and paresthesia. Continued gabapentin at
___ and started flexeril at 10 mg BID.
# Metastatic lung adenocarcinoma
Metastatic disease to ___, R buttock. She is s/p palliative RT
to
scapula, ___, R buttock. She was due for next cycle of
___ ___, but will likely have to push back
next cycle per primary oncologist as currently receiving
steroids.
# Pancytopenia
Platelets noted to be lower than prior; leukopenia and anemia
similar to prior. Believed to be likely chemotherapy induced.
Continued home folic acid
# Opiate induced constipation:
Continued senna 2 tabs BID, Colace 1 tab BID, plus Miralax and
Milk of magnesia PRN
TRANSITIONAL ISSUES
[]Follow up: Heme-onc with ___
Center
[]Will need to continue wearing C-collar for 4 weeks until
follow up at ___
[]Will require further radiation therapy for C6 spinal lesion
per RT
[]Continue Dexamethasone at 4mg BID to be tapered by oncologist
at next appointment
[]With improving pancytopenia on discharge, will need follow up
CBC
[]Required several doses of dilaudid while inpatient, will need
to follow up pain control (discharged with oxycodone)
[]Patient is at risk of malnutrition, will need to continue to
encourage PO intake and supplement as needed
[]Will benefit from ongoing physical therapy
Emergency Contact: husband ___. Home-
___. Cell- ___
Code Status: Full presumed
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. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Dexamethasone 2 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 600 mg PO TID
6. Omeprazole 20 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
8. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 17.2 mg PO BID
11. OxyCODONE SR (OxyconTIN) 20 mg PO BID
12. OxyCODONE SR (OxyconTIN) 40 mg PO QHS
13. Milk of Magnesia 30 mL PO DAILY:PRN constipation
14. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
Discharge Medications:
1. Cyclobenzaprine 10 mg PO BID
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
3. Dexamethasone 4 mg PO BID
RX *dexamethasone [Decadron] 4 mg 1 tablet(s) by mouth twice a
day Disp #*40 Tablet Refills:*0
4. OxyCODONE SR (OxyconTIN) 50 mg PO QHS
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every night
Disp #*30 Tablet Refills:*2
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
6. Docusate Sodium 100 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 600 mg PO TID
9. Milk of Magnesia 30 mL PO DAILY:PRN constipation
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
12. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
13. OxyCODONE SR (OxyconTIN) 20 mg PO BID
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
16. Senna 17.2 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
metastatic lung adenocarcinoma
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 caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were having severe right
arm pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- An MRI showed new lesions in your ___ and one ___ fracture
which could explain your arm pain
- You were started on radiation therapy for the ___
- You received several doses of dilaudid and your pain improved
a bit with radiation
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please return to the hospital if you experience any new or
worsening right arm pain, back pain, numbness or tingling in
your arms or legs or loss of sensation.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19804575-DS-10
| 19,804,575 | 24,769,885 |
DS
| 10 |
2143-11-30 00:00:00
|
2143-11-30 18:06:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / ___
Attending: ___.
Chief Complaint:
Shortness Of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMH pulmonary fibrosis, bronchial hyperresponsiveness,
atrial fibrillation, CAD s/p MI, CKD, and DM who presents with
progressively worsening shortness of breath for the past two
weeks. Although he has had exertional dyspnea for a few years
now (related to his pulmonary fibrosis), he has noticed marked
SOB beyond his baseline and experiences wheezing. He describes a
cough productive of scant white phlegm, rhinorrhea, and
generalized fatigue. No fevers/chills, myalgias, n/v, diarrhea,
chest pain. No orthopnea or swelling of extremities. He has a
positive sick contact: his wife had cough and runny nose for the
past week. She is now better.
Of note, he is followed by pulmonology and his PFTs in ___
were with normal FVC, FEV1, and ratio.
In the ED, initial vs were: T97.2 HR59 BP128/55 R20 O2Sat 99%.
Labs were remarkable for WBC 5.4, anemia with hematocrit 37.5%
(baseline 35-37%), creatinine of 2.3 (baseline 2.0-2.2), INR of
2.2 (on warfarin). Significant wheezing was noted on exam.
Patient was given prednisone 60mg, azithromycin 500mg, and
albuterol/ipratropium nebs. A CXR was without infiltrate, and
EKG was consistent with priors.
On arrival to the floor, his initial vitals were 97.8 148/62 58
97RA. He continues to complain of shortness of breath and cough.
No additional complaints. His daughter is also present.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
sore throat, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
All other 10-system review negative in detail.
Past Medical History:
1. Coronary artery disease - MI at ___ old, first patient at
___ to receive TPA.
2. Chronic systolic heart failure EF ___
3. Atrial fibrillation on coumadin - patient had been on
amiodarone, but began to show early pulmonary fibrosis and this
was stopped. Also s/p 2 cardioversions.
4. Hyperlipidemia
5. Diabetes mellitus II since ___
6. Chronic renal failure - recent basline of 1.9 to 2.0
7. Retinopathy
8. Glaucoma
9. Status post Billroth II for bleeding gastric ulcer- > ___
years ago
10. Colonic polyps
11. Claudication
12. Osteoarthritis
13. Gout
14. polymyalgia rheumatica
15. Seasonal allergies
16. Right eye blindness since birth with right ptosis
17. Probable fibrotic NSIP, prior amiodarone use
18. Bronchial hyperresponsiveness
Social History:
___
Family History:
Postive family history for diabetes and heart disease; sister
with colon cancer, another sister with lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 97.8 148/62 58 97RA.
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI, OP clear
NECK supple, no JVD, no LAD
PULM Decreased aeration at bases. Diffuse wheezing and rhonci.
No rales.
CV: irregular rhythm at rate of 60, normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, trace lower ext edema
NEURO: right eyelid drooped, he is blind out of this eye since
birth. Otherwise, CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
DISCHARGE PHYSICAL EXAM:
VS 98 120/50 66 20 98
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI, OP clear
NECK supple, no JVD, no LAD
PULM: Pt able to speak in full sentences without SOB. End
expiratory wheezing throughout. Good aeration. No rales.
CV: irregular rhythm at rate of 60, normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, trace lower ext edema
NEURO: right eyelid drooped with clouding of right lens, he is
blind out of this eye since birth. Otherwise, CNs2-12 intact,
motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 12:33PM BLOOD WBC-5.4 RBC-3.88* Hgb-11.5* Hct-37.5*
MCV-97 MCH-29.8 MCHC-30.7* RDW-15.5 Plt ___
___ 12:33PM BLOOD Neuts-63.7 ___ Monos-9.5 Eos-2.8
Baso-0.6
___ 12:33PM BLOOD ___ PTT-44.1* ___
___ 12:33PM BLOOD Glucose-140* UreaN-53* Creat-2.3* Na-140
K-5.0 Cl-105 HCO3-22 AnGap-18
___ 02:52AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.2
INTERIM LABS: ___ Cr 2.8
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-15.3*# RBC-3.53* Hgb-10.4* Hct-33.6*
MCV-95 MCH-29.5 MCHC-30.9* RDW-16.1* Plt ___
___ 07:35AM BLOOD ___ PTT-45.7* ___
___ 07:35AM BLOOD Glucose-182* UreaN-103* Creat-2.4*
Na-130* K-4.7 Cl-98 HCO3-20* AnGap-17
___ 07:35AM BLOOD Calcium-8.7 Phos-4.3# Mg-2.2
========================
MICROBIOLOGY:
___ 12:33 pm BLOOD CULTURE: no growth in 48 hours
___ 5:30 pm Influenza A/B by ___: Negative for Influenza A
and B.
___ 6:34 pm URINE NEGATIVE FOR LEGIONELLA SEROGROUP 1
ANTIGEN.
========================
ECG ___ Atrial fibrillation with a controlled ventricular
response rate of 58 beats per minute. Premature ventricular
complexes. Right bundle-branch block with left anterior
fascicular block. Anteroseptal myocardial infarction of
indeterminate age. Non-specific ST segment changes in the high
lateral leads. Compared to the previous tracing of ___ the
ventricular ectopy is new.
========================
CXR ___: No acute cardiopulmonary process. Prominence of
interstitial
markings is unchanged from prior study.
Brief Hospital Course:
___ year-old male with PMH pulmonary fibrosis, bronchial
hyperresponsiveness, atrial fibrillation, CAD s/p MI, CKD, and
DM who presents with worsening shortness of breath, cough, and
wheezing for two weeks.
Active Issues:
# Acute Bronchitis: His clinical presentation of cough, diffuse
inspiratory/expiratory wheezing and subjective dyspnea was most
consistent with acute viral bronchitis complicated by reactive
airway disease. He remained hemodynamically stable, without
evidence of CHF exacerbation and did not require supplemental
oxygen. Of note, CXR was without infiltrate or pulmonary edema.
DFA flu swab and urinary legionella were negative. He was
treated with four day course of duonebs, azithromycin, and
prednisone 60mg and his lung exam and symptoms improved greatly.
He was discharged home with an additional day of prednisone
40mg. Importantly, discharge examination was notable for end
expiratory wheezing, although ambultory sats WNL.
# ARF on CKD: His baseline Cr is ___, but there was elevation
to 2.8 during his stay likely prerenal in nature. His
lisinopril was held for 2 days and his creatinine started to
trend down back to his baseline.
# Supratherapeutic INR: He remained on his home regimen until
his Coumadin rose to 3.2 on ___ and 3.9 on ___. Coumadin held
___ and ___. Discharge instructions to hold coumadin night of
___ and restart at home dose on ___ with INR check on ___ and
further titration by HCA ACMS.
#Hyperglycemia/DM: In setting of prednisone and infection, he
initially had poorly controlled glucose during this admission to
400s. He continued his home NPH 48units and was supplemented
with HSSI with good effect. No change to his insulin regimen
was made on discharge as he was discharged with only one more
day of prednisone 40mg.
Chronic Issues:
#Interstitial Lung Disease: likely a product of amiodarone use,
followed by ___ clinic. Unclear how much of current
presentation is attributed to his fibrosis and ILD.
# Afib: CHADS II score of 3, rate well controlled without
medications, anticoagulated on warfain. Supratherapeutic INR
discussed above.
#CAD/CHF: stable, he continued Imdur, ASA, Lasix, Lisinopril
(held briefly in the setting of rising creatinine)
#HLD: stable, continued simvastatin
#BPH: stable, continued tamsulosin
#Gout: stable, continued allopurinol
#Allergic rhinitis: stable, continued fluticasone and
fexofenadine
TRANSITIONAL ISSUES:
#Full Code
#Discharge examination with faint end expiratory wheezing,
however ambulatory sats WNL.
#Follow-up with PCP and ___ within 2 weeks.
#Will need creatinine follow-up at PCP ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
4. Calcitriol 0.25 mcg PO EVERY OTHER DAY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Furosemide 40 mg PO DAILY
hold for SBP<100
8. NPH 48 Units Breakfast
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP<100
10. Lisinopril 20 mg PO DAILY
hold for SBP<100
11. Loratadine *NF* 10 mg Oral daily
12. Ranitidine 150 mg PO DAILY
13. Simvastatin 20 mg PO DAILY
14. Tamsulosin 0.4 mg PO HS
hold for SBP<100
15. Warfarin 2 mg PO DAILY16
16. Multivitamins 1 TAB PO DAILY
17. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Furosemide 40 mg PO DAILY
hold for SBP<100
5. Calcitriol 0.25 mcg PO EVERY OTHER DAY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Lisinopril 20 mg PO DAILY
hold for SBP<100
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
RX *albuterol sulfate 90 mcg ___ puffs inhaled every ___ hours
Disp #*1 Inhaler Refills:*2
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP<100
11. Loratadine *NF* 10 mg Oral daily
12. Multivitamins 1 TAB PO DAILY
13. Ranitidine 150 mg PO DAILY
14. Simvastatin 20 mg PO DAILY
15. Tamsulosin 0.4 mg PO HS
hold for SBP<100
16. NPH 48 Units Breakfast
17. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
18. Warfarin 2 mg PO DAILY16
Start ___
Discharge Disposition:
Home
Discharge Diagnosis:
Acute bronchitis
Reactive airway 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 care of you while you were admitted to
___. You were admitted with cough and shortness of breath and
we found you to have acute bronchitis and reactive airways. You
were treated with nebulizer breathing treatments, antibiotics,
and oral prednisone which you tolerated well.
When you return home, you will take 40mg of prednisone tomorrow
morning. That will complete your course of prednisone for this
acute bronchitis. You should continue all your medications as
prescribed. Please use your albuterol inhaler as needed for
continued shortness of breath.
Please take 2mg coumadin on ___, 2mg on ___ and call
___ clinic on ___ with home INR.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19804575-DS-11
| 19,804,575 | 26,628,850 |
DS
| 11 |
2144-02-07 00:00:00
|
2144-02-11 19:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Avandia
Attending: ___.
Chief Complaint:
Pleuritic chest pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with pulmonary fibrosis (from
amiodarone and asbestos), bronchial hyperresponsiveness, atrial
fibrillation (on coumadin), CAD s/p MI, CKD, and DM presenting
to the emergency department with worsening shortness of breath.
In ___, he was seen by his outpatient cardiologist who noted
low blood pressure, so his lasix dose was decreased from 40 mg
to 20 mg daily. Over the next two months, his weight increased
from 210 lbs to 216 lbs and he noted increasing shortness of
breath. He was seen in clinic on ___ and CXR at that
time was notable for stable interstitial disease and volume
overload. He has noted no change in his baseline cough and it
has remained minimally productive of clear sputum. His daughter
___ nurse) increased his lasix back to 40 mg daily and his
weight over the next two days decreased to 213 lbs. On ___
___, he woke with sharp, pleuritic chest pain on his left
side, so he went to ___ for evaluation. They
were concerned for pneumonia in the ED based on chest pain,
dyspnea, and CXR with possible infiltrate, so he was started on
ceftriaxone and azithromycin and sent him to the ___ for
further care.
On arrival to the ED, initial VS were 99.3 70 177/79 22 100% 4L
NC. Labs were notable for proBNP of 2581, Creatinine of 2.0
(baseline 2.0-2.3), hyperkalemia to 6.1 (hemolyzed),
Lactate:1.8, WBC count of 13.7 (85.2% PMNs). Given continued
concern for pneumonia, he was also given a dose of Zosyn. Chest
x-ray was stable from the study on ___ showing pulmonary
edema and stable interstitial lung disease. He was also wheezy
and given his underlying bronchial hyperresponsiveness, he was
given solumedrol 125 mg IV x 1 and started on nebulizer
treatments, before being sent to the floor for further
management.
Transfer VS were 98.3 68 122/47 20 96%. On arrival to the floor,
patient reports improved dyspnea following steroids and
nebulizers. He reports cough as above that is improved from his
baseline and resolution of the pleuritic chest pain felt earlier
in the day. He denies chest pain or pressure and notes that the
pain today was not similar to his prior MI.
REVIEW OF SYSTEMS:
Denies fever, chills, headache, rhinorrhea, congestion, sore
throat, chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
1. Coronary artery disease - MI many years ago, first patient at
___ to receive TPA
2. Chronic systolic heart failure EF ___
3. Atrial fibrillation on coumadin - patient had been on
amiodarone, but began to show early pulmonary fibrosis and this
was stopped. Also s/p 2 cardioversions
4. Hyperlipidemia
5. Diabetes mellitus II since ___
6. Chronic renal failure - recent basline of 1.9 to 2.0
7. Retinopathy
8. Glaucoma
9. Status post Billroth II for bleeding gastric ulcer- > ___
years ago
10. Colonic polyps
11. Claudication
12. Osteoarthritis
13. Gout
14. polymyalgia rheumatica
15. Seasonal allergies
16. Right eye blindness since birth with right ptosis
17. Probable fibrotic NSIP, prior amiodarone use
18. Bronchial hyperresponsiveness
Social History:
___
Family History:
Postive family history for diabetes and heart disease; sister
with colon cancer, another sister with lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 98.0 141/61 77 18 98% 2___
GEN - Alert, oriented, no acute distress
HEENT - NCAT, MMM, EOMI, ambliopic right eye, sclera anicteric,
OC/OP clear
NECK - supple, difficult to assess JVP
PULM - Bibasilar rales, diffuse wheezes, good air movement
CV - Irregularly irregular, normal rate, S1/S2, no m/r/g
ABD - Soft, NT/ND, normoactive bowel sounds, no guarding or
rebound, remote midline scar
EXT - WWP, 1+ pitting edema, right leg more swollen than left
(stable per patient and daughter) 2+ pulses palpable bilaterally
NEURO - CN II-XII intact (with the exception of ambliopic right
eye), motor function grossly normal
SKIN - no ulcers or lesions
DISCHARGE PHYSICAL EXAM:
VS - 98.1/98.1 140/60 70 18 96% 2___
GEN - Alert, oriented, no acute distress
HEENT - NCAT, MMM, EOMI, ambliopic right eye, sclera anicteric,
OC/OP clear
NECK - supple, difficult to assess JVP
PULM - Bibasilar rales, diffuse wheezes, good air movement
CV - Irregular rhythm, normal rate, normal S1/S2, no m/r/g
ABD - Soft, NT/ND, normoactive bowel sounds, no guarding or
rebound, remote, well-healed midline scar
EXT - WWP, 1+ pitting edema, right leg more swollen than left
(stable per patient and daughter) 2+ pulses palpable bilaterally
NEURO - CN II-XII intact (with the exception of ambliopic right
eye), motor function grossly normal
SKIN - no ulcers or lesions
Pertinent Results:
Admission labs:
___ 03:30PM BLOOD WBC-13.7* RBC-3.91* Hgb-11.1* Hct-37.2*
MCV-95 MCH-28.5 MCHC-29.9* RDW-16.7* Plt ___
___ 03:30PM BLOOD Neuts-85.2* Lymphs-5.6* Monos-8.1 Eos-0.6
Baso-0.5
___ 03:30PM BLOOD Glucose-182* UreaN-49* Creat-2.0* Na-137
K-6.1* Cl-104 HCO3-18* AnGap-21*
___ 03:30PM BLOOD Lactate-1.8
Notable labs:
___ 03:30PM BLOOD cTropnT-0.03* proBNP-2581*
___ 12:31AM BLOOD CK-MB-3 cTropnT-0.03*
___ 07:20AM BLOOD CK-MB-3 cTropnT-0.03*
Discharge labs:
___ 07:20AM BLOOD WBC-8.2 RBC-3.60* Hgb-10.2* Hct-33.1*
MCV-92 MCH-28.3 MCHC-30.7* RDW-16.9* Plt ___
___ 07:20AM BLOOD ___ PTT-49.1* ___
___ 07:20AM BLOOD Glucose-293* UreaN-56* Creat-2.1* Na-137
K-4.3 Cl-102 HCO3-24 AnGap-15
___ 07:20AM BLOOD Calcium-8.3* Phos-3.1 Mg-2.1
Micro:
___ Urine culture: negative (final)
Studies:
___ CXR:
PA and lateral views of the chest demonstrates stable
cardiomegaly. Fibrotic changes particullary at the periphery of
the lung parenchyma are stable. There is no evidence of pleural
effusion. No focal consolidations worrisome for pneumonia.
moderate tortuosity of the thoracic aorta
IMPRESSION: Fibrotic changes of the lungs with cardiomegaly,
stable from 2 days prior.
___ CXR:
As compared to the previous radiograph, the fibrotic changes of
the lung parenchyma has moderately increased. In addition, there
is a minimal prominence of the vascular structures. Given the
increased size of the cardiac silhouette, a combination of
progressive fibrosis and mild fluid overload is likely. However,
neither the frontal nor the lateral radiographs show evidence of
pleural effusion. Moderate tortuosity of the thoracic aorta.
Brief Hospital Course:
___ year old man with pulmonary fibrosis (from amiodarone and
asbestos), bronchial hyperresponsiveness, atrial fibrillation
(on coumadin), CAD s/p MI, CKD, and DM presenting to the
emergency department with worsening shortness of breath with
signs of decompensated heart failure.
# Acute on chronic decompensated systolic heart failure: Patient
with EF of ___ on TTE in ___. His lasix dose was recently
decreased from 40 mg to 20 mg daily which was associated with 6
lb weight gain and increasing shortness of breath. CXR on
___ with volume overload and stable on ___ (day of
admission). He has responded well to increasing lasix back to 40
mg daily at home and weight was down to 213 lbs (target 210
lbs). Patient was started on ceftriaxone/azithromycin at OSH and
received a dose of Zosyn on arrival to ___ ED given concern
for pneumonia, but given lack of new cough, fever or
consolidation on CXR, antibiotics were discontinued on arrival
to the floor. He has responded well to IV lasix and his
pleuritic chest pain resolved prior to discharge. His lung exam
was notable for prominent wheezing, likely from bronchial
hyperresponsiveness triggered by pulmonary edema, which
responded well to standing nebulizers. His weight on discharge
was 211.
# Interstitial Lung Disease: Likely a product of amiodarone use
and asbestos exposure as a ___. He is followed by ___
___. While much of current presentation of dyspnea is
attributed to his pulmonary edema in the setting of
decompensated heart failure (above), his fibrosis and ILD is
certainly playing a role in the form of bronchial
hyperresponsiveness. He is diffusely wheezy on exam and has
responded well to steroids in the ED and standing nebulizers on
the floor. He was seen by pulmonary who agreed that his symptoms
are most likely related to pulmonary edema. If his wheezing
persists, they recommended uptitrating Advair to four puffs
twice a day and using a spacer to maximize efficiency of
inhaler.
# Microscopic hematuria: Unclear etiology. Patient reports no
trauma or recent foley catheter use. He is asymptomatic. This
should be evaluated further in the outpatient setting with
urology follow up.
# CKD: His baseline Cr is 2.0-2.3 and he is currently within
that range. Likely related to diabetes.
# Type 2 diabetes: He was continued on NPH 42 units QAM, and was
started on a humalog insulin sliding scale. His glucose was
poorly controlled on this regimen given solumedrol dosed in the
ED. His family was somewhat reluctant to change current regimen
to a more standard basal/bolus (glargine/humalog) regimen as it
would require many injections per day. They were encouraged to
follow up with endocrinology to pursue alternative options.
# Afib: CHADS2 score of 3, rate well controlled without
medications, anticoagulated on warfain 2 mg daily and in
therapeutic range at 2.2 on admission.
# CAD: Stable. Continued Imdur, ASA, Lasix, Lisinopril.
# HLD: Stable. Continued simvastatin.
# BPH: Stable. Continued tamsulosin.
# Gout: Stable. Continued allopurinol.
# Allergic rhinitis: stable, continued fluticasone and
fexofenadine.
# Transitional issues:
- Code status: Full (confirmed ___
- Target weight: 210 lbs; discharge weight 211 lbs
- If any rebound in wheezing post-discahrge on reasonable lasix
dosage, would consider increase in flovent dose first, as well
as maximizing spacer usage to increase effectiveness of inhlaer
medications.
- He should follow-up with Drs. ___ next month
or earlier if needed.
- Would consider endocrinology follow up to address insulin
regimen if family is willing as NPH once daily dosing is not
ideal.
- Patient noted to have microscopic hematuria on admission. No
evidence of trauma or recent foley catheter use. Patient should
be referred to urology for further workup if this persists.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Furosemide 40 mg PO DAILY
hold for SBP<100
5. Calcitriol 0.25 mcg PO EVERY OTHER DAY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Lisinopril 10 mg PO DAILY
hold for SBP<100
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP<100
11. Loratadine *NF* 10 mg Oral daily
12. Multivitamins 1 TAB PO DAILY
13. Ranitidine 150 mg PO DAILY
14. Simvastatin 20 mg PO DAILY
15. Tamsulosin 0.4 mg PO HS
hold for SBP<100
16. NPH 42 Units Breakfast
17. Warfarin 2 mg PO DAILY16
Start ___
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.25 mcg PO EVERY OTHER DAY
5. Fish Oil (Omega 3) 1000 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. NPH 42 Units Breakfast
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Lisinopril 10 mg PO DAILY
11. Loratadine *NF* 10 mg Oral daily
12. Multivitamins 1 TAB PO DAILY
13. Ranitidine 150 mg PO DAILY
14. Simvastatin 20 mg PO DAILY
15. Tamsulosin 0.4 mg PO HS
16. Warfarin 2 mg PO DAILY16
17. Furosemide 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Acute on chronic decompensated systolic heart failure
- Bronchial hyperresponsiveness
- Pulmonary fibrosis
Secondary diagnoses:
- Coronary artery disease
- Atrial fibrillation on coumadin
- Diabetes mellitus II
- Chronic renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. Ambulatory sat
92-94% on room air.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___. You were
first seen at ___ where they were concerned about
pneumonia based on your chest x-ray. When you arrived at the
___, you chest x-ray was actually similar to a prior x-ray
which did not show pneumonia, so we discontinued your
antibiotics. We think your symptoms are related to the extra
fluid on your lungs from decreasing your water pill (Lasix).
You received one dose of steroids in the ED and we gave you
nebulizer treatments and additional lasix which helped with your
breathing.
You were seen by the lung doctors who recommended that you
increase your fluticasone to 4 puffs twice a day if you continue
to have wheezing. You should also use the spacer to make sure
the medication distributes properly in your lungs. Also, make
sure you rinse out your mouth after use.
Your blood sugars were high in the hospital because you received
a dose of steroids in the ED. You should resume your normal
insulin regimen on discharge.
Please weigh yourself daily. If your weight increases by more
than 3 lbs please call your doctor. Your lasix dose may need to
be increased.
Followup Instructions:
___
|
19804575-DS-9
| 19,804,575 | 26,266,749 |
DS
| 9 |
2143-08-06 00:00:00
|
2143-08-08 21:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Avandia
Attending: ___.
Chief Complaint:
lower extremity worse
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with Afib and CAD p/w bilateral ___ rash x 2 weeks. Reports
that the rash started on the dorsum of the feet, has slowly been
creeping upward. He reports the rash is pruritic. Mild bilateral
symmetric swelling that is worse at night but has improved since
admission. He has not missed any doses of Lasix, reports no
change in diet, the only change in activity is that he has been
staying inside more over the past week due to the humidity's
affect on his interstitial lung disease. He reports mild
shortness of breath that is baseline for him and only occurs
with activity. Recent PFTs are stable. He denies fever, chills,
headache or neckpain. He has not used new soaps or detergents.
He has not had exposure to bug bites or new animals or plants.
.
Initial VS in the ED: 97 66 156/72 16 98%
Exam notable for bilateral erythematous rash with areas of
significant confluence and palpable purpura as well as small
pustules.
.
Labs notable for supratheraputic INR of 4.5, Hct of 37 c/w
baseline, Cr of 2.0 lower than baseline 2.4.
.
Patient was given a chest x-ray which showed a small right
pleural effusion without focal consolidation. Bilateral ___ US
was performed, showing no DVT bilaterally. VS prior to transfer:
98.7 °F (Oral), Pulse: 53, RR: 16, BP: 150/59, O2Sat: 100,
O2Flow: (Room Air)
Past Medical History:
1. Coronary artery disease - patient states he had an MI ___
years ago and was the first patient at ___ to receive TPA.
2. Chronic systolic heart failure
3. Atrial fibrillation on coumadin - patient had been on
amiodarone, but began to show early pulmonary fibrosis and this
was stopped. Also s/p 2 cardioversions.
4. Hyperlipidemia
5. Diabetes mellitus II since ___
6. Chronic renal failure - recent basline of 1.9 to 2.0
7. Retinopathy
8. Glaucoma
9. Status post Billroth II for bleeding gastric ulcer- > ___
years ago
10. Colonic polyps
11. Claudication
12. Nocturnal leg cramps
13. Osteoarthritis
15. Gout
Social History:
___
Family History:
Postive family history for diabetes and heart disease; sister
with colon cancer, another sister with lung cancer.
Physical Exam:
Admission Physical Exam:
Vitals: T:97.0 BP:150/80 P:64 R:18 O2:
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx ___. Mucous membranes
normal.
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis 2+
edema
Neuro: CNII-XII intact. EOMI intact. Str 5 in all extremities.
Skin: Dorsum of foot and anterior leg- nonblanching confluent
purpura and brown hyperpigmentation with scattered scabs and
scaling around the ankles. Scattered pustules are present on the
leg and up the thigh. Forearms- diffuse petechiae along the
anterior forearm and stable brusing of the posterior forearm
consistent with Warfarin use.
Discharge Physical Exam:
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx ___. Mucous membranes
normal.
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact. EOMI intact. Str 5 in all extremities.
Skin: Dorsum of foot and anterior leg- nonblanching confluent
purpura and brown hyperpigmentation with scattered scabs and
scaling around the ankles. Erythema and edema improved.
Scattered pustules are present on the leg and up the thigh.
Forearms- diffuse erythematous macules along the anterior
forearm and stable brusing of the posterior forearm consistent
with Warfarin use.
Pertinent Results:
Admission Labs
___ 10:05AM BLOOD WBC-7.8 RBC-3.98* Hgb-12.0* Hct-37.6*
MCV-94 MCH-30.1 MCHC-31.9 RDW-16.4* Plt ___
___ 10:05AM BLOOD Neuts-70.7* Lymphs-13.8* Monos-8.7
Eos-6.4* Baso-0.4
___ 10:05AM BLOOD Plt ___
___ 11:58AM BLOOD ___ PTT-63.1* ___
___ 10:05AM BLOOD Glucose-123* UreaN-56* Creat-2.0* Na-141
K-5.0 Cl-108 HCO3-26 AnGap-12
___ 10:05AM BLOOD CRP-17.7*
___ 03:28PM BLOOD ___ * Titer-1:80
Discharge Labs:
___ 07:55AM BLOOD WBC-7.7 RBC-4.04* Hgb-12.0* Hct-38.3*
MCV-95 MCH-29.8 MCHC-31.4 RDW-16.3* Plt ___
___ 07:55AM BLOOD Plt ___
___ 07:55AM BLOOD ___ PTT-57.2* ___
___ 07:55AM BLOOD Glucose-180* UreaN-55* Creat-2.0* Na-141
K-5.3* Cl-105 HCO3-28 AnGap-13
___ 07:55AM BLOOD Calcium-8.3* Phos-3.6 Mg-2.0
IMAGING:
BILAT LOWER EXT VEINS Study Date of ___ 10:02 AM
FINDINGS:
Gray-scale and Doppler images of the right and left common
femoral, both
superficial femoral, popliteal, and proximal calf veins were
obtained. There is wall-to-wall flow with normal response to
compression and augmentation in all visible veins.
IMPRESSION: No DVT in either lower extremity.
CHEST (PA & LAT) Study Date of ___ 10:49 AM
FINDINGS:
PA and lateral chest radiographs were obtained. Lung volumes
are slightly low. There is increased interstitial markings,
similar to the prior study from ___. There is no focal
consolidation, large pleural effusion, or pneumothorax. Mild
cardiomegaly is unchanged.
Brief Hospital Course:
Assessment and Plan: This is a ___ with Afib and CAD p/w
worsening leg swelling and bilateral ___ rash x 2 weeks.
# Acute on chronic venous stasis dermatitis - The patient was
admitted initially with a bilateral worsening lower extremity
rash. The rash appeared as a macular nonblanching erythema
superimposed upon chronic stasis dermatitis changes in the
setting of an increase in lower extremity edema. Bilateral lower
extremity ultrasound revealed no DVT. His leg edema resolved
with IV diuresis. He was started on triamcinolone topical cream
and his lower extremities were wrapped to help to mobilize
fluid. The patient clinically improved and he was discharged
home with ___ services and close follow up with his PCP.
# Folliculitis - Patient also noted to have a superimposed
folliculitis of his bilateral lower extremities. He was started
on Keflex and discharged home with plans to complete at 7 day
course.
# Lower extremity edema - ___ be related to acute on chronic CHF
exacerbated vs venous stasis. There was no evidence of DVT. He
was given 1 dose of IV lasix with improvement in his lower
extremity swelling. He was discharge with plans to resume his
home lasix dosing.
# Hx of CAD - continued ASA, statin, imdur.
# Atrial fibrillation - INR supratherapeutic on admission. His
warfarin was held on ___ and ___. He was discharged with
instructions to have his INR checked on ___ and discuss ongoing
dosing of his warfarin with the ___ clinic.
# Interstitial lung disease - continued fluticasone and
albuterol prn
# CKD - stable
# DM - continued home insulin regimen with a sliding scale while
in house. Blood sugars remained well controlled.
# Gout - continued allopurinol
# BPH - continued tamsulosin
# GERD - continued ranitidine
TRANSITIONAL ISSUES
- Patient will need close monitoring of his INR and adjustment
of his warfarin dosing as hew as supratherapeutic during
admission. He should have his next INR drawn on ___
- Patient should follow up with his PCP to assess for
improvement of his lower extremity infection after he completes
a course of Keflex and topical steroid cream.
- blood cultures pending at time of discharge
- Patient full code during admission
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Allopurinol ___ mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Fluticasone Propionate 110mcg 2 PUFF IH BID
5. Furosemide 40 mg PO DAILY
hold for SBP<100
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP<100
7. Lisinopril 20 mg PO DAILY
hold for SBP<100
8. Ranitidine 150 mg PO BID
9. Simvastatin 20 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
hold for SBP<100
11. Warfarin 2 mg PO DAILY16
12. Aspirin 81 mg PO DAILY
13. Loratadine *NF* 10 mg Oral daily
14. NPH 48 Units Breakfast
15. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheeze
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeze
4. Calcitriol 0.25 mcg PO EVERY OTHER DAY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Furosemide 40 mg PO DAILY
hold for SBP<100
8. NPH 48 Units Breakfast
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
hold for SBP<100
10. Lisinopril 20 mg PO DAILY
hold for SBP<100
11. Loratadine *NF* 10 mg Oral daily
12. Ranitidine 150 mg PO DAILY
13. Simvastatin 20 mg PO DAILY
14. Tamsulosin 0.4 mg PO HS
hold for SBP<100
15. Cephalexin 500 mg PO Q8H
please get blood cultures first
RX *cephalexin 500 mg 1 capsule(s) by mouth Q8 hours Disp #*21
Capsule Refills:*0
16. Triamcinolone Acetonide 0.025% Cream 1 Appl TP BID
apply to forearm rash and lower leg rash
RX *triamcinolone acetonide 0.025 % apply to affected area twice
daily Disp #*60 Gram Refills:*1
17. Warfarin 2 mg PO DAILY16
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: folliculitis
Secondary Diagnosis: chronic systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were admitted to
___. You were admitted because you were found to have
increased lower extremity swelling and a rash. This was likely
related to venous stasis, lower extremity swelling, and a
superimposed infection called folliculitis. You were started on
a topical steroid cream, antibiotics, and given some intravenous
lasix with improvement in your symptoms. Also your coumadin dose
was held given that your INR was elevated.
The following changes have been made to your medication regimen:
Please START taking
- keflex ___ mg every 8 hours for 7 days (last day ___
- triamcinolone cream 0.25 % twice daily
Please CHANGE
- ranitidine to once daily (dosed for your renal function)
Your INR was high (4.5). We held your coumadin on ___.
Please HOLD your warfarin dose on ___ as your INR is still
high (4.2).
Please have your INR checked on ___ and discuss with your
providers what dose of coumadin you should take.
Please take the rest of your medications as prescribed and
follow up with your doctors as ___.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19805439-DS-3
| 19,805,439 | 24,908,577 |
DS
| 3 |
2118-09-09 00:00:00
|
2118-09-09 09:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / latex / adhesive
Attending: ___.
Chief Complaint:
neck pain
Major Surgical or Invasive Procedure:
1. Anterior cervical diskectomy and interbody arthrodesis
C5-C6.
2. Interbody reconstruction with biomechanical device C5-
C6.
3. Anterior plate instrumentation C5, C6.
4. Autograft, same incision.
History of Present Illness:
___ known cervial disk herniation having progressive bilateral
UE weakness over the last 1.5 week. Acutely worsened ___ days
ago with severe neck pain and R shoulder pain. Had an outpatient
MRI yesterday which showed disc narrowing at C5-C6, no cord
signal abnormality. Due to pain, patient presented to ___
___ today and sent here for spine eval. Denies
urinary/bowel incontinence, ___ symptoms. Of note pateint was
seen by Dr. ___ ___ - He noted a previous large C5-C6
disk herniation. At the time she had no emergent signs requiring
surgical intervention. No signs of myelopathy.Her chief
complaint is neck pain. Many symptoms have been present for a
long period of time. It was unclear to him whether surgical
intervention would help her with her primary complaint.
Past Medical History:
bronchial asthma, panic disorder, depression, bipolar and ADD.
Social History:
She is single with the domestic partner. She smokes one pack per
day for ___ years.
Physical Exam:
Admission PE
98.6 76 116/65 18 100% RA
RUE
Motor ___ C5 Deltoid ___ C6 Wrist Extension ___ C7
Triceps ___ C8 Finger Flexion ___ T1 Finger Abduction
SILT C5-T1
___ negative
LUE
Motor ___ C5 Deltoid ___ C6 Wrist Extension ___ C7
Triceps ___ C8 Finger Flexion ___ T1 Finger Abduction
SILT C5-T1
___ negative
RLE
Motor ___ L2 Hip flexion/adduction ___ L3 Knee Extension
___ L4 Tib Ant ___ L5 ___ ___ S1 ___ ___ S2 Toe Flexion
SILT L2-S2
Babinski down going
Clonus no beats
LLE
Motor ___ L2 Hip flexion/adduction ___ L3 Knee Extension
___ L4 Tib Ant ___ L5 ___ ___ S1 ___ ___ S2 Toe Flexion
SILT L2-S2
Babinski down going
Clonus no beats
Discharge Physical Exam:
General:Well appearing sitting up in bed, some discomfort to
surgical site, pleasant
CV:RRR
Resp:CTAB
ABd:soft,ntnd,+bs's
Extremities:wwp,2+distal pulses
___ LUE: throughout, RUE: 4+/5 Grip, ___
Del/EF/EE/WF/WE/IO
+SILT BUE's
Pertinent Results:
___ 04:45AM BLOOD WBC-14.2* RBC-4.01 Hgb-12.9 Hct-37.8
MCV-94 MCH-32.2* MCHC-34.1 RDW-11.8 RDWSD-40.9 Plt ___
___ 03:55PM BLOOD Neuts-60.8 ___ Monos-5.8 Eos-3.0
Baso-0.4 Im ___ AbsNeut-7.78* AbsLymp-3.81* AbsMono-0.74
AbsEos-0.39 AbsBaso-0.05
___ 04:45AM BLOOD Plt ___
___ 04:45AM BLOOD Glucose-87 UreaN-7 Creat-0.6 Na-138 K-4.1
Cl-104 HCO3-25 AnGap-13
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure. Refer to
the dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with oral pain medication. Diet was advanced
as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. The patient was voiding
independently. The patient was ambulating independently.
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:
Prilosec 40 mg capsule,delayed release oral
1 capsule,delayed ___ Twice Daily
___ ___ 16:04)
Ativan 1 mg tablet oral
1 tablet(s) Three times daily, as needed
___ ___ 16:05)
tramadol 50 mg tablet oral
2 tablet(s) Three times daily
___ ___ 16:05)
Zoloft 100 mg tablet oral
2 tablet(s) Once Daily
___ ___ 16:05)
Adderall 30 mg tablet oral
1 tablet(s) Once Daily at noon
___ ___ 16:06)
Adderall XR 30 mg capsule,extended release oral
1 capsule,extended release 24hr(s) Twice Daily (AM and ___
___ ___ 16:06)
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q8H:PRN headache
2. HYDROmorphone (Dilaudid) 6 mg PO Q4H:PRN pain
please do not operate heavy machinery,drink alcohol or drive
RX *hydromorphone [Dilaudid] 4 mg 1.5 tablet(s) by mouth every
four (4) hours Disp #*80 Tablet Refills:*0
3. Sertraline 50 mg PO DAILY
4. Tizanidine 4 mg PO TID
5. Diazepam 5 mg PO Q6H:PRN pain or spasm
may cause drowsiness
RX *diazepam 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*50 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID constipation
please take while on pain medication
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Herniated nucleus pulposus C5-C6.
2. Spinal cord compression.
3. Nerve root compression.
4. Right arm pain 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.
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
___. 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:
___
|
19805513-DS-8
| 19,805,513 | 23,086,985 |
DS
| 8 |
2132-05-05 00:00:00
|
2132-06-17 09:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
LLQ abd pain, distention, N/V
Major Surgical or Invasive Procedure:
Colonoscopy with colonic stent placement
History of Present Illness:
35 previously healthy woman who presents with LLQ of about 2
months duration which has slowly increased over that time. More
recently, she became increasingly distended and for the past
week
has not been able to pass stool or flatus. She saw her PCP who
treated her for constipation, and last night she tried Miralax
and Milk of Magnesia resulting in a small bowel movement this
morning, which contained a small amount of blood. She reports
she
also has been having difficulty keeping food down and
experiencing intermittent nausea for the past week, with
vomiting
about once a day for the past 3 days. In addition she complains
of epigastric burning pain, which she says has worsened since
she
started taking Ibuprofen for her abdominal pain. She denies any
sick contacts or foods different from baseline. She denies
fevers/chills, chest pain, or shortness of breath. She denies
changes in urinary habits.
Past Medical History:
PMH: Does have a reported history of anorexia nervosa
PSH: None
Social History:
___
Family History:
Non contributory
Physical Exam:
NAD, A&Ox3
RRR, no m/r/g
CTAB
abd soft, mild left side TTP, improved from admission
MAE, no edema
Pertinent Results:
___ 02:30PM URINE MUCOUS-MANY
___ 02:30PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 02:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:30PM URINE GR HOLD-HOLD
___ 02:30PM URINE UCG-NEGATIVE
___ 02:30PM URINE HOURS-RANDOM
___ 02:30PM URINE HOURS-RANDOM
___ 02:55PM PLT COUNT-347
___ 02:55PM NEUTS-90.7* LYMPHS-5.9* MONOS-3.0 EOS-0.2
BASOS-0.1
___ 02:55PM WBC-10.1# RBC-4.41 HGB-12.4 HCT-36.9 MCV-84
MCH-28.1# MCHC-33.6 RDW-15.7*
___ 02:55PM ALBUMIN-4.3 CALCIUM-9.1 PHOSPHATE-2.1*
MAGNESIUM-2.4
___ 02:55PM LIPASE-33
___ 02:55PM ALT(SGPT)-17 AST(SGOT)-26 ALK PHOS-67 TOT
BILI-0.4
___ 02:55PM estGFR-Using this
___ 02:55PM GLUCOSE-103* UREA N-17 CREAT-0.5 SODIUM-140
POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-26 ANION GAP-20
CT abd/pelvis:
LOWER CHEST: There is mild bibasilar dependent atelectasis. The
included
portions of the heart and pericardium are unremarkable. There is
no pleural
effusion.
LIVER: There is mild periportal edema. The liver enhances
homogeneously, with
no focal lesions or intrahepatic biliary duct dilatation. The
gallbladder is
unremarkable and the portal vein is patent.
PANCREAS: The pancreas does not demonstrate focal lesions or
peripancreatic
stranding or fluid collection.
SPLEEN The spleen is homogeneous and normal in size.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys do not show solid or cystic lesions and
demonstrate
symmetric nephrograms and excretion of contrast. No
pelvicaliceal dilatation
or perinephric abnormalities are present.
GI TRACT: Enteric contrast is seen to the level of the proximal
small bowel.
The stomach is distended. There is diffuse fluid distension of
small bowel
measuring up to at most 3.7cm and large bowel up to 6.2 cm in
the transverse
colon. The cecum is very mildly dilated up to 8.4 cm. There is
wall
thickening and edema with mucosal hyper-enhancement involving
the distal
transverse colon to the level of the splenic flexure. In the
distal descending
colon, there appears to be a transition point with more colonic
wall
thickening and hyper-enhancement distal to this point (601b:17).
The sigmoid
colon and rectum are collapsed. The appendix is visualized and
normal.
VASCULAR: The aorta is normal in caliber without aneurysmal
dilatation. The
origins of the celiac axis, SMA, bilateral renal arteries, and
___ appear
patent.
RETROPERITONEUM AND ABDOMEN: There is no retroperitoneal or
mesenteric lymph
node enlargement. There is a small to moderate amount of
ascites. No abdominal
wall hernia or free air is identified.
PELVIC CT: The urinary bladder and distal ureters are
unremarkable. No pelvic
wall or inguinal lymph node enlargement is seen. There is a
small amount of
pelvic free fluid. The uterus and bilateral adnexa are
unremarkable.
OSSEOUS STRUCTURES: No blastic or lytic lesions suspicious for
malignancy is
present. The bones appear probably demineralized.
IMPRESSION:
1. Multifocal areas of colonic wall thickening and mucosal
hyper-enhancement
involving the distal transverse colon and descending colon are
likely
infectious or inflammatory in etiology. The presence of small to
moderate
amount of ascites may favor an infectious process somewhat. The
transverse
colon is dilated up to 6.2 cm and developing toxic megacolon
cannot be
excluded.
2. Diffuse distension of fluid filled loops of small and large
bowel with a
transition point in the descending colon secondary to the
infectious or
inflammatory process could indicate an ileus versus obstruction
of large bowel
associated with inflammatory narrowing. Peritonitis can also
explain diffuse
bowel dilatation, but there is collapse of sigmoid and rectum
beyond the
second segment of marked inflammatory change along the colon.
3. Suspicion for bony demineralization. DEXA scan is recommended
for further
evaluation.
CT chest:
There is no concerning consolidation or lung nodules. There is
mild bibasilar
atelectasis and small nonhemorrhagic pleural effusions. There is
no
pneumothorax. The airways are patent to the segmental level.
The thyroid is normal. Supraclavicular, axillary, mediastinal
and hilar lymph
nodes are not enlarged. Aorta and pulmonary arteries are normal
size. There
are no filling defects in the pulmonary arteries concerning for
pulmonary
emboli. Cardiac configuration is normal and there is no
appreciable coronary
calcification.
Relative osteopenia is again noted.
This study is not designed to evaluate the upper abdominal
contents. Colonic
wall thickening and ascites are better characterized on the
prior CT abdomen
and pelvis of ___.
IMPRESSION:
Small non-hemorrhagic pleural effusions. No evidence of
intrathoracic
malignancy.
Colonoscopy:
A ulcerated circumferential 5 cm mass of malignant appearance
was found in the sigmoid colon / descending colon. The mass
caused a complete obstruction. The scope could not traverse the
lesion.
Cold forceps biopsies were performed for histology.
Brief Hospital Course:
Mrs. ___ was admitted to ___ for abdominal pain, nausea and
vomiting. She had these symptoms for 2 months which had been
worsening. A CT scan showed a possible mass in the transverse to
descending colon. She was taken by GI for colonoscopy. At that
time they placed a stent, which relieved her symptoms. She was
eventually started on a regular diet, which she tolerated
without difficulty. Her pain resolved and at the time of
discharge she was doing well. She Will follow up at ___ for
elective colectomy.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Continue to take while taking narcotic medication
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day
Disp #*50 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left Colon mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for a bowel obstruction. You
were given bowel rest and intravenous fluids, a nasogastric tube
was placed in your stomach to decompress your bowels, and GI
placed a colonic stent. Your obstruction has subsequently
resolved after placement of the stent. 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. 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.
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:
___
|
19805532-DS-2
| 19,805,532 | 23,283,321 |
DS
| 2 |
2182-04-12 00:00:00
|
2182-04-12 18:20:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
COPD exacerbation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M w hx asthma (since childhood), multiple environmental
allergies, COPD, and current smoker, presented with 2 days of
productive cough and increased shortness of breath.
Has long hx of hospitalizations for COPD, one requiring
intubation ___ years ago, most recently in ___. Just moved to
___ from ___. Started having a cold w rhinorrhea and
sneezing several days ago, which is how his exacerbations
usually
being. Describes green sputum and one episode of post-tussive
emesis (non-bloody). He is on several inhaled maintenance
medications for his COPD. He denies fevers, chills, chest pain,
abdominal pain, dysuria, frequency, extremity weakness or
paresthesia, recent travel, hemoptysis, nausea, or diarrhea.
His pulmonologist is Dr. ___ in ___ (___)
and he requests she be contacted in the morning.
Peak flows post duonebs were 125 in AM, 150 in ___.
In the ED, initial vitals: T 97.1 HR 112 BP 116/80 RR 18 97%RA
- Exam notable for:
-No increased work of breathing
-Vital signs stable, afebrile, normal SPO2
-Breath sounds severely decreased in all lung fields, scattered
expiratory wheezes, no focal consolidation
-No JVD, peripheral edema or signs of heart failure
- Labs notable for: lactate 1.4 --> 3.6 --> 3.4, WBC 14.8, HGB
13.0, gluc 124, BMP wnl, trop neg x2, flu negative
- Imaging notable for: CXR w hyperexpanded lungs otherwise WNL
- Pt given: pred, azithro, montelukast
___ 05:16 PO PredniSONE 60 mg
___ 05:17 IH Albuterol 0.083% Neb Soln 1 NEB
___ 05:17 IH Ipratropium Bromide Neb 1 NEB
___ 05:55 IH Albuterol 0.083% Neb Soln 1 NEB
___ 05:55 IH Ipratropium Bromide Neb 1 NEB
___ 06:31 IH Albuterol 0.083% Neb Soln 1 NEB
___ 06:31 IH Ipratropium Bromide Neb 1 NEB
___ 06:50 PO Azithromycin 500 mg
___ 12:19 IH Ipratropium Bromide Neb 1 NEB
___ 12:19 IH Albuterol 0.083% Neb Soln 1 NEB
___ 12:19 PO/NG Montelukast 10 mg
___ 17:40 IH Ipratropium Bromide Neb 1 NEB
___ 17:40 IH Albuterol 0.083% Neb Soln 1 NEB
- Vitals prior to transfer: HR 101 BP 123/75 RR 22 100% RA
Upon arrival to the floor, the patient reports the above
history.
He has been smoking on and off since age ___, recently quit but
then started smoking again.
REVIEW OF SYSTEMS: As above.
Past Medical History:
- Asthma
- COPD
- Seasonal allergies
- Osteoarthritis
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: Temp: 99.2 PO BP: 130/77 HR: 101 RR: 18 O2 sat: 95% RA
GENERAL: well developed, well nourished, frequent coughing fits
HEENT: sclera anicteric, MMM
CARDIAC: regular rate and rhythm, no murmurs, rubs, or gallops
LUNGS: poor air movement throughout w wheezing and rhonchi,
slightly inc WOB on RA
ABDOMEN: soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
EXTREMITIES: warm, well perfused, no cyanosis or edema
NEURO: AOx3, face symmetric, moving all extremities w purpose
and
against gravity
DISCHARGE PHYSICAL EXAM
=======================
Pertinent Results:
ADMISSION LABS
==============
___ 07:35AM BLOOD WBC-14.8* RBC-4.42* Hgb-13.0* Hct-40.2
MCV-91 MCH-29.4 MCHC-32.3 RDW-14.5 RDWSD-48.2* Plt ___
___ 07:35AM BLOOD Neuts-79.9* Lymphs-11.1* Monos-5.7
Eos-2.3 Baso-0.4 Im ___ AbsNeut-11.79* AbsLymp-1.64
AbsMono-0.84* AbsEos-0.34 AbsBaso-0.06
___ 07:35AM BLOOD Glucose-124* UreaN-15 Creat-0.9 Na-141
K-4.1 Cl-106 HCO3-21* AnGap-14
___ 07:35AM BLOOD cTropnT-<0.01
___ 08:35PM BLOOD cTropnT-<0.01
___ 10:43AM BLOOD ___ pO2-71* pCO2-43 pH-7.39
calTCO2-27 Base XS-0
___ 07:46AM BLOOD Lactate-1.4
IMAGING
=======
CXR (___)
----------
IMPRESSION:
1. No definite pneumonia.
2. The lungs are hyperexpanded, compatible with provided history
of COPD.
DISCHARGE LABS
==============
Brief Hospital Course:
SUMMARY
=======
___ yo M with hx of COPD, asthma, seasonal allergies, current
smoker who presented to ED with increased sputum production,
worsening cough, rhinorrhea with concern for COPD exacerbation
likely precipitated by viral URI.
ACTIVE ISSUES
=============
#COPD Exacerbation
#Asthma
Patient presented with increased sputum production and worsening
cough consistent with COPD exacerbation in the setting of
several days of rhinorrhea, cough, occasional fevers/chills at
home, which was thought to be a viral URI. Flu PCR was negative,
and CXR was clear. Patient had a mild leukocytosis to 14.8. He
was given prednisone 60 mg and azithromycin 250 mg in the ED
(___) as well as duonebs q6h and ipratropium q2h PRN for a
planned 5-day course of both prednisone 40 mg and azithromycin
250 mg. Patient remained on room air during his hospital stay
with goal oxygen saturation of 88-92%, and he remained above
goal on room air during his hospitalization. His home
montelukast was continued.
#Abnormal EKG
Patient found to have incomplete RBBB on EKG; unsure if this is
a new finding as did not have patient's baseline EKG's since he
just moved to ___. A new RBBB in the setting of COPD could
indicate developing right heart strain; as patient was euvolemic
on presentation and remained euvolemic as well as normal cardiac
exam, no urgent need for echocardiogram, and it was decided to
defer echo for the patient to receive as an outpatient.
#Smoking cessation
Patient in contemplative stage. He has tried Chantix in the past
which has worked for him, but he has said that his insurance
didn't cover it which is why he stopped.
#Elevated lactate
Thought to be ___ albuterol use as patient was not septic.
Initial lactate 3.6 after nebulizer in ED, repeat 3.4, and not
trended as it was downtrending.
CHRONIC ISSUES
==============
#Seasonal allergies
-Patient's home montelu___ was continued.
TRANSITIONAL ISSUES
===================
[ ]Smoking cessation - as patient in contemplative stage, please
continue to support him and provide resources as needed
[ ]Abnormal EKG - please help patient coordinate getting an
echocardiogram done to assess for right heart strain or other
reasons for incomplete RBBB
CORE MEASURES
=============
Contact: None
Code: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
3. Montelukast 10 mg PO DAILY
4. Ipratropium-Albuterol Neb 1 NEB NEB ASDIR
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 1 Dose
Start on ___
RX *azithromycin 250 mg 1 tablet(s) by mouth Once a day Disp #*1
Tablet Refills:*0
2. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN intense
coughing
RX *codeine-guaifenesin 10 mg-100 mg/5 mL 5 mL by mouth As
needed for cough at bedtime Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 1 Dose
Start on ___
RX *prednisone 20 mg 2 tablet(s) by mouth Once a day Disp #*2
Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Ipratropium-Albuterol Neb 1 NEB NEB ASDIR
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1
ampule neb Every 6 hours as needed Disp #*56 Ampule Refills:*0
6. Montelukast 10 mg PO DAILY
7. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
COPD Exacerbation
SECONDARY DIAGNOSES
===================
Asthma
Seasonal allergies
Upper respiratory viral infection
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 WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because of a flare-up of your
COPD. We think it was due to a viral infection of your
respiratory system.
WHAT WAS DONE WHILE I WAS HERE?
We gave you steroids, various forms of nebulizers, antibiotics,
and cough medicine to help calm your lungs down.
WHAT DO I NEED TO DO ONCE I LEAVE THE HOSPITAL?
-Continue taking the antibiotic and steroid for one more day
(your last day will be ___.
-Continue using the duonebs treatment every 6 hours until you
are back at your baseline breathing status.
-Continue using your home medications as previously directed.
-Please continue to think about quitting smoking, as it will
greatly help your breathing; you can speak with your primary
doctor about quitting strategies when you are ready.
-Please follow-up with your primary doctor within 1 week of
leaving the hospital.
Be well,
Your ___ Care Team
Followup Instructions:
___
|
19805562-DS-21
| 19,805,562 | 29,834,353 |
DS
| 21 |
2160-03-13 00:00:00
|
2160-03-28 12:53:00
|
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left calf wound, cellulitis
Major Surgical or Invasive Procedure:
___: PROCEDURE:
1. Split-thickness skin graft 10 x 15 cm from left thigh to
left calf.
2. Placement of 10 x 15 cm VAC sponge.
___: Excisional debridement of left leg, skin, fat,
fascia, and drainage of hematoma with placement of a VAC
dressing
20 x 10 cm.
___: PROCEDURE:
1. Split-thickness skin graft 10 x 15 cm from left thigh to
left calf.
2. Placement of 10 x 15 cm VAC sponge.
History of Present Illness:
Mr. ___ is a ___ year old gentleman who presents 9 days after
falling off his tractor and being struck on his LLE. He
sustained
a 4in x 6in soft tissue injury for which he initially presented
to an OSH ED. Notably plain films at the time of the original
injury were reportedly negative for fracture or bony
involvement.
He had been receiving wound care as an outpatient with
superficial debridement, bacitracin and gauze dressings but the
leg had continued to swell and the skin overlying the wound
turned black. He was advised to present to ___ by his PCP with
concern for compartment syndrome. On exam the lateral aspect of
his left calf has a necrotic eschar overlaying a tense fluid
pocket, likely hematoma. The entire left calf is erythematous
with scattered ecchymosis, although the patient endorses much of
this is chronic changes following a total hip replacement in
___. There is notably a well-demarcated rind of blanching
erythema directly around the edges of the wound. Sensation,
motor
and pulses are all intact and the limb compartments are soft and
mildly tender.
Past Medical History:
PAST MEDICAL HISTORY:
Chronic anemia secondary to a bleeding "GI plexus"
OSA
Afib on Coumadin
CHF, reportedly normal TTE
HTN
OA
HLD
MVA with head injury ___
Vitamin D deficiency
Chronic bronchitis
Diaphragmatic hernia
PAST SURGICAL HISTORY:
L total hip replacement ___
Retinal repair
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission PHYSICAL EXAMINATION:
VSS: 98.4 100 138/96 20 100%RA
GEN: No acute distress, well-nourished, appropriately groomed.
NEURO: Alert and oriented to time, person and place. CN II-XII
grossly intact. Sensation to pressure and fine touch intact and
symmetric bilaterally
HEENT: Pupils equal, round, reactive to light and accommodating;
sclerae anicteric. No nystagmus or ptosis. Oropharynx moist and
pink. Nose and ears atraumatic
CV: Irregularly irregular rhythm, no murmurs, rubs or gallops,
2+
peripheral pulses symmetrically
RESP: Clear to auscultation bilaterally, no wheezes, rales or
crackles
GI: Abdomen obese and soft, non-tender and non-distended. No
hepatosplenomegaly. Abdomen dull to percussion. Bowel sounds
normoactive. Rectal exam deferred
LYPMH: No cervical, axillary or inguinal lymphadenopathy
GU: Deferred
MSK: The lateral aspect of his left calf has a necrotic eschar
overlaying a tense fluid pocket. The entire left calf is
erythematous with scattered chronic ecchymoses. There is a
well-demarcated rind of blanching erythema directly around the
edges of the wound. Sensation, motor and pulses are all intact
and the limb compartments are soft and mildly tender.
Discharge Physical Exam:
VS: VSS afebrile
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, nontender to palpation
EXTREMITIES: left thigh skin graft donor site: dressed with
xeroform, no erythema. left calf wound with skin graft taking
well to wound bed, dressed with adaptic and kerlix.
Pertinent Results:
___ 10:50AM BLOOD WBC-6.3 RBC-4.06* Hgb-11.1* Hct-36.7*
MCV-90 MCH-27.3 MCHC-30.2* RDW-17.8* RDWSD-59.4* Plt ___
___ 08:03AM BLOOD WBC-6.5 RBC-4.04* Hgb-11.1* Hct-36.5*
MCV-90 MCH-27.5 MCHC-30.4* RDW-17.7* RDWSD-58.8* Plt ___
___ 06:55AM BLOOD WBC-5.8 RBC-3.91* Hgb-10.5* Hct-35.6*
MCV-91 MCH-26.9 MCHC-29.5* RDW-17.9* RDWSD-58.9* Plt ___
___ 09:30AM BLOOD WBC-6.3 RBC-4.05* Hgb-10.9* Hct-36.6*
MCV-90 MCH-26.9 MCHC-29.8* RDW-17.8* RDWSD-59.0* Plt ___
___ 06:31AM BLOOD WBC-5.7 RBC-3.97* Hgb-10.7* Hct-35.6*
MCV-90 MCH-27.0 MCHC-30.1* RDW-17.7* RDWSD-59.2* Plt ___
___ 06:28AM BLOOD ___
___ 07:10AM BLOOD ___
___ 10:50AM BLOOD ___
___ 10:50AM BLOOD Glucose-149* UreaN-12 Creat-0.8 Na-144
K-3.4 Cl-105 HCO3-27 AnGap-15
___ 08:03AM BLOOD Glucose-102* UreaN-9 Creat-0.7 Na-145
K-3.6 Cl-108 HCO3-28 AnGap-13
___ 06:55AM BLOOD Glucose-93 UreaN-11 Creat-0.7 Na-141
K-3.7 Cl-104 HCO3-26 AnGap-15
___ 09:30AM BLOOD Glucose-170* UreaN-13 Creat-0.8 Na-140
K-3.7 Cl-102 HCO3-27 AnGap-15
IMAGING
==========================================
left ankle/tib-fib XR:
1. No fracture is identified.
2. Plantar subluxation of the navicular may be a chronic
process.
Degenerative changes are noted in the knee and ankle joints.
3. Soft tissue hematoma in the left lateral calf.
PATHOLOGIC DIAGNOSIS:
Eschar, left calf, excisional debridement: Extensively necrotic
skin and fibroadipose with acute
inflammation, abscess formation and hematoma.
Brief Hospital Course:
___ year old male on Coumadin admitted to the General Surgery
service for management of a left calf soft tissue hematoma with
associated cellulitis. The patient was hemodynamically stable.
He received antibiotics with some benefit but the area continued
to be exquisitely tender and clearly needed drainage and
debridement. The patient was therefore consented and taken to
the operating room for excisional debridement of left leg, skin,
fat, fascia, and drainage of hematoma with placement of a VAC
dressing which went well without complication (reader referred
to the Operative Note for details). After a brief, uneventful
stay in the PACU, the patient arrived on the floor tolerating a
regular diet and on oral pain medicine and on antibiotics. The
patient was hemodynamically stable.
POD2 the VAC dressing was taken down and the wound bed appeared
very healthy and well granulated, with very little residual
circumferential skin necrosis. It was felt that the patient was
appropriate for placement of a split-thickness skin graft to
definitively close the wound. Antibiotics were discontinued at
this time due to resolution of cellulitis, normal labs and the
patient had been afebrile.
On ___ the patient was taken to the operating room and underwent
split-thickness skin graft from left thigh to left calf with
placement VAC sponge which went well without complication
(reader referred to the Operative Note for details). Coumadin
was re-started post-op.
On POD5 the VAC was removed from the skin graft site. The wound
was taking to the graft and it appeared healthy. At the time of
discharge on POD5, 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 ___ services
for wound care. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
..
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Diltiazem Extended-Release 300 mg PO DAILY
5. Warfarin 7.5 mg PO 3X/WEEK (___)
6. Pravastatin 40 mg PO QPM
7. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
8. Furosemide 40 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. flaxseed oil 1,000 mg oral DAILY
11. Potassium Chloride 10 mEq PO BID
12. Ascorbic Acid ___ mg PO DAILY
13. Vitamin D 5000 UNIT PO DAILY
14. melatonin 10 mg oral QHS:PRN insomnia
15. Warfarin 5 mg PO 4X/WEEK (___)
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 325 mg 2 tablet(s) by mouth three times a day
Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
4. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*25 Tablet Refills:*0
5. Ascorbic Acid ___ mg PO DAILY
6. Atenolol 50 mg PO DAILY
7. Diltiazem Extended-Release 300 mg PO DAILY
8. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. flaxseed oil 1,000 mg oral DAILY
11. Furosemide 40 mg PO DAILY
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Lisinopril 40 mg PO DAILY
14. melatonin 10 mg oral QHS:PRN insomnia
15. Potassium Chloride 10 mEq PO BID
Hold for K >
16. Pravastatin 40 mg PO QPM
17. Vitamin D 5000 UNIT PO DAILY
18. Warfarin 5 mg PO 4X/WEEK (___)
19. Warfarin 7.5 mg PO 3X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Soft tissue crush injury / infected hematoma to the left calf
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to ___ with a traumatic soft tissue injury to
your left calf. The site was incised and drained of an old
hematoma in the OR. The cellulitis resolved and the wound bed
was amenable to a skin graft, so the decision was made to take
you back to the OR for a skin graft. You tolerated this
procedure well. The VAC dressing has been removed and the wound
looks healthy. The dressing over the left thigh graft donor site
should remain in place until it peels up on its own; you may
trim the edges. You are medically cleared to be discharged home
to continue your recovery. You will be set up with a visiting
nurse for wound care. Please note the following discharge
instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, but DO NOT get graft sites wet. Wrap them up in
plastic before showering.
Followup Instructions:
___
|
19805768-DS-12
| 19,805,768 | 29,559,147 |
DS
| 12 |
2161-05-19 00:00:00
|
2161-05-21 17:16:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
exertional dyspnea, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with PMHx notable for hypertension and GERD
presenting to the ED for cough and dyspnea x3 weeks.
Reports most concerning symptom is significant resting dyspnea.
Initially began 3 weeks ago with a hacking, nonproductive cough
without any associated chest pain. Gradually progressed to the
point where he can no longer walk across the room without
feeling
severely short of breath. He denies any orthopnea/PND, night
sweats, chills, hemoptysis, chest pain, or palpitations.
History notable for 10 lb weight loss over the last ___ weeks
which he attributes to significantly decreased appetite. This
has
improved over past several days. Reports remote volunteer work
in
homeless shelter but otherwise has no significant history of
occupational or other exposures.
Initially presented to his PCP 1 week ago and received
fluticasone inhaler without improvement. Seen again by PCP 1 day
ago where he was diagnosed with PNA by CXR. Started on
azithromycin. Over past 24h symptoms have not significantly
worsened. Presented today because he is worried that he was not
getting better.
Review of systems further negative for headache, abdominal pain,
nausea, vomiting, or dysuria.
ED course notable for 97.8 96 117/75 22 94% NC. Labs notable for
WBC 8.0, BNP 249, trop negative. EKG with sinus tachycardia. CXR
with right greater than left-sided reticulonodular opacities
without significant change from prior. Started on IV
azithromycin.
Past Medical History:
hypertension
GERD
hx H. pylori infection
iron deficiency anemia
macular degeneration
renal mass
prostatic cyst
depression
cholecystectomy
colonic polyps
Social History:
___
Family History:
Colon cancer in father, HTN and depression in mother, and
___ disease in living brother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
Vitals: T 98.8 BP 131/83 HR 85 RR 20 O2Sat 92% 3L NC
GENERAL: Elderly appearing man in no acute distress.
HEENT: AT/NC, PERRL, anicteric sclera, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs
LUNGS: On 3L O2 NC. Diffuse crackles b/l, more prominent on R.
Breathing without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants
EXTREMITIES: no cyanosis, clubbing, trace edema to midway up
shins.
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE PHYSICAL EXAM
==============================
PHYSICAL EXAM:
Vitals: 97.6 102/68 82 18 93% RA (sitting, 92-93% while
ambulating on RA
GENERAL: Elderly appearing man in no acute distress.
HEENT: AT/NC, PERRL, anicteric sclera, MMM
NECK: supple, no LAD
HEART: RRR, S1/S2, no murmurs
LUNGS: Diffuse crackles b/l, R > L. Decreased breath sounds at
bases b/l. No egophany. Breathing without use of accessory
muscles
ABDOMEN: nondistended, nontender in all quadrants, large midline
scar (old)
EXTREMITIES: no cyanosis, clubbing, trace edema to midway up
shins.
NEURO: alert and orietend , moving all 4 extremities with
purpose
Pertinent Results:
ADMISSION LABS
=======================
___ 08:30PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-LG*
___ 08:30PM URINE RBC-3* WBC-25* BACTERIA-FEW* YEAST-NONE
EPI-0 TRANS EPI-<1
___ 08:30PM URINE AMORPH-RARE*
___ 08:30PM URINE MUCOUS-RARE*
___ 04:19PM K+-4.2
___ 03:50PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 03:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-2* PH-7.0
LEUK-LG*
___ 03:50PM URINE RBC-2 WBC-63* BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 03:50PM URINE MUCOUS-OCC*
___ 02:53PM GLUCOSE-91 UREA N-25* CREAT-1.0 SODIUM-139
POTASSIUM-6.8* CHLORIDE-94* TOTAL CO2-29 ANION GAP-16
___ 02:53PM cTropnT-<0.01
___ 02:53PM proBNP-249
___ 02:53PM WBC-8.0 RBC-4.32* HGB-12.7* HCT-38.1* MCV-88
MCH-29.4 MCHC-33.3 RDW-14.0 RDWSD-45.6
___ 02:53PM NEUTS-77.6* LYMPHS-14.4* MONOS-6.4 EOS-0.4*
BASOS-0.4 IM ___ AbsNeut-6.20* AbsLymp-1.15* AbsMono-0.51
AbsEos-0.03* AbsBaso-0.03
___ 02:53PM PLT COUNT-519*
___ 12:30PM GLUCOSE-108*
___ 12:30PM UREA N-30* CREAT-1.2 SODIUM-142 POTASSIUM-4.4
___ 12:30PM estGFR-Using this
___ 12:30PM WBC-11.8* RBC-4.74 HGB-14.0 HCT-42.0 MCV-89
MCH-29.5 MCHC-33.3 RDW-13.9 RDWSD-44.7
___ 12:30PM NEUTS-83.0* LYMPHS-8.5* MONOS-7.0 EOS-0.2*
BASOS-0.5 IM ___ AbsNeut-9.78* AbsLymp-1.00* AbsMono-0.83*
AbsEos-0.02* AbsBaso-0.06
___ 12:30PM PLT COUNT-568*#
PERTINENT LABS
=======================
___ 12:30PM BLOOD WBC-11.8* RBC-4.74 Hgb-14.0 Hct-42.0
MCV-89 MCH-29.5 MCHC-33.3 RDW-13.9 RDWSD-44.7 Plt ___
___ 07:10AM BLOOD WBC-7.5 RBC-4.41* Hgb-12.9* Hct-39.8*
MCV-90 MCH-29.3 MCHC-32.4 RDW-14.6 RDWSD-47.9* Plt ___
MICROBIOLOGY
=======================
___ 12:00 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
___ PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
UA
===
Urine Specimen Type RANDOM W
Urine Color Yellow YELLOW N/A W
Urine Appearance Clear CLEAR N/A W
Specific Gravity 1.025 1.001 - 1.035 W
DIPSTICK URINALYSIS
Blood NEG NEG N/A W
Nitrite NEG NEG N/A W
Protein NEG NEG mg/dL W
Glucose NEG NEG mg/dL W
Ketone NEG NEG mg/dL W
Bilirubin NEG NEG N/A W
Urobilinogen 0.2 0.2 - 1 mg/dL W
pH 6.0 5 - 8 units W
Leukocytes SM* NEG N/A W
MICROSCOPIC URINE EXAMINATION
RBC 8* 0 - 2 #/hpf W
WBC 15* 0 - 5 #/hpf W
Bacteria NONE NONE /hpf W
Yeast NONE NONE /hpf W
Epithelial Cells 0 #/hpf W
OTHER URINE FINDINGS
Urine Mucous FEW* NONE /hpf W
IMAGING
=====================
___ Chest CT IMPRESSION:
___ nodular opacities diffusely in the right lung and at
the left lung base compatible with multifocal infectious process
with both typical and atypical organisms..
___ (PA & LAT)
IMPRESSION:
Stable findings of reticular nodular opacities mostly in the
right lung which
remain concerning for infection.
___ (PA & LAT)
IMPRESSION:
New diffuse reticulonodular opacities, most prominent in the
right lung.
Differential considerations may include acute viral infection,
disseminated
tuberculosis, sarcoid, or disseminated carcinoma. Recommend
clinical
correlation.
DISCHARGE LABS
============================
___ 07:10AM BLOOD WBC-7.5 RBC-4.41* Hgb-12.9* Hct-39.8*
MCV-90 MCH-29.3 MCHC-32.4 RDW-14.6 RDWSD-47.9* Plt ___
___ 07:10AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-91 UreaN-24* Creat-0.9 Na-142
K-4.9 Cl-103 HCO3-23 AnGap-16
___ 07:25AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.8
___ 05:15PM BLOOD D-Dimer-___*
Brief Hospital Course:
___ male with PMHx notable for hypertension and GERD
admitted for cough, dyspnea x3 weeks with new O2 requirement. Pt
got a CXR and CT that showed Tree and ___ opacities. Pulmonology
was consulted and they decided that the most likely diagnosis is
pneumonia due to aspiration due to hx of GERD. They discussed
lifestyle modifications with him (small meals, not eating before
bed, raising head of bed). Patient got azithromycin and
ceftriaxone in the hospital, discharged on levofloxacin for at
total of 7 days of antibiotics. He initially required 3L of O2
by nasal cannula but on discharge spo2 was 92-93% at rest and
while ambulating on RA without symptoms of dyspnea. We continued
to treat his hypertension and GERD with his home medications. Of
note, patient also appeared to have a UTI on admission based on
results of his UA which showed leuk esterase, WBCs, bacteria,
and RBCs (however was asx and culture was negative). The UA
improved over the course of the hospitalization but we recommend
repeating another UA in several weeks to see if there is
continued inflammation.
ACUTE ISSUES:
=============
#Pneumonia
Per pulm patient most likely has aspiration pneumonia ___ to
GERD. They recommend that he continue is 7 day treatment for
CAP. Legionella negative. Was continued on CTX and azithromycin.
He was ambulating well prior to discharge and maintaining
saturations > 89%.
#Weight loss
10lb weight loss confirmed in OMR since ___. Notes decreased
PO intake due to loss of appetite. However, in context of
ongoing
cough and CXR findings, can also consider TB, malignancy, or
other systemic processes. Reassuring that he denies any other
constitutional symptoms such as fevers, nightsweats. No
lymphadenopathy appreciated. LDH elevated at 271. Most likely
___ to pneumonia. Recommend it is followed up and if weight loss
continues then undergo further workup in outpatient setting.
#Proteinuria/bacteruria
Patient had +leuk, protein, bacteria, and WBCs in urine at time
of admission. Culture was negative but if sample was from after
patient received ceftriaxone then we would expect a negative
culture. Repeat UA showed small leuk esterase, 15 WBCs, and 8
RBCS which is significantly better than his prior UA. Presuming
pt had a UTI that is improving with ceftriaxone. If he has
another UTI should have urologic work up.
CHRONIC ISSUES:
===============
#hypertension: Continued home Hydrochlorothiazide 25 mg PO/NG
DAILY and home Lisinopril 10 mg PO/NG DAILY
#gastroesophageal reflux disease: Continued Omeprazole 40 mg PO
DAILY and increased to BID per pulm recs. Continued home
ranitidine. Was given GERD lifestyle precautions: elevate the
___, at least ___ hours after last meal before sleep, avoid EtOH
and caffeine
#allergic rhinitis: continued fluticasone
Transitional Issues:
====================
-New medications: Levofloxacin 500 mg qd (to complete 7 day
course for community acquired pneumonia on ___
-Changed medications: Omeprazole was increased from 40 mg qd to
BID
-Imaging: Please repeat chest CT in 12 weeks to see if tree and
___ opacities have resolved.
-GERD: Please decrease omeprazole to qd after a month (he has a
history of osteopenia). Consider GI referral or surgical
referral for further management.
-Labs: Repeat UA to evaluate for inflammation and microscopic
hematuria.
-Code status: Full code
-Emergency contact: ___ ___ (do not contact
unless emergency)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN nasal
allergies
2. Hydrochlorothiazide 25 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Urocit-K 10 (potassium citrate) 10 mEq (1,080 mg) oral TID
6. Ranitidine 300 mg PO QHS
7. Aspirin 81 mg PO DAILY
8. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
Discharge Medications:
1. Levofloxacin 500 mg PO Q24H
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
2. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
3. Aspirin 81 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN nasal
allergies
5. Hydrochlorothiazide 25 mg PO DAILY
6. Lisinopril 10 mg PO DAILY
7. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
8. Ranitidine 300 mg PO QHS
9. Urocit-K 10 (potassium citrate) 10 mEq (1,080 mg) oral TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
==================
Aspiration pneumonitis
Community acquired pneumonia
Secondary diagnosis:
====================
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
You were in the hospital with pneumonia (an infection in your
lungs) most likely due to your acid reflux.
WHAT HAPPENED IN THE HOSPITAL?
We started you on antibiotics to help treat the pneumonia as
well as gave you oxygen since testing showed that the level of
oxygen in your blood was low. You had a CT and the lung doctors
saw ___ and recommended lifestyle management as it was
consistent with gastroesophageal reflux disease.
WHAT SHOULD I DO WHEN I GO HOME?
Continue to take your antibiotics and omeprazole as prescribed
(the frequency of omeprazole was changed). Please do not eat
large meals prior to lying down and instead, eat small meals and
remain upright for several hours prior to lying down. Try as
much as you can to avoid foods and drinks that increase reflux
symptoms (spicy foods, chocolate, and coffee). Follow up with
your primary care doctor ___ below, the soonest appointment was
with a resident working with Dr. ___.
We wish you the best!
-Your Care Team at ___
Followup Instructions:
___
|
19805768-DS-13
| 19,805,768 | 29,914,724 |
DS
| 13 |
2161-05-22 00:00:00
|
2161-05-22 20:58:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea, tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMHx notable for HTN and GERD presents with dyspnea and
tachycardia after recent admission (discharged ___ for PNA.
Patient reports history of poor appetite and cough for about one
month. He was then admitted to ___ and treated with
levaquin/azithro for what was presumed to be an aspiration PNA
from GERD. Patient reports that at the time of discharge he was
still having some significant DOE. He said he returned home and
continued to have dyspnea even with the slightest activity. He
said he feels fine at rest though "even going to the fridge
makes
me short of breath." He otherwise says he has been feeling
somewhat better as his cough has been improving quite a bit but
is still having less PO intake than is normal for him due to
decreased appetite (at baseline he says if you put two
cheeseburgers in front of him he would make them disappear
immediately). Denies fevers, chills, CP, palpitations, n/v/d,
constipation, calf pain, or dizziness/LH.
In the ED, initial VS were: 97.6 104 110/66 20 94% 2L NC
Labs showed: BUN 33, plt 513, BNP 73, lactate 1.3
UA: Trace protein, 40 ketones, few bacteria
Imaging showed:
CXR: Improving ill-defined opacities within the lungs
bilaterally, more pronounced in the lung bases and on the right,
likely reflective of resolving aspiration pneumonia.
CTA Chest: 1. Re-demonstration of ___ nodular opacities
diffusely in the right lung and at the left lung base with
smaller regions of focal consolidations
along the right lung fissures in base suggestive of an ongoing
infectious process not significantly changed from study of ___.
2. No evidence of pulmonary embolism or aortic abnormality.
Patient received: Levofloxacin 750 mg IV, 1L NS
On arrival to the floor, patient reports feeling somewhat
anxious
as to the prospect that he will not get back to the baseline
level of health that he enjoyed prior to his original
hospitalization for PNA. He otherwise is feeling better and has
been able to get down some diet ginger ale.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
hypertension
GERD
hx H. pylori infection
iron deficiency anemia
macular degeneration
renal mass
prostatic cyst
depression
cholecystectomy
colonic polyps
Social History:
___
Family History:
Colon cancer in father, HTN and depression in mother, and
___ disease in living brother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: 98.4 99/68 83 18 94% RA
GENERAL: Pleasant gentleman sitting comfortably in bed
HEENT: NCAT, MMM
NECK: Neck veins flat sitting upright
HEART: RRR, no m/r/g
LUNGS: Faint bibasilar crackles
ABDOMEN: Soft, NT/ND, BS+
EXTREMITIES: WWP, no c/c/e
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
=======================
Vitals: 97.8 115/75 79 18 95% 2L
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Lungs: mild rhonchi with inspiration with somewhat reduced air
movement but significantly improved from prior hospitalization
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, no rebound tenderness
or guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
==============
___ 03:10PM BLOOD WBC-7.7 RBC-5.03 Hgb-14.7 Hct-44.5 MCV-89
MCH-29.2 MCHC-33.0 RDW-14.3 RDWSD-45.9 Plt ___
___ 03:10PM BLOOD Neuts-73.2* ___ Monos-6.5
Eos-0.3* Baso-0.5 Im ___ AbsNeut-5.60 AbsLymp-1.46
AbsMono-0.50 AbsEos-0.02* AbsBaso-0.04
___ 03:10PM BLOOD Glucose-72 UreaN-33* Creat-1.2 Na-138
K-4.5 Cl-95* HCO3-24 AnGap-19*
___ 03:10PM BLOOD proBNP-73
___ 07:45AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.8
___ 03:11PM BLOOD Lactate-1.3
___ 03:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:10PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-40* Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 03:10PM URINE RBC-1 WBC-4 Bacteri-FEW* Yeast-NONE Epi-0
___ 03:10PM URINE CastHy-11*
MICRO LABS:
==========
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD NO GROWTH TO DATE
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD NO GROWTH TO DATE
___ CULTURE-PENDINGEMERGENCY WARD
NO GROWTH TO DATE
IMAGES:
=======
CXR (___): Improving ill-defined opacities within the lungs
bilaterally, more pronounced in the lung bases and on the right,
likely reflective of resolving aspiration pneumonia.
CTA (___): 1. Re-demonstration of ___ nodular opacities
diffusely in the right lung and at the left lung base with
smaller regions of focal consolidations in the right lung
suggestive of an ongoing infectious process not significantly
changed from study of ___. 2. No evidence of
pulmonary embolism or aortic abnormality.
DISCHARGE LABS:
==============
___ 07:45AM BLOOD WBC-5.5 RBC-4.33* Hgb-12.7* Hct-38.2*
MCV-88 MCH-29.3 MCHC-33.2 RDW-14.3 RDWSD-45.9 Plt ___
___ 07:45AM BLOOD Glucose-79 UreaN-31* Creat-1.0 Na-139
K-4.1 Cl-98 HCO3-23 AnGap-18*
Brief Hospital Course:
___ recently admitted for aspiration pneumonitis/aspiration
pneumonia thought to be ___ to GERD with PMHx notable for
hypertension and GERD who was sent to the ED by his PCP because
of continuing SOB and tachycardia. In the Ed patient got one
dose of levaquin and IL of NS. He had a CXR that showed
improvement of prior pneumonia. CTA showed no pulmonary emboli
and tree and ___ opacities and consolidations consistent with
his prior scans. Patients vitals have been within normal limits
on the floor but was mildly orthostatic by elevated HR which was
though to be ___ dehydration. Patient got more fluids and the
tachycardia resolved and orthostatics negative. He has no
fevers, chills, sputum production, or cough, and his WBC is
normal. He does not de-sat on room air with ambulation and he
walked down the hall without difficulty. Shortness of breath
thought to be ___ resolving pneumonia and de-conditioning. Sent
home on no new medications but with a prescription for pulmonary
___ to help with re-conditioning.
#Dyspnea:
Patient was seen by pulmonology on last admission and CT showed
tree and ___ opacities which they thought were likely aspiration
pneumonitis/aspiration pneumonia ___ to GERD. Since his d/c he
has had continuing SOB with activity but his cough is improving.
He went to his PCP ___ ___ and he was mildly tachycardia and she
thought he was dehydrated. She sent him to the ED for fluids.
His CXR looked improved. He got 1L NS and a dose of levaquin. In
the ED given his tachycardia and SOB they got a CTA which did
not show a PE and showed similar tree and ___ pattern and
opacities consistent with PNA. Pt is very anxious that he is
dying (especially when the possibility of a PE was brought up).
His continuing SOB is most likely ___ to his
pneumonia/pneumonitis as well as continuing anxiety. Given that
his pneumonia appears to be improving and he completed a course,
they were discontinued. He had normal ambulatory sats and was
not orthostatic upon discharge.
#Anxiety:
Patient is very anxious that he will never return to his
baseline. I believe this anxiety is contributing to his SOB. Pt
reports he has long hx of depression (both circumstantial and
genetic) and has never been treated effectively with an
antidepressant. We discussed starting an SSRI for anxiety which
he is not interested in at the current time but he will think
about it.
#Tachycardia:
Most likely secondary to hypovolemia (initially) and
de-conditioning. His vitals and HR improved with IVF. He was
given a prescription to pulmonary rehab prior to discharge.
#Elevated Cr:
SG 1.025, hyaline casts, ketonuria, protein. Mild ___ probably
secondary to poor PO intake and dehydration. Cr 1.2 --> 1.0.
Improved with IVF.
#Hypertension: Continued home medications
#Gastroesophageal reflux disease: Continued omeprazole 40 mg BID
(from last admission) and home ranitidine. Encouraged continued
lifestyle changes to mitigate GERD/reflux impact on lungs per
previous Pulmonary consult recommendations.
#hx allergic rhinitis: continued home fluticasone
Transitional Issues:
====================
-New medications: No new medications were started this
admission.
-Imaging: Please repeat chest CT in 12 weeks to see if tree and
___ opacities have resolved.
-He was given a prescription to pulmonary ___ upon discharge.
-GERD: Please decrease omeprazole to qd after a month (he has a
history of osteopenia). Consider GI referral or surgical
referral for further management.
-Labs: Repeat UA to evaluate for inflammation and microscopic
hematuria.
-Code status: Full code
-Emergency contact: ___ ___ (do not contact
unless emergency)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Hydrochlorothiazide 25 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Omeprazole 40 mg PO BID
5. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
6. Urocit-K 10 (potassium citrate) 10 mEq (1,080 mg) oral TID
Discharge Medications:
1. Omeprazole 40 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral BID
6. Urocit-K 10 (potassium citrate) 10 mEq (1,080 mg) oral TID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Aspiration Pneumonia
Dehydration
Secondary Diagnosis
Gastroesophageal reflux disease
HYPERTENSION
Discharge Condition:
Discharge condition: stable
Mental Status: A&O x3
Ambulatory status: ambulatory
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. Please see below
for information on your time in the hospital.
WHY WAS I IN THE HOSPITAL?
You were in the hospital because you were dehydrated and you
were having difficulty breathing in the setting of a resolving
pneumonia.
WHAT HAPPENED IN THE HOSPITAL?
We gave you 1 dose of antibiotics in the emergency room, we gave
you fluids to help with your dehydration, and you got a chest
xray and cat scan of your lungs.
WHAT SHOULD I DO WHEN I GO HOME?
You should continue to eat and drink when you are hungry and
thirsty. You should go to pulmonary rehab (see below). You
should follow up with your primary care doctor in 11 weeks for a
cat scan of your chest to make sure your pneumonia has fully
resolved.
We wish you the best!
-Your Care Team at ___
Followup Instructions:
___
|
19805942-DS-16
| 19,805,942 | 25,649,665 |
DS
| 16 |
2120-10-12 00:00:00
|
2120-10-15 21:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
indomethacin / meglumine
Attending: ___.
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
DC cardioversion ___
History of Present Illness:
Ms. ___ is a ___ year-old lady with a PMH of hyperlipidemia,
rheumatic mitral valve disease with mild-moderate mitral
stenosis and mild mitral regurgitation, and prior PVCs, who
presented with persistent palpitations, found to be in atrial
fibrillation with RVR. Past Holter in ___ showed frequent
premature ventricular beats and two short runs of SVT. As she
was mostly asymptomatic in the past, she was not started on a
beta blocker.
Four days prior to this admission, she began to experience
palpiations, accompanied by intermittent periods of chest
pressure, shortness of breath (as if "the air gets blocked and
she is starving for air") and dizziness when going from sitting
to standing. She is comfortable sleeping on her stomach. She
denies having any syncope, chest pain, lower extremity edema,
PND, fevers, chills, nausea, vomiting, diarrhea, constipation,
dysuria or hematuria. At her outpatient cardiologist's office,
EKG showed afib/flutter at ___hanges.
In the ED, initial vitals were: HR 160, RR 18; 30 minutes later
they were: 135 122/88 16 94%. EKG showed afib/flutter with RVR
at 168 bpm, with ST elevations in aVR and V1, and ST depressions
in I, V4-V6. Labs were unremarkable, with troponin-T < 0.01.
Portable chest x-ray showed: mildly enlarged heart with streaky
opacities in the left midlung and right lung base suggestive of
atelectasis, evidence of mild fluid overload. UA/UCx and BCx
were not sent. Patient was given metoprolol tartrate 5 mg IV
x2, and placed on diltiazem and heparin IV drips. She was
discussed with ___ attending Dr. ___ recommended
admission to ___ floor. Vital signs prior to admission were:
98 124 ___ 16 98%.
On arrival to the floor, patient was comfortable, but continued
to experience sensation of heart palpitations. She denied any
shortness of breath, chest pain/pressure or dizziness on
arrival.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, ankle edema, or syncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-Rheumatic MV disease with mild-mod mitral stenosis and mild
mitral regurgitation, echo ___
-PVCs
3. OTHER PAST MEDICAL HISTORY:
- hearing loss
- colonic polyp
- H/O: hysterectomy
- Pseudophakia
- s/p cataract surgery ___
Social History:
___
Family History:
Mother with DM, HTN, heart disease (pt thinks secondary to
Avandia). Father with "valve problem" in his ___, where it
"would not shut" all the way. Grandparents lived into their ___.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 98.3 113/56 133 18 94RA
GENERAL: WDWN female 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 10 cm at 45 degrees.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Irregularly irregular, tachycardic, normal S1, S2. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. + bibasilar crackles,
no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
DISCHARGE PHYSICAL EXAMINATION:
VS: Tm 98.3 85-115/52-66 ___ 93-100% 68.8 from 70.2kg
yesterday
I: 750
O: 1350
GENERAL: WDWN female 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 no JVP elevation
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Irregularly irregular, tachycardic, normal S1, S2. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. + bibasilar crackles,
no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. 2+ radial, dp, pt pulses
Pertinent Results:
LABS
___ 11:42PM PTT-70.1*
___ 09:03PM CK(CPK)-35
___ 09:03PM CK-MB-2 cTropnT-<0.01
___ 09:03PM TSH-4.3*
___ 01:40PM GLUCOSE-111* UREA N-11 CREAT-0.8 SODIUM-143
POTASSIUM-5.1 CHLORIDE-108 TOTAL CO2-24 ANION GAP-16
___ 01:40PM cTropnT-<0.01
___ 01:40PM WBC-8.8 RBC-4.49 HGB-13.5 HCT-40.8 MCV-91
MCH-30.2 MCHC-33.2 RDW-12.6
___ 01:40PM NEUTS-70.8* ___ MONOS-4.8 EOS-0.3
BASOS-0.2
___ 01:40PM PLT COUNT-263
___ 01:40PM ___ PTT-28.0 ___
___ 06:03AM BLOOD ___ PTT-35.7 ___
___ 06:03AM BLOOD Glucose-90 UreaN-11 Creat-0.8 Na-141
K-3.9 Cl-107 HCO3-26 AnGap-12
___ 06:03AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.9
___ 06:40AM BLOOD Triglyc-121 HDL-39 CHOL/HD-4.7
LDLcalc-120
IMAGING/STUDIES:
ECG ___
Atrial fibrillation with slowing of the ventricular response as
compared with previous tracing of ___. The ischemic
appearing ST-T wave changes are less prominent but persist in
leads I, aVL and V4-V6. Clinical correlation is suggested.
TRACING #2
TEE ___
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. Mild spontaneous echo
contrast is seen in the body of the right atrium. Mild
spontaneous echo contrast is seen in the right atrial appendage.
Right atrial appendage ejection velocity is good (>20 cm/s). No
thrombus is seen in the right atrial appendage The aortic valve
leaflets (3) are mildly thickened. Trace aortic regurgitation is
seen arising from the aortic root in between the left and
noncoronary cusps. The mitral valve leaflets are moderately
thickened. The mitral valve shows characteristic rheumatic
deformity. There is moderate valvular mitral stenosis (area
1.0-1.5cm2). Moderate (2+) mitral regurgitation is seen.
IMPRESSION: SEC seen in the right atrium and right atrial
appendage with no atrial clot identified. Rheumatic mitral
valvular disease with moderate mitral stenosis and moderate
mitral regurgitation.
CXR ___
1. Findings which may suggest slight vascular congestion.
2. Streaky multifocal opacities in the lower lungs, suggestive
of chronic
carring, although acuity is difficult to judge without prior
comparisons.
Correlation with prior radiographs may be helpful if available.
Otherwise,
depending on the level of clinical concern for subtle early
pneumonia,
short-term follow-up radiographs, preferably with PA and lateral
technique, if
possible, could be considered.
Brief Hospital Course:
Ms. ___ is a ___ year-old lady with a PMH of hyperlipidemia,
rheumatic mitral valve disease with mild-moderate mitral
stenosis and mild mitral regurgitation and prior PVCs, who
presented with persistent palpitations and was found to be in
atrial fibrillation with RVR s/p DCCV.
# New atrial fibrillation/flutter: Unclear trigger, no signs of
infection or ischemia, two sets of troponin negative, TSH only
mildly elevated at 4.3. Time course was also unclear, although
patient reported palpitations over the preceding 2 weeks. She
was started on heparin and diltiazem drips in ED. Rate control
was achieved, warfarin started, diltiazem drip discontinued
overnight in favor of PO metoprolol due to asymptomatic SBP ___.
Underwent TEE on ___ which showed no evidence of intra-atrial
thrombus and subsequent DC cardioversion resulted in successful
conversion to normal sinus rhythm. Switched from heparin gtt to
lovenox as bridge to warfarin. INR subtherapeutic at 1.6 morning
of discharge.
.
# Acute pulmonary edema: Presented with bibasilar crackles and
evidence of vascular congestion on CXR in the setting of afib
with RVR 120s-150s. Pt briefly required supplemental oxygen, but
was weaned to room air after diuresis with PO lasix and return
to NSR.
.
# TRANSITIONAL ISSUES:
- Anticoagulation: Initiated on warfarin this admission, pt to
follow up at ___ in ___ for INR
check on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 162 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. MSM *NF* (methylsulfonylmethane) 1,000 mg Oral daily
Discharge Medications:
1. Enoxaparin Sodium 70 mg SC BID
RX *enoxaparin 80 mg/0.8 mL 70 mg(s) SC Twice a day Disp #*14
Syringe Refills:*0
2. Aspirin 162 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Warfarin 5 mg PO DAILY16
RX *warfarin 1 mg 5 tablet(s) by mouth daily Disp #*150 Tablet
Refills:*0
5. MSM *NF* (methylsulfonylmethane) 1,000 mg Oral daily
6. Metoprolol Succinate XL 75 mg PO DAILY
RX *metoprolol succinate 25 mg 3 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Atrial fibrillation with rapid ventricular response
SECONDARY DIAGNOSES:
Rheumatic mitral valve disease with stenosis and regurgitation
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
to the hospital for an abnormal heart rhythm called atrial
fibrillation. You had a procedure called cardioversion that
returned your heart to a normal rhythm and rate.
You will need to take a blood thinner from now on to reduce your
risk of stroke. You will need to continue injecting lovenox
until instructed to stop by the ___ clinic. The
___ clinic will also monitor your labs and help you
with your warfarin dosing.
Please note the following changes to your medications:
START taking:
1. warfarin
2. metoprolol
Please see below for your follow-up appointments.
Wishing you all the best!
Followup Instructions:
___
|
19805942-DS-17
| 19,805,942 | 23,444,000 |
DS
| 17 |
2121-04-27 00:00:00
|
2121-04-28 15:57:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
indomethacin / meglumine
Attending: ___.
Chief Complaint:
afib with RVR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with a history of rheumatic
mitral valve disease (with MS and MR) and paroxysmal atrial
fibrillation (s/p DCCV ___ who presents for recurrent afib
with RVR. The patient's first episode of atrial fibrillation was
in ___ of this year and she was successfully treated with a
TEE cardioversion and started on Coumadin and metoprolol. She
has not had any (known) recurrences of afib until today. The
patient was in her usual state of health until this morning when
she was eating breakfast when she began to feel dizzy, nauseous,
weak and a little bit short of breath. She could feel that her
heartbeat racing. She presented to her cardiologist Dr. ___
___ performed an EKG in clinic which demonstrated atrial
fibrillation with rapid ventricular response in the 120s. Dr.
___ referred her to the Emergency Room.
In the ED, initial vitals were 0 97.9 52 129/74 16 96%. EKG
showed sinus bradycardia @ 49 bpm, incomplete RBBB with TWI in
V1-V3 (stable from prior EKGs). She was then admitted to the
cardiology service for further management.
On arrival to the floor, her VS were T 98 HR 51 BP 151/86 RR20
100% on RA. She feels well at the moment and denies any
complaints.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, syncope or presyncope.
She reports some ankle edema that has resolved.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-Rheumatic MV disease with mild-mod mitral stenosis and mild
mitral regurgitation, echo ___
-Atrial Fibrillation (s/p DCCV ___
-PVCs
3. OTHER PAST MEDICAL HISTORY:
- hearing loss
- colonic polyp
- H/O: hysterectomy
- Pseudophakia
- s/p cataract surgery ___
Social History:
___
Family History:
Mother with DM, HTN, heart disease (pt thinks secondary to
Avandia).
Father with "valve problem" in his ___, where it "would not
shut" all the way.
Grandparents lived into their ___.
Physical Exam:
Admission Physical Exam:
VS: T 98 BP 151/86 HR 51 RR 20 100% on RA
Wt: 69.3 kg
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: bradycardic rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
Discharge Physical Exam:
VS: 97.7 46 119/74 18 96% RA
Wt: 69kg
IOs 8hr: 400/BRP
IOs 24hr: 720/250
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI
Neck: supple, no JVD
CV: bradycardic rhythm, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, NT/ND, BS+
Ext: WWP, no c/c/e, 2+ distal pulses bilaterally
Neuro: moving all extremities grossly
Pertinent Results:
Admission Labs:
___ 03:25PM BLOOD WBC-5.0 RBC-4.56 Hgb-13.6 Hct-39.6 MCV-87
MCH-29.8 MCHC-34.4 RDW-12.7 Plt ___
___ 03:25PM BLOOD Neuts-48.7* Lymphs-44.3* Monos-5.7
Eos-0.7 Baso-0.7
___ 03:25PM BLOOD ___ PTT-58.2* ___
___ 03:25PM BLOOD Glucose-90 UreaN-10 Creat-0.8 Na-140
K-4.0 Cl-106 HCO3-28 AnGap-10
___ 03:25PM BLOOD GreenHd-HOLD
Discharge Labs:
___ 05:00AM BLOOD WBC-5.4 RBC-4.44 Hgb-13.7 Hct-38.7 MCV-87
MCH-30.9 MCHC-35.4* RDW-12.7 Plt ___
___ 05:00AM BLOOD Plt ___
___ 05:00AM BLOOD ___ PTT-44.7* ___
___ 05:00AM BLOOD Glucose-87 UreaN-20 Creat-0.8 Na-142
K-4.0 Cl-106 HCO3-28 AnGap-12
___ 05:00AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.1
Imaging:
Echo ___
EXERCISE ECG AND HEMODYNAMIC DATA: Utilizing the standard ___
protocol the patient was exercised for 7:24 minutes, achieving a
maximum heart rate of 152 bpm , which is 97% of predicted
maximal heart rate. The target heart rate was 85% of age
predicted maximal heart rate and was acheived during the test.
The peak BP was 152/92 mmHG with a rate pressure product of
23,100. The tested was stopped due to general fatigue and foot
fatigue. The patient had no symptoms during the test. The
patient had no chest pain. There were normal blood pressure and
heart rate responses to stress. In response to stress, the ECG
showed no ST-T wave changes (see exercise report for details).
POST STRESS IMAGING: Post exercise imaging was obtained at rates
between 138 bpm and 111 bpm. All exercise images, including
continuous capture, were reviewed. After exercise, echo images
demonstrated appropriate augmentation of all left ventricular
segments with systolic decrease in LV cavity size. Post exercise
stress images show hyperdynamic global LV systolic function.
CONCLUSIONS
1. The left atrial volume is severely increased.
2. The aortic valve is trileaflet and is mildly thickened. There
is trace-to-mild aortic regurgitation. There is no evidence of
aortic stenosis.
3. The mitral valve leaflets are thickened, with tethering of
the leaflet tips, dense focal calcification at the tip of the
anterior mitral leafletand adjoining chordate, and diastolic
doming of the anterior leaflet, consistent with rheumatic mitral
valve disease. Mild mitral regurgitation is present. The peak
transvalvular velocity is 1.5 m/sec, with peak/mean gradients of
9 / 4 mm Hg. The Mitral valve area by PHT is 1.3 cm2. The Mtiral
valve area by panimetry is 1.7 cm2.
4. Tricuspid valve appears structurally and functionally normal.
Trace regurgitation is seen. Normal PA systolic pressure,
estimated at 23 mmHg above RA pressure.
5. Ventricular chamber sizes, wall thicknesses, and resting
contraction are normal.
6. No prior report available for comparison.
7. No 2D echocardiographic evidence of inducible ischemia at the
level of stress achieved. Rest images show evidence of rheumatic
valvular disease. Message sent to Dr. ___.
TEE ___
IMPRESSION: SEC seen in the right atrium and right atrial
appendage with no atrial clot identified. Rheumatic mitral
valvular disease with moderate mitral stenosis and moderate
mitral regurgitation
EKG ___ (Intern Read): Sinus bradycardia at 49. Left atial
enlargement. Incomplete RBBB with TWI in V1-V3 (stable from
previous EKGs).
CXR ___
FRONTAL AND LATERAL VIEWS OF THE CHEST: The heart size remains
mildly enlarged. The previously seen pulmonary edema has
entirely resolved. There is no pleural effusion, pneumothorax
or focal airspace consolidation. The mediastinal and hilar
structures are unremarkable.
Brief Hospital Course:
Ms. ___ is a ___ female with a history of rheumatic
mitral valve disease (with MS and MR) and paroxysmal atrial
fibrillation (s/p DCCV ___ who presents for recurrent afib
with RVR.
ACTIVE ISSUES:
# Paroxysmal Atrial Fibrillation:
The patient had symptomatic afib with RVR at her Cardiologist's
office prior to admission, but she had spontaneously converted
back into sinus rhythm by the time she arrived in the ER. There
is no evidence in her history to suggest an illness that might
have triggered her to go back into afib. She appears clinically
euvolemic without evidence of heart failure. She was seen by EP,
who recommended decreasing her Metoprolol Succinate from 50 to
25mg daily and then adding Metoprolol Tartrate 25mg PRN rapid
heart beat.
#Supra-therapeutic INR
INR 4.5 on admission. Coumadin was held. She was discharged on
3mg daily with INR follow-up.
TRANSITIONAL ISSUES:
[]Patient discharged on 3mg Coumadin. Needs INR check on ___
at her ___.
# CODE: Full Code
# EMERGENCY CONTACT: ___ (daughter) - ___, ___
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 162 mg PO DAILY
2. Warfarin 4 mg PO DAYS (___)
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Warfarin 2.5 mg PO DAYS (WE,TH,FR)
5. Fish Oil (Omega 3) 1000 mg PO BID
6. MSM (methylsulfonylmethane) 1,000 mg Oral daily
Discharge Medications:
1. Aspirin 162 mg PO DAILY
2. Fish Oil (Omega 3) 1000 mg PO BID
3. MSM (methylsulfonylmethane) 1,000 mg Oral daily
4. Warfarin 3 mg PO DAILY16
RX *warfarin [Coumadin] 1 mg 3 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Outpatient Lab Work
Patient will need INR drawn on ___ at her ___
___. Results should be faxed to ___.
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Metoprolol Tartrate 25 mg PO DAILY:PRN rapid heart beat
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Fibrillation
Rheumatic Heart Disease
Mitral Stenosis
Mitral Regurgitation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
because you had a rapid heart rate and you were seen by your
cardiologist. You did not have a rapid heart rate and were
asymptomatic in the hospital. You were also seen by the
electrophysiology (EP) doctors who recommended ___ your
Long-acting Metoprolol Succinate (Toprol XL) from 50mg to 25mg
daily. If you have symptoms of a rapid heart beat, then you
should take 1 dose of short acting Metoprolol (Metoprolol
Tartrate). We held your Coumadin since your INR was elevated.
You should take 3mg Coumadin over the weekend and have your INR
checked at ___ Anticoagulation Program on ___.
Followup Instructions:
___
|
19805942-DS-18
| 19,805,942 | 25,183,245 |
DS
| 18 |
2125-05-10 00:00:00
|
2125-05-10 21:30:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
indomethacin / meglumine
Attending: ___
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old female with a past medical history
of
rheumatic heart disease with moderate mitral regurgitation and
mild mitral stenosis, paroxysmal atrial fibrillation, and
hyperlipidemia. Initially diagnosed with AF w/ RVR in ___ s/p
TEE DCCV. The patient has had longstanding paroxysmal atrial
fibrillation and cardioverts on her own. She had an episode of
palpitations in ___ which lasted for approximately 3
hours but terminated just prior to her presentation to the ED.
Earlier this year she reported an increase in palpitations. In
___ patient was prescribed flecainide 50mg BID per EP but
never started taking it.
Since ___ night she had experienced palpitations with a sense
of intermittent chest discomfort described as a sharp sensation
and intermittent mild shortness of breath along with a mild
headache. Palpitations have been constant since that time. Took
flecainide yesterday x2 (has not been taking but was prescribed
in ___ by Dr. ___, this is the first time she has ever
taken it) reports that did not help palpitations. Took other
meds as scheduled including metoprolol and warfarin. Symptoms
have persisted and she had seen her primary cardiologist this
AM,
noted her to be in atrial fibrillation with increased
ventricular
rates and low normal blood pressure along with her symptoms as
described above. Given her continuing symptoms, along with
atrial
fibrillation with increased ventricular rates, the decision was
made to pursue cardioversion by the emergency room staff on an
urgent basis.
She denies any chest pain, shortness of breath, orthopnea, PND,
___ edema, or claudication.
[x] cardioversion: 100J, one shock. 10mg etomidate, no
complications.
Post-cardioversion EKG: NSR @ 55, STD in V1-2 CWP
In the ED, initial vitals were 98.7 145 117/83 22 98% RA
EKG showed af w/ RVR, and stable t wave inversions in v1,v2,v3
HR @140.
Vitals on transfer: 97.3 69 109/49 24 97% RA.
Labs notable for 3.3, K 4.2
Patient was given:
___ 12:59 IV Metoprolol Tartrate 5 mg
___ 12:59 PO Metoprolol Tartrate 25 mg
___ 14:38 IV Prochlorperazine 10 mg
Atrius cardiology consulted.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, syncope, or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-Rheumatic MV disease with mild-mod mitral stenosis and mild
mitral regurgitation, echo ___
-Atrial Fibrillation (s/p DCCV ___
-PVCs
3. OTHER PAST MEDICAL HISTORY:
- hearing loss
- colonic polyp
- H/O: hysterectomy
- Pseudophakia
- s/p cataract surgery ___
Social History:
___
Family History:
Mother with DM, HTN, heart disease (pt thinks secondary to
Avandia).
Father with "valve problem" in his ___, where it "would not
shut" all the way.
Grandparents lived into their ___.
Physical Exam:
ADMISSION PHYSICAL
==================
VS: 97.4PO, 125 / 66, R Lying 61 16 99 RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVD at 5-6cm
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
DISCHARGE
==========
VS: 97.9 PO 101 / 67 R Lying 61 20 91 RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVD at 5-6cm
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs/rubs/gallops. No thrills,
lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, 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
Pertinent Results:
ADMISSION LABS
============
___ 12:45PM BLOOD WBC-7.6 RBC-4.72 Hgb-14.1 Hct-42.4 MCV-90
MCH-29.9 MCHC-33.3 RDW-12.6 RDWSD-41.6 Plt ___
___ 12:45PM BLOOD Neuts-50.1 ___ Monos-7.8 Eos-0.7*
Baso-0.3 Im ___ AbsNeut-3.82# AbsLymp-3.10 AbsMono-0.59
AbsEos-0.05 AbsBaso-0.02
___ 12:45PM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-135
K-6.5* Cl-98 HCO3-25 AnGap-12
___ 12:45PM BLOOD CK(CPK)-69
___ 12:45PM BLOOD CK-MB-1 cTropnT-<0.01
___ 12:45PM BLOOD Calcium-8.6 Phos-3.9 Mg-2.0
___ 12:45PM BLOOD TSH-3.2
___ 12:45PM BLOOD Free T4-1.4
DISCHARGE LABS
==============
___ 06:40AM BLOOD WBC-5.1 RBC-4.09 Hgb-12.1 Hct-36.7 MCV-90
MCH-29.6 MCHC-33.0 RDW-12.5 RDWSD-40.9 Plt ___
___ 06:40AM BLOOD Glucose-94 UreaN-14 Creat-0.8 Na-142
K-5.3* Cl-105 HCO3-26 AnGap-11
___ 06:40AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.1
MICRO
=====
UCx NGTD
IMAGING
=======
CXR ___
No acute pathology
Brief Hospital Course:
Ms. ___ is a ___ year-old female with a past medical history
of rheumatic heart disease with moderate mitral regurgitation
and mild mitral stenosis, paroxysmal atrial fibrillation,
hyperlipidemia, AF w/ RVR in ___ s/p TEE DCCV on metop
presenting with palpitations.
#Afib with RVR: Symptoms of palpitations, intermittent chest
discomfort, mild shortness of breath started ___. Patient
went to outpatient cardiologist, was found to be in atrial
fibrillation with increased ventricular rate, normal-low blood
pressure, therapeutic INR. Patient was sent to ED for better
control. In ED, patient was cardioverted at 100J, one shock
followed by 10mg etomidate, no complications. She was admitted
for observation. EP team consulted for further management and
recommended flecainide only after CAD/structural heart disease
ruled out properly. Patient wanted to continue the conversation
with her cardiologist and PCP as outpatient before committing
herself to further imaging or procedures. No medication changes
on discharge. Of note, patient was prescribed flecainide by ___
clinic in ___ but never took this medication. Patient
should be continued on Coumadin since DOACs not well studied in
patients with more than mild MS.
- continued metoprolol 25mg XL daily today, continued on
Coumadin, daily dose is 2 mg on ___ 3 mg all other days
#Rheumatic heart disease: Mild mitral regurgitation at rest,
mild to moderate mitral stenosis in the setting of rheumatic
heart disease seen on Echo in ___. Likely has resulted in
her afib given the atrial strain associated with prolonged
mitral stenosis/regurg. No evidence of volume overload.
#Dyslipidemia: Continued pravastatin 10 mg tablet daily
#Osteoporosis: Continued home vitamin D
TRANSITIONAL ISSUE
=================
[ ] Will be started on an anti-arhythmic medication as an
outpatient. CAD must be ruled out prior to starting flecainide.
#CODE STATUS: Full (presumed)
#CONTACT: Name of health care proxy: ___
Phone number: ___
Comments: Pt would like her ___ to be
contacted in emergency ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Pravastatin 10 mg PO QPM
___ MD to order daily dose PO DAILY16
4. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Pravastatin 10 mg PO QPM
3. Vitamin D 1000 UNIT PO DAILY
4. ___ MD to order daily dose PO DAILY16
___ - 2mg
___- 3mg
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
=================
Atrial fibrillation with rapid ventricular response
Atrial fibrillation
Secondary diagnosis
===================
Rheumatic heart disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you here at ___.
What happened while you were in the hospital?
- You presented to the emergency department with worsening
palpitations.
- In the emergency department you were found to have atrial
fibrillation with rapid ventricular response, or AF with RVR.
This is when your heart starts to be irregularly and very fast.
You were given medication to control your heart rate and you
were also cardioverted. Your rhythm returned to normal after the
cardioversion.
- The electrophysiology (EP) team was consulted to help guide
further management. They recommended starting the medication
Flecainide. Prior to doing this, it is important to rule out any
coronary artery disease or heart disease or else it can be
dangerous to take Flecainide. Further management regarding your
heart rate will be done as an outpatient.
What to do on discharge?
- Continue to take all your medications as prescribed except
flecainide. Do not take this medication until you meet with your
cardiologist. Your cardiologist may refer you to an EP doctor.
- If you experience any chest pain, palpitations,
lightheadedness, please return to the emergency department.
- Please follow up with your cardiologist and primary care
doctor.
We are happy to see you feeling better.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19806522-DS-17
| 19,806,522 | 20,606,850 |
DS
| 17 |
2155-02-20 00:00:00
|
2155-02-20 21:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall, Seizure, Acute Renal Failure
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old Male who presents from nursing home after
unwitnessed fall. The patient had been in his ususal state of
health and mental status, when the nurse heard him fall, and
discovered the patient on the floor of his room with a right
sided head laceration. By report he had no loss of bowel or
bladded continence, and while his hands and mouth were
twitching, his mental status was at baseline. The patient was
tachycardic in the 120s and hypertensive to the 180s. Oxygen was
given to the patient, although he was not hypoxemic. There was
no prodrome prior to the fall, and he did not note anything
wrong prior to the event, although he is poorly oriented and
limited in his verbal expression.
On arrival to the ___ ED, he was noted with his baseline
mental status, answering simple questions with "I'm Fine" and
responding to name only. He was noted in acute renal failure.
Head, Neck, Chest and abdominal CTs were obtained, which
demonstrated severe bullous emphysema, a thyroid nodule and a
left adrenal nodule. While in the ED he experienced a witnessed
tonic/clonic seizure, although had no post-ictal state that
could be noted (although with his limited baseline, this may
have been masked). There was concern from the ED staff, that he
aspirated during the event.
Overnight he was given 500cc of IVF for probably hypovolemia. He
reports today that he is OK and denies any problems.
Past Medical History:
Schizophrenia
HTN (Baseline BPs in the 120s-130s/60s-70s)
Enucleated L eye
Positive PPD
Type 2 DM
Social History:
___
Family History:
Unable to obtain
Physical Exam:
Admission:
Vitals: 100.7 131/44 110 18 98% RA ___ 146
General: Alert, oriented x1, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI in R eye,L
eye socket closed, difficult to assess pupillary response in R
given cataract
Neck: supple, JVP not elevated, no LAD or bruits
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi but difficult to auscultate
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, brisk cap refill
Neuro: Oriented to person and that he is in a hospital. CNII-XII
intact, ___ strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred.
Skin: 6 cm laceration on R scalp, crusted blood noted, closed
with staples.
Discharge:
Vitals: 98 141/55 66 18 99% RA
General: Alert, oriented x1, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI in R eye, L
eye socket closed
Neck: supple, JVP not elevated
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, brisk cap refill
Neuro: Oriented to person. Able identify and distinguish between
2 and 3 fingers.
Skin: 6 cm laceration on R scalp, crusted blood noted, closed
with staples, healing well.
Pertinent Results:
___ 06:25AM BLOOD WBC-8.4 RBC-3.52* Hgb-10.7* Hct-31.7*
MCV-90 MCH-30.5 MCHC-33.8 RDW-12.7 Plt ___
___ 10:55AM BLOOD WBC-9.1 RBC-4.12* Hgb-12.4* Hct-38.0*
MCV-92 MCH-30.2 MCHC-32.8 RDW-13.0 Plt ___
___ 10:55AM BLOOD Neuts-66.8 ___ Monos-4.5 Eos-1.7
Baso-0.7
___ 06:25AM BLOOD Glucose-69* UreaN-17 Creat-1.1 Na-139
K-3.3 Cl-100 HCO3-27 AnGap-15
___ 10:55AM BLOOD Glucose-208* UreaN-23* Creat-1.4* Na-135
K-4.0 Cl-96 HCO3-22 AnGap-21*
___ 06:25AM BLOOD CK(CPK)-224
___ 07:20PM BLOOD CK(CPK)-123
___ 10:55AM BLOOD ALT-12 CK(CPK)-58 AlkPhos-69 TotBili-0.3
___ 06:25AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:20PM BLOOD CK-MB-3 cTropnT-<0.01
___ 10:55AM BLOOD cTropnT-<0.01
___ 10:55AM BLOOD CK-MB-2
___ 06:25AM BLOOD Albumin-3.6 Calcium-8.7 Phos-2.5* Mg-1.8
___ 12:04PM URINE Color-Yellow Appear-Clear Sp ___
___ 12:04PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 12:04PM URINE RBC-54* WBC-2 Bacteri-NONE Yeast-NONE
Epi-0
___ 12:04PM URINE Mucous-RARE
___ 06:07PM URINE Hours-RANDOM Creat-41 Na-71 K-55 Cl-101
___ 12:04 pm URINE
URINE CULTURE: Neg
___ 10:55 am BLOOD CULTURE Source: Venipuncture #1.
Blood Culture, Routine (Pending):
CT HEAD W/O CONTRAST Study Date of ___ 11:03 AM
IMPRESSION: No evidence of acute intracranial process.
CT C-SPINE W/O CONTRAST Study Date of ___ 11:05 AM
IMPRESSION:
1. No evidence of acute cervical spinal fracture or
malalignment.
2. Large right apical bleb. Left apical blebs and scarring.
CT ABD & PELVIS WITH CONTRAST Study Date of ___ 12:28 ___
IMPRESSION:
1. No acute process.
2. Severe emphysema with large right apical bullae.
3. Atherosclerotic disease of the aorta without evidence of
aneurysm. Severe calcification at the origin of the left renal
artery and bilateral external iliac arteries likely causing flow
limiting stenosis but not well assessed on this non-angiographic
study.
4. Nodular hyperplasia of the left adrenal gland.
CHEST (PORTABLE AP) Study Date of ___ 5:26 ___
FINDINGS: Biapical bullous emphysema is present with adjacent
scarring.
Lungs are otherwise clear. Heart size, mediastinal and hilar
contours are normal.
EKG ___: Sinus rhythm. Right bundle-branch block. J point
elevation in the anterolateral leads which may be due to early
repolarization but cannot exclude ischemic process. Clinical
correlation is suggested. Compared to tracing #1 ST segment
elevation appears more prominent and the heart rate is slower.
Discharge:
___ 06:10AM BLOOD WBC-7.8 RBC-3.69* Hgb-11.5* Hct-33.7*
MCV-91 MCH-31.3 MCHC-34.3 RDW-12.8 Plt ___
___ 06:10AM BLOOD Glucose-96 UreaN-12 Creat-1.1 Na-141
K-3.9 Cl-104 HCO3-29 AnGap-12
___ 06:10AM BLOOD Calcium-9.3 Phos-2.9 Mg-1.9
___ 06:05AM BLOOD TSH-1.5
Brief Hospital Course:
This is an ___ yo M w/ a history of DMII, hypertension, and
schizophrenia who presented from a nursing home with an
unwitnessed fall and subsequent self-limited convulsive episode
in the ED, with possible aspiration, admitted for monitoring and
syncope work-up.
# Syncope vs. mechanical fall: Unclear circumstances of what
occurred. Per discussion w/ nurse from nursing home, sounds like
it could have been either a mechanical fall, syncope, or a
seizure (event in ED appears to have been a true self-limited
seizure episode). There was low concern for a primary cardiac
cause for the syncope: EKG consistent with RBB, no evidence of
other blocks on telemetry and no other significant arrythmias
seen. No evidence of significant structural heart disease on
exam. Troponins were negative. Neurocardiogenic causes are
possible but impossible to disentangle given absence of history.
Orthostatis is possible but he was hypertensive during the
event. Later in the admission,he technically met criteria for
orthostatics by HR and answered "yes" to dizziness but the
meaning of his answers have been difficult to asses (A+0x1 at
baseline) and his BP did not drop significantly, so overall low
concern for orthostasis. No bruits on exam to suggest a carotid
etiology. A primary seizure event is possible, though myoclonic
movements can be seen in syncope - seizure event in ED was most
likely post-traumatic per neurology (see below). It is also
quite likely that this was simply a mechanical fall (he has
fallen before). His hydration status was maintained, monitored
on telemetry. He was kept on fall precautions. Attempts were
made to acquire medical records from his PCP but were
unsuccessful. If he has not had an echocardiogram, TTE as an
outpatient would complete the workup but likely to be low-yield.
He should be assessed carefully by ___ at rehab for ambulation
safety. Given that he has only one eye, with a cataract and DM,
he should be referred back to his ophthalmologist for a vision
exam as declining vision could contribute to falls. At discharge
he still had staples in place.
# Seizure in the ED: Self-limited, ~60 sec. He was seen by
neurology who felt this was likely to be post-traumatic in
origin. No known seizure disorder or obvious etiologies on
initialy work-up. CT head was negative. EEG with frontal and
temporal slowing (possibly indicating dementia) preliminarily
but final read pending at discharge. B12/RPR/TSH were sent for a
dementia workup He was maintained on seizure and aspiration
precautions, and started on a one week course of prophylactic
Keppra 500 mg BID (day 1 = ___. He will followup with neurology
in clinic.
# Dementia: Per discussion with nurse from nursing home, his
current mental status (communicative, answers questions with
answers of uncertain meaningfulness, A+Ox1) appears to be at his
baseline. Soft two point restraints initially were used for
safety and fall prevention while in bed but he was able to sit
in a chair in the work area under observation. He was given one
dose of 2.5 mg Zyprexa overnight when he continued to try to get
out of bed.
# Possible aspiration event: Occured during seizure in the ED.
Was never hypoxic on the floor, and CXR had no evidence of
pneumonitis. He was given a diet as recommended by speech and
swallow and maintained on aspiration precautions.
# Acute Renal Failure: Cr 1.4 on admission. Likely pre-renal as
it resolved with hydration.
# Type 2 Diabetes controlled with Complications: Not on insulin.
Unclear if hypoglycemia could have contributed to presentation
(on glipizide, sugars not checked at the time) but sugars during
admission were well-controlled. A1c within normal limits. His
home diabetes meds were held on admission and he was maintained
on an insulin sliding scale. He was given a diabetic diet and
his home meds were restarted at discharge. He should have yearly
followup with a podiatrist (corns seen on his feet) and
ophthalmologist.
# Benign Hypertension: Appears well-controlled for the most part
at baseline. Hypertensive to 180/80 during initial event. His
home antihypertensives were held while admitted as he was
normotensive. They were restarted at discharge.
# Schizophrenia: Not on any anti-psychotic medication at
baseline. He got one dose of zyprexa as above. No changes were
made.
# COPD: Looks like severe emphysema with prominent apical
blebs/bullae but no known history of lung disease. It may not be
necessary to refer him to pulmonology as he is apparently
asymptomatic and oxygenates well on room air. A referral to
pulmonary would be indicated if he were to become symptomatic.
#Peripheral Vascular Disease: "Severe calcification at the
origin of the left renal artery and bilateral external
liac arteries likely causing flow limiting stenosis but not well
assessed on this non-angiographic study, as well as nodular
hyperplasia of the left adrenal gland". He does not have any
obvious manifestations of peripheral vascular disease. If he
were to develop any, appropriate followup would be indicated.
His unilateral renal artery stenosis could be contributing to
his hypertension so could consider referral for further workup
if thought to be appropriate. This is not a contraindication to
ACE-I therapy. The adrenal finding is likely not clinically
significant. He does not have any evidence of adrenal
hyperplasia. It could be followed up if clinically concerned.
Transitional issues:
- He should follow up with neurology in clinic.
- He is being discharged on 1 week of Keppra 500 mg BID, day 1 =
___ (last day ___
- If he were to become symptomatic from a pulmonary perspective,
he should be referred to pulmonology
- If he has not had a echocardiogram recently, consider getting
a TTE to complete syncope workup, though unlikely to be high
yield given absence of sigmata of structural heart disease or
CHF
- He should be evaluated by ___ at rehab for ambulatory safety
and need for any assist devices
- The final read of his EEG was pending at discharge and should
be followed up
- B12/RPR were pending at discharge and should be followed up
- He should be reminded to rise slowly from sitting and should
stay hydrated (goal 2L fluids daily)
- Staples should be removed from scalp sometime between ___
- His incidental findings on CT (L renal artery stenosis,
bilateral iliac stenosis, and severe radiographic emphysema)
should be followed up as clinically indicated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bacitracin Ophthalmic Oint 1 Appl LEFT EYE DAILY
2. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
3. Potassium Chloride 20 mEq PO DAILY
4. Docusate Sodium 200 mg PO DAILY
5. Lisinopril 2.5 mg PO DAILY
6. GlipiZIDE 10 mg PO BID
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Guaifenesin 15 mL PO Q4H:PRN cough
9. Acetaminophen 325 mg PO Q4H:PRN pain
10. calamine *NF* per rectum Miscellaneous prn itching
hemorrhoids
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Fall
Seizure
Secondary diagnoses:
Diabetes
Hypertension
Schizophrenia
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 ___:
It was a pleasure caring for you at ___. You were admitted
after falling at your nursing home. We are still unsure why you
fell but do not think it was related to your heart. One
possibility is that you got dizzy when standing up: You should
remain hydrated and rise slowly from sitting. Another
possibility is that your vision has been worsening: we want you
to see your ophthalmologist and have your vision rechecked.
You also had a seizure in the emergency room. We think this was
a result of hitting your head after falling. We are discharging
you with a medication called Keppra, which you should take for 5
more days. We also want you to followup with the neurology
specialists in their clinic.
The staples in your scalp should be removed sometime between
___
Please take all of your medications as prescribed.
Followup Instructions:
___
|
19806781-DS-15
| 19,806,781 | 22,246,486 |
DS
| 15 |
2116-01-30 00:00:00
|
2116-02-01 08:12:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Levaquin / Vancomycin / Sulfa (Sulfonamide
Antibiotics) / Shellfish Derived / Iodine-Iodine Containing /
Prochlorperazine Maleate / Cartia XT / Cipro / Seroquel /
clonazepam / Reglan
Attending: ___.
Chief Complaint:
Tachycardia, n/v, epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F with HTN, HL and well controllled asthma who presents with
10 days of sinus tachycardia, nausea/vomiting, and epigastric
pain. A week ago she went to an OSH with sinus tachycardia and
hypokalemia (2.5 per patient). They repleted her potassium and
discharged her. She followed up with her PCP and stopped her
HCTZ, adderall, and claritin. She scheduled a stress test for
today. However, walking to the stress test she got tachycardic
to the 160s was sent to the ED.
In the ED, initial VS were: T 98.7 HR 142 BP 131/87 RR18 O2
sat95%. She appeared tremulous, agitated, diaphoretic and warm.
There was no thyromegaly or nodules on thyroid exam. She had no
proptosis, lid lag, rales, peripheral edema or JVD. A CXR did
not show any evidence of an acute process. She received 2 L of
NS in the ED and Propranolol 10 mg PO.
She c/o anxiety, palpitations, heat-intolerance, eye discomfort,
hand tremors, join aches, depressed mood, epigastric pain, and
swelling for 2 weeks. She reports a 15 lb weight loss in a
month. She has also noticed an erythematous and pruritc rash
over her chest and back of her arms for the last month
(including when she was on claritin). Denies recent albuterol
use, fever, chills, AMS, diarrhea, abdominal pain, neck pain,
voice changes or dysphagia. Denies history of neck radiation.
Labs were notable for TSH of <0.2 and free T4 of 2.4. Tox screen
was negative.
On arrival to the MICU, the patient was alert, oriented, and in
no acute distress. Her HR was in the ___ s/p 10 mg of
propranolol.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, or night sweats. Denies headache,
sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure or weakness. Denies constipation. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Cervical Cancer s/p hysterectomy
HYPERLIPIDEMIA
HYPERTENSION
DEPRESSION
Asthma- well controlled
DEGENERATIVE DISC DISEASE s/p surgery
CRUSH INJURY RIGHT FOOT
NARCOTIC CONTRACT IN CHART
H/O ACUTE RENAL FAILURE
H/O RETINAL DETACHMENT
*S/P APPENDECTOMY
*S/P ___ FUNDOPLICATION
*S/P TONSILLECTOMY & ADENOIDECTOMY
Social History:
___
Family History:
Sister- hypothyroidism
Physical ___:
Physical Exam on Admission:
Vitals: T98.6, HR106, BP133/74, RR26, O2sat: 99%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL.
mild proptosis R>L. No lid lag. No enlarged thyroid, non tender,
no palpable nodules.
Neck: supple, JVP not elevated, no LAD. ___ erythematous rash
across chest and back of arms.
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly. Surgical scars.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Right foot with surgical scars.
Neuro: CNII-XII intact. Mildy hypereflexive in upper
extremities.
Physical Exam on Discharge:
Vitals: T:98.6 HR:106 BP125/71, RR22 O2sat:94%RA
Exam otherwise unchanged from admission
Pertinent Results:
Lab results on admission:
___ 06:00PM BLOOD WBC-6.2 RBC-4.19* Hgb-12.9 Hct-37.6
MCV-90 MCH-30.7 MCHC-34.2 RDW-12.8 Plt ___
___ 06:00PM BLOOD Neuts-75.0* Lymphs-12.3* Monos-9.2
Eos-3.1 Baso-0.5
___ 06:00PM BLOOD ___ PTT-28.3 ___
___ 02:15PM BLOOD Na-141 K-4.2 Cl-103
___ 06:00PM BLOOD Glucose-104* UreaN-14 Creat-0.6 Na-138
K-3.5 Cl-105 HCO3-20* AnGap-17
___ 06:00PM BLOOD ALT-35 AST-26 AlkPhos-51 TotBili-0.2
___ 02:15PM BLOOD Mg-2.3
___ 06:00PM BLOOD Albumin-4.4
___ 04:21AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2
___ 02:15PM BLOOD TSH-<0.02*
___ 02:15PM BLOOD Free T4-2.4*
Lab Results on Discharge:
___ 04:21AM BLOOD WBC-4.2 RBC-3.64* Hgb-11.3* Hct-32.4*
MCV-89 MCH-31.1 MCHC-34.9 RDW-13.0 Plt ___
___ 04:21AM BLOOD Plt ___
___ 04:21AM BLOOD Glucose-95 UreaN-12 Creat-0.5 Na-140
K-3.5 Cl-110* HCO3-24 AnGap-10
___ 04:21AM BLOOD CK(CPK)-54
___ 11:15AM BLOOD T4-11.8 T3-179
___ 06:00PM BLOOD Anti-Tg-PND Thyrogl-PND antiTPO-PND
___ 06:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Imaging:
CXR ___: No evidence of acute disease. Moderate hiatal
hernia.
Thyroid Scan Technetium ___: Globally decreased tracer
uptake in the thyroid gland compatible with sub-acute
thyroiditis.
Brief Hospital Course:
___ yo woman who presented with tachycardia, agitation, and n/v
in the setting of a decreased TSH and elevated free T4 c/w
thyrotoxicosis and hyperthyroidism.
ACUTE CARE
# Tachycardia/Hyperthyroidism: Her decreased TSH (<0.2) and
increased free T4 (2.4) suggest a hyperthyroid state.
Endocrinology had a low suspicion for thyroid storm given her
history and physical exam with no overt signs of heart failure
at this point. The most likely etiology of her hyperthyroidism
is thyroiditis given findings of uptake scan. The patient was
started on Propanolol 10mg q6h PRN heart rate. The patient's
thyroid antibodies were pending at time of discharge. The
patient will have repeat thyroid function tests in one week to
monitor her course, and she should have follow up regarding her
thyroid function, ideally with endocrinology or with her PCP.
There is no indication for treatment with PTU in the setting of
thyroiditis.
CHRONIC CARE
# Hypokalemia: Reports taking Potassium chloride 10 mEq as an
outpatient before this past month of symptoms. At the OSH she
was reported to be hypokalemic. On admission her potassium was
4.2. She has been taking KCl since she presented to the OSH one
week ago. Possibly secondary to increased catecholamines from
the thyroid storm leading to intracellular shift of postassium.
___ also be exacerbated by hydrochlorothiazide and salmeterol.
# Nausea: Presented witn nausea and vomiting. Cont home Zofran
PRN nausea
# Asthma: Well controlled. She was asked to hold this medication
at time of discharge due to hypokalemia, tachycardia. She may
continue the fluticasone.
# Hypertension: Not hypertensive on admission. As patient is
starting propanolol, asked her to stop her hydrochlorothiazide
but to continue Benicar. As well, the patient reports
hypokalemia, which is likely exacerbated in the setting of
hydrochlorothiazide.
# Hyperlipidemia: Hold resuvastatin for now
# Depression: Has been on buproprion for years with good results
but reports that her mood has been down over the last few weeks
since she has been feeling fatigued. Continue home Buproprion
HCl XL 300 mg daily
# Neuropathic pain: After her accident ___ years ago she has had
difficulty with neuropathic pain in her back and legs. Continue
home gabapentin and cymbalta. Has not been taking hydrocodone-
acetaminophen for the last few weeks.
# GERD: s/p ___ fundoplication. Continue home omeprazole
ISSUES OF TRANSITIONS IN CARE
# Code: Full (confirmed)
# Contacts: Husband ___ ___, daughter ___
___ ___.
# ___ Studies: thyroid antibodies
# Issues to discuss at follow up:
- improvement in thyroid function tests
- use of propanolol. Address restarting hydrochlorothiazide.
- Hypokalemia: asked patient to avoid using salmeterol,
hydrochlorothiazide.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Ondansetron 4 mg PO BID:PRN nausea
2. Epinephrine 1:1000 0.3 mg IM ONCE:PRN anaphylaxis
3. olmesartan *NF* 20 mg Oral daily
4. Amphetamine Salt Combo *NF* (amphetamine-dextroamphetamine)
20 mg Oral BID
1 tablet in AM, 1 table at noon
5. Amphetamine Salt Combo *NF* (amphetamine-dextroamphetamine)
10 mg Oral DAILY
In ___
6. Gabapentin 100 mg PO TID
7. Duloxetine 20 mg PO DAILY
8. Lorazepam 1 mg PO HS
at bedtime
9. Rosuvastatin Calcium 40 mg PO DAILY
10. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
11. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
12. Omeprazole 20 mg PO DAILY
with breakfast
13. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
14. BuPROPion 300 mg PO DAILY
15. Hydrochlorothiazide 12.5 mg PO DAILY
16. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
Discharge Medications:
1. Outpatient Lab Work
Please have your TSH, Free T4 checked on ___. Please have
the results faxed to Dr ___, ___ and to Dr. ___
at ___.
2. BuPROPion 300 mg PO DAILY
3. Duloxetine 20 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH DAILY
5. Gabapentin 100 mg PO TID
6. Lorazepam 1 mg PO HS
7. Omeprazole 20 mg PO DAILY
with breakfast
8. Ondansetron 4 mg PO BID:PRN nausea
9. Epinephrine 1:1000 0.3 mg IM ONCE:PRN anaphylaxis
10. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
11. olmesartan *NF* 20 mg Oral daily
12. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
13. Rosuvastatin Calcium 40 mg PO DAILY
14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
15. Propranolol 10 mg PO Q6H
RX *propranolol 10 mg 1 tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
thyroiditis
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 at the ___
___. As you know, you were admitted for
symptoms of thyroiditis. You were seen by the endocrinologists,
who have advised you to use Propanolol for rapid heart rate, to
keep your heart rate between 80-100. Stop hydrochlorothiazide.
Otherwise, you can continue your other medications as you are.
Followup Instructions:
___
|
19806999-DS-17
| 19,806,999 | 24,906,420 |
DS
| 17 |
2159-06-26 00:00:00
|
2159-06-26 15:50:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness, headache, numbness/tingling on the right
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ right handed woman with hypertension who presents
to the ED with the above symptoms; she provides her own history.
She reports that for the past month now, she has been
experiencing intermittent ___ times/week) headaches described
as
starting on the back of her neck, and extending forward to the
right side of her head. She notes tight neck muscles and a
"pulling sensation" and her headaches are described as a
constant
pressure. Tylenol at night may sometimes take the edge off.
These
have been getting slightly more frequent, but she hadn't sought
medical attention for the same.
Yesterday evening, she went to the movie theater and noticed
that
her arm went quite heavy. She did not notice any clumsiness or
weakness; she could text and use her hands to eat. At that time,
she noticed the relatively acute onset of 1) numbness and
tingling over the right hemibody (including trunk) as well as 2)
"dizziness", which she clarifies as a sensation of something
"rushing to my head" when she got up from a seated position.
These two sensations continued to persist overnight and till
this
morning. She had some difficulty sleeping last night. On review
of systems, she denies any difficulty with the left leg or arm.
She has not fallen or had any clumsiness with her lower
extremities. No episodes of loss of consciousness, double
vision,
dysphagia, vomitting, nausea, chest pain, congestion or
drooling.
Past Medical History:
past medical history includes a recent cholecysectomy for
gallstones. She was seen by cardiology a decade ago for
palpitations and suspected premature beats. She has never been
diagnosed with a stroke or heart attack.
Social History:
___
Family History:
Family history is negative for
significant neurological illness.
Physical Exam:
V/s were 98.1F, HR 64, BP 175/112, RR 18,
100%. She is pleasant and cooperative and appeared to be in no
distress. Her neck muscles were tight (trapezius and splenius)
and were tender to palpation. Neck excursion was limited.
Bending
her neck to her left exacerbated her symptoms. Chest examination
revealed clear lung sounds and a relatively slow heart rate
without murmurs. Pulses were symmetric. Belly was obese but soft
and nontender. Lower extremities were without edema. There were
a
few scattered tattoos.
Neurologically, she was awake, alert and oriented x 3. She could
recall ___ backwards and had no paraphasic errors. Speech was
clear. She had difficulty with doing simple calculations (#
quarters in $1.75). Pupils were round, equal and reactive to
light (___) with full visual fields to confrontation. Eye
movements were full to confrontation. Face was symmetric without
ptosis or droop. Facial sensation testing revealed diminished
(~50%) pinprick sensation and cold sensation over the right face
(extending to the scalp) that split down the midline. Face
position sense was preserved. Vibration over the left forehead
was sensed stronger than vibration over the right forehead.
Tongue was strong and midline. Bilateral SCMs and traps were
___.
Motor examination identified a positive ___ sign on the
right. Tone and bulk were normal. Major muscle groups were
tested
at ___, including brachioradialis, infraspinatus, supraspinatus
and intrinsic muscles of the hand. Reflexes were symmetric and
2+
in the upper extremities and 1+ in the lower extremities with
downgoing toes bilaterally.
Sensory examination once again identified diminished pinprick
over the right hemibody that split sharply down the midline.
Vibration sense and joint position sense were normal at both
great toes and symmetric. No R/L confusion, no extinction.
Finger-nose testing was without dysmetria. Gait and tandem gait
were normal, and Romberg was negative.
Pertinent Results:
___ 10:21AM GLUCOSE-103* UREA N-12 CREAT-0.8 SODIUM-142
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-22 ANION GAP-18
___ 10:21AM estGFR-Using this
___ 10:21AM WBC-7.1 RBC-5.11 HGB-14.2# HCT-41.6 MCV-81*
MCH-27.7# MCHC-34.1# RDW-14.4
___ 10:21AM PLT COUNT-205
___: identified no acute lesions or hypodensities
MRI/MRA head and neck
No acute infarct or intracranial hemorrhage.
Nonspecific white matter abnormalities, of uncertain clinical
significance, could be sequelae of chronic small vessel ischemic
disease but some what atypical give her age. Also, on the
differential would be headaches, vasculitis, demyelinating
disease and lyme disease. No significant stenosis on the head
and neck MRA.
Brief Hospital Course:
___ woman with hypertension presents with one month of
intermittent headaches followed by ~ 1 day of right hemibody
numbness that splits down the midline with + ___ on the
right. CT head unremarkable. MRI/MRA head and neck showed no
acute infarct or intracranial hemorrhage. There was no
significant stenosis on the head and neck MRA. Based on her
history, exam and imaging, it is highly unlikely that patient
had a stroke. Seizure is highly unlikely as her sensory
symptoms persisted for days without spreading or other symptoms
suggestive of seizures. Complex migraine is considered but
there is no clear relationship between the onset of her sensory
symptoms and her headaches. We have given patient aspirin 81mg
daily while she was in the hospital but given that she did not
have a stroke, she will not have to continue with the aspirin.
Her fasting lipid is still pending at this time. Her a1c is
5.9. She was continued to half dose of her home atenolol
initially when stroke was still considered a possible etiology.
She was discharged on her home does of atenolol. For her
chronic daily headaches, she was prescribed nortriptyline 10mg
qhs as a trial. We have set up a follow up appointment for her
to follow up with her PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Calcium Carbonate Dose is Unknown PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Calcium Carbonate 1000 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Nortriptyline 10 mg PO HS
RX *nortriptyline 10 mg 1 by mouth at bedtime Disp #*30 Capsule
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Tension/cerevicogemic headaches
Subjective right hemibody altertation in skin sensations of
undetermined etiology
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro exam: Non focal. Decreased sensation to pinprick and
temperature on the right hemibody.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care you. You were here because of
headaches and abnormal sensation on the right side of the body.
You have got CT scan and MRI of your head which did not show any
stroke. We do not think that your symptoms are related to a
stroke. For your headache, we have prescribed nortriptyline to
be taken everyday at bedtime. Please follow up with your PCP as
scheduled.
Medication changes:
- We ADDED NORTRIPTYLINE 10mg qhs to be taken every day at
bedtime to treat your headaches.
Please continue to take the rest of your home medications as
previously prescribed.
Please call your doctor or go to the emergency room if
experience any of the danger signs listed below.
Followup Instructions:
___
|
19807025-DS-5
| 19,807,025 | 21,434,336 |
DS
| 5 |
2117-10-30 00:00:00
|
2117-10-30 14:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Heroin overdose
Major Surgical or Invasive Procedure:
Intubation ___
History of Present Illness:
The patient is a ___ with history of substance abuse, presenting
from OSH with heroin overdose. The patient was found by his
fiance unresponsive and blue at 10pm, last seen normal at
8:30pm. Initially found by EMS to have an oxygen sat of 66% on
room air. He was given naltrexone 2mg IV x 2 with improvement in
his mental status. He was brought to ___ where he was
noted to be dyspneic. He was intubated for combativeness and
hypoxia. A head, neck and chest CT were performed. Reportedly,
the patient had a fever for the last two days. He was given
piperacillin-tazobactam, levofloxacin, and vancomycin. CT head,
C-spine, and chest was unremarkable.
In the ED, initial vital signs were 103.4 hr 97 120/68 rr 16
100% on vent (A/C Vt 500 rate 14 Fi02 100 ___. Labs
demonstrated mild leukocytosis to 11.5k with left shift,
unremarkable chem-7, serum tox screen was negative. Urine tox
screen significant for opiates, cocaine, and methadone. UA was
unremarkable. Lactate 1.1. Patient was given tylenol and
maintained on propofol and fentanyl gtt.
On arrival to the MICU, initial vital signs were 113 129/82 21
94%/intubated, patient is intubated and somewhat agitated.
Past Medical History:
PTSD
Opiate Abuse
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION:
General- intubated, sedated, not responding to sternal rub
HEENT- pupils 2mm and minimally reactive
Neck- supple
CV- RRR, no m/r/g
Lungs- coarse breath sounds anteriorly
Abdomen- soft, nontender
GU- foley in place
Ext- WWP no c/c/e
Neuro- unresponsive to commands
Pertinent Results:
ADMISSION:
___ 04:45AM BLOOD WBC-11.5* RBC-4.57* Hgb-14.5 Hct-41.4
MCV-91 MCH-31.9 MCHC-35.1* RDW-11.9 Plt ___
___ 04:45AM BLOOD Neuts-86.8* Lymphs-6.8* Monos-5.3 Eos-0.7
Baso-0.3
___ 04:45AM BLOOD ___ PTT-26.9 ___
___ 04:45AM BLOOD Glucose-101* UreaN-16 Creat-1.2 Na-133
K-4.6 Cl-96 HCO3-26 AnGap-16
___ 04:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE:
___ 04:55AM BLOOD WBC-5.8 RBC-4.45* Hgb-13.9* Hct-40.1
MCV-90 MCH-31.4 MCHC-34.8 RDW-11.9 Plt ___
___ 04:55AM BLOOD Glucose-113* UreaN-9 Creat-1.0 Na-135
K-4.3 Cl-99 HCO3-29 AnGap-11
___ 04:55AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9
ECHOCARDIOGRAM (___)
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The estimated pulmonary
artery systolic pressure is normal. No vegetation/mass is seen
on the pulmonic valve. There is no pericardial effusion.
CTA CHEST (___)
No evidence of pulmonary embolism. Findings compatible with
extensive bilateral aspiration pneumonia.
MRI C-SPINE (___)
In comparison with the prior cervical spine CT examination dated
___, again a calcific lesion is noted inferior to the level of
C1, consistent with the provided diagnosis of longus coli
calcific tendinitis, associated with small amount of
retropharyngeal fluid with no evidence of narrowing of the
airway.
There is no evidence of abnormal enhancement to suggest
leptomeningeal
disease, there is no evidence of a large abscess formation, no
drainable fluid collections are identified.
Brief Hospital Course:
___ with history of substance abuse, presenting from OSH with
heroin overdose.
# Respiratory failure:
Secondary to heroin overdose with component of noncardiogenic
pulmonary edema. Received naloxone in the field with
improvement in symptoms. Patient was easily extubated after
arrival. He was persisently hypoxemic after extubation which was
thought to be secondary to aspiration pneumonitis found on CT.
There was no evidence of pulmonary embolism.
# Fevers:
Patient reporting history of ___ days fevers prior to
presentation, found to have mild neutrophilic leukocytosis. Was
given vancomycin/piperacillin-tazobactam/levofloxacin at OSH. An
echocardiogram was performed to evaluate for endocarditis given
drug use history, though no vegetations were identified on TTE.
Blood cultures have remained negative. Other possible foci
included an effusion identified on OSH CT C-SPINE. An MRI was
performed to evaluate for abscess; this was not evident on
imaging. Patient was discharged on short course of
amoxicillin-clavulanate for aspiration pneumonitis/pneumonia.
# Heroin overdose:
Patient with history of polysubstance abuse. During
hospitalization, patient required clonidine, lorazepam, and
hydromorphone to prevent agitation. Patient was unwilling to
wait for social work evaluation.
Patient left against medical advise after demonstrating
understanding of risks of leaving hospital prior to complete
evaluation. He was provided with course of
amoxicillin-clavulanate as above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Prazosin 1 mg PO QHS
2. Fluoxetine 60 mg PO DAILY
3. ClonazePAM 2 mg PO DAILY:PRN anxiety
Discharge Medications:
1. ClonazePAM 2 mg PO DAILY:PRN anxiety
2. Fluoxetine 60 mg PO DAILY
3. Prazosin 1 mg PO QHS
4. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 5 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: heroin overdose
aspiration pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ for difficulty breathing due to a
heroin overdose. You were on a breathing machine for a short
amount of time. You were also having fevers and were found to
have a pneumonia. You need to complete a course of antibiotics
for this. You should see your primary care doctor within ___
days of leaving the hospital to discuss how you are doing. You
should avoid using heroin and other illicit drugs, please
discuss with your primary care doctor ___ referral to a suboxone
provider.
Given the fact that you were receiving sedating medications, you
were advised to remain in your room for a loved one to pick you
up, but you insisted on leaving by yourself. You therefore
signed yourself out against medical advice despite the risk of
harm to yourself in leaving on your own.
Followup Instructions:
___
|
19807183-DS-14
| 19,807,183 | 23,147,327 |
DS
| 14 |
2154-10-04 00:00:00
|
2154-10-05 10:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Nasal Pain, with swelling of nasal bridge
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with history of migraines, asthma, and
depression who presents with nasal pain. Patient reports that
she was in her USOH until ___ when she developed nasal and
facial congestion. She initially thought her symptoms were
related to a URI however her symptoms gradually worsened and she
stated having worsening facial and teeth pain with associated
neck pain. She also had chills and subjective fevers. Given her
symptoms she presented to her PCP 1 day prior to admission who
felt patient had a sinus infection. Patient was given Augmentin.
On day of admission, she had worsening facial and nasal pain and
represented to her PCP's office. Given worsening symptoms, she
was referred to the ED for further evaluation.
In the ED, initial VS were: 98.9 72 141/84 16. Evaluation
revealed soft tissue swelling on right nare without e/o abscess
on CT. I+D was attempted and approximately 2cc of pus was
expressed. Patient received morphine, dilaudid, zofran, vanc and
unasyn. Patient was then admitted for further management. VS
prior to transfer were 99.0 82 129/88 16 93%.
On arrival to the floor, patient complains of continued nasal
pain with associated neck pain and photophobia (only in right
eye). Denied teeth swelling or abscess. Denied SOB, chest pain,
dysphagia or odynophagia.
Past Medical History:
- Migraines
- Asthma
- Depression
- Patient reported prior leg/foot soft tissue infection
requiring debridement
Social History:
___
Family History:
Patient reports recurrent skin infections in several family
members
Physical Exam:
ADMISSION EXAM:
VS: 98.0 BP 132/85 80 18 98% RA
GENERAL: uncomfortable appearing, NAD, holding right eye shut
HEENT: NCAT, EOMI however reporting pain on eye movements,
sclera anicteric, no conjunctivitis, significant erythema and
edema of nose, right > left, edema of right nare with bogginess
of right turbinate, tenderness over right frontal and maxillary
sinuses, OP clear, uvula midline
NECK - supple, no thyromegaly, no JVD, no carotid bruits, full
ROM. tenderness over right side of neck, +submandibular LAD
LUNGS - course breath sounds throughout
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
DISCHARGE EXAM:
VS:98 132/85 80 18 97%RA
GENERAL: comfortable appearing, NAD
HEENT: NCAT, EOMI, sclera anicteric, no conjunctivitis, erythema
and edema of nose greatly improved, but still slightly red, well
within outlined margins, mild tenderness over right frontal and
maxillary sinuses, OP clear, uvula midline
NECK - supple, no thyromegaly, no JVD, no carotid bruits, full
ROM. tenderness over right side of neck, +submandibular LAD
LUNGS - expiratory wheezing over b/l lower lung fields
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
___ 05:55PM WBC-9.5 RBC-3.93* HGB-12.5 HCT-37.2 MCV-95
MCH-31.7 MCHC-33.5 RDW-13.8
___ 05:55PM NEUTS-74.4* ___ MONOS-4.3 EOS-1.2
BASOS-0.4
___ 05:55PM PLT COUNT-263
___ 05:55PM GLUCOSE-92 UREA N-5* CREAT-0.5 SODIUM-140
POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14
___ 06:03PM LACTATE-1.___:
CT NECK WITH INTRAVENOUS CONTRAST: There is soft tissue
swelling along the anterior aspect of the right nostril
measuring up to 14 mm on axial
projection. Findings correspond with physical exam finding of
focal abscess at this site. No rim-enhancing drainable fluid
collection is identified at this site. There is no extension
into the adjacent facial soft tissues or deep structures of the
neck.
The globes are symmetric. There is no periorbital cellulitis or
abscess. CT appearance of the extraocular muscles and optic
nerves appears normal. The salivary glands appear normal. No
cervical lymphadenopathy is identified. Views of the
aerodigestive tract appear within normal limits. There is mild
mucosal thickening within the ethmoid air cells. The remainder
of the visualized paranasal sinuses and mastoid air cells are
well aerated. Limited views of the intracranial structures
appear within normal limits. The neck vasculature is grossly
patent. The thyroid gland is homogeneous without focal nodule.
The imaged lung apices are clear. No cervical spine abnormality
is evident.
IMPRESSION: 14 mm soft tissue density along the anterior right
naris. No CT evidence of drainable fluid collection. No
extension to the orbits, face, or deep spaces of the neck.
___. ___
___. ___
Brief Hospital Course:
___ with history of depression, asthma, and migraines presenting
with nasal pain found to have nasal/preseptal cellulitis.
ACTIVE ISSUES:
# Nasal/preseptal cellulitis: No orbital involvement or evidence
of abscess on CT although per ED report, able to drain 2cc pus
on I+D that was not sent for culture. Despite lack of evidence
for orbital involvement, patient exhibiting symptoms of eye
involvement including pain with eye movements. Nasal
involvement, zoster ophthalmicus should remain on differential
however appears less likely given appearance. She was continued
on vancomycin and unasyn. Her exam greatly improved, with no
eye pain or involvement and good vision. She had minimal
tenderness to palpation and resolving erythema over nose. She
was then switched to Bactrim and Augmentin to complete a ___t discharge.
# Asthma: She initially had expiratory wheezing on exam, likely
related to URI although septic embolic from ENT process is also
possibility, but less likely given benign findings on CT and
rapid clinical improvement. She was treated with albuterol nebs
while inpatient and discharged on her home medications.
CHRONIC ISSUES:
# Migraines: continued home medications while inpatient.
# Depression: continued home medications while inpatient.
# FEN: IVFs / replete lytes prn / regular diet
# PPX: heparin SQ, bowel regimen
# ACCESS: PIV
# CODE: full code
# DISPO: ___ for now
TRANSITIONAL ISSUE:
- patients having an ankle abscess drained in the past, may
benefit from ID re: colonization?
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Topiramate (Topamax) 100 mg PO HS
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Sumatriptan Succinate 50 mg PO Frequency is Unknown
5. Clonazepam 1 mg PO QHS
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
Discharge Medications:
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Clonazepam 1 mg PO QHS
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Topiramate (Topamax) 100 mg PO HS
5. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth Every 8 hours Disp #*25 Tablet Refills:*0
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every ___ hours
Disp #*10 Tablet Refills:*0
7. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth Twice a day Disp #*30 Tablet Refills:*0
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Sumatriptan Succinate 50 mg PO PRN Migraine
Discharge Disposition:
Home
Discharge Diagnosis:
Soft tissue abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___, you were admitted to ___ after being
transferred from your primary care physician for facial
swelling. You had a soft tissue abscess that was drained and
you were treated with antibiotics. You will continue on these
two antibiotics for a total of 7 days.
Please see below for your follow-up appointments.
It was a pleasure caring for you and we wish you a speedy
recovery!
Followup Instructions:
___
|
19807332-DS-21
| 19,807,332 | 22,419,561 |
DS
| 21 |
2181-11-04 00:00:00
|
2181-11-04 17:40:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
Bone marrow biopsy (___)
History of Present Illness:
Mr. ___ is a ___ female with history of
recently diagnosed CLL, HIV, diabetes, hyperlipidemia,
hypertension, and bipolar disorder who presents with anemia.
Patient was told to come to the ED by his PCP for abnormal lab
results from 2 days ago. He was told that his hemoglobin was low
and may need blood transfusions. He reports that for the past
few weeks he has experienced worsening fatigue, weakness, and
labored breathing with activity. For the past week he has felt
dizzy with sitting and standing. Today he started to experience
midline minor chest pressure with activity, non-radiating, and
resolved with rest and was associated with palpitations. He
denies bruising, melena, and BRBPR.
On arrival to the ED, initial vitals were 97.6 79 122/61 18 99%
RA. Exam was unremarkable. Labs were notable for CBC 51.8, H/H
5.5/16.8, Plt 73, Na 140, K 4.2, BUN/Cr ___, and negative UA.
CXR was negative for pneumonia. No medications given. ___ was
consulted who recommended transfusion and admission. Prior to
transfer vitals were 97.6 84 120/69 20 100% RA.
On arrival to the floor, patient reports feeling tired. He
denies pain. He denies fevers/chills, night sweats, headache,
vision changes, cough, hemoptysis, abdominal pain,
nausea/vomiting, diarrhea, hematemesis, hematochezia/melena,
dysuria, hematuria, and new rashes or bruising.
Past Medical History:
CLL
Type II Diabetes
Hypertension
Hyperlipidemia
HIV
Bipolar Disorder
Social History:
___
Family History:
Leukemia in maternal relative. Lung cancer in grandparents who
were all smokers. Cousin with leukemia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: Temp 98.8, BP 114/68, HR 81, RR 18, O2 sat 97% RA.
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, positive bowel sound.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
==========================
VS: Temp: 98.9 PO BP: 117/67 HR: 70 RR: 18 O2 sat: 98% RA
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP without erythema, exudates or
ulcers.
CARDIAC: RRR with normal s1/s2, no murmurs, rubs or gallops
appreciated.
LUNG: Normal respiratory effort, CTAB without crackles, wheezes,
or rhonchi.
ABD: Soft, obese, non-tender, non-distended, normoactive bowel
sound. No masses appreciated.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, CN II-XII grossly intact. Strength normal
throughout.
SKIN: Warm, dry. No rashes. Biopsy site without bleeding,
ecchymosis or erythema.
Pertinent Results:
ADMISSION LABS:
================
___ 11:10PM BLOOD WBC-51.8* RBC-1.71*# Hgb-5.5*# Hct-16.8*#
MCV-98 MCH-32.2* MCHC-32.7 RDW-15.2 RDWSD-53.8* Plt Ct-73*
___ 11:10PM BLOOD Neuts-6* Bands-0 Lymphs-91* Monos-1*
Eos-0 Baso-1 ___ Myelos-1* AbsNeut-3.11
AbsLymp-47.14* AbsMono-0.52 AbsEos-0.00* AbsBaso-0.52*
___ 11:10PM BLOOD Glucose-139* UreaN-27* Creat-1.0 Na-140
K-4.2 Cl-101 HCO3-26 AnGap-13
___ 11:10PM BLOOD ALT-18 AST-22 LD(LDH)-294* AlkPhos-85
TotBili-0.2
___ 11:10PM BLOOD Albumin-4.3 Calcium-8.8 Phos-4.6* Mg-2.2
Iron-175*
PERTINENT LABS:
================
___ 11:10PM BLOOD Ret Aut-0.7 Abs Ret-0.01*
___ 11:10PM BLOOD calTIBC-306 ___ Ferritn-655*
TRF-235
DISCHARGE LABS:
=================
___ 06:50AM BLOOD WBC-49.3* RBC-2.59* Hgb-8.1* Hct-24.3*
MCV-94 MCH-31.3 MCHC-33.3 RDW-16.3* RDWSD-53.8* Plt Ct-63*
___ 06:50AM BLOOD Neuts-5* Bands-0 Lymphs-91* Monos-4*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-2.47
AbsLymp-44.86* AbsMono-1.97* AbsEos-0.00* AbsBaso-0.00*
___ 06:50AM BLOOD Glucose-124* UreaN-25* Creat-0.9 Na-136
K-4.5 Cl-100 HCO3-25 AnGap-11
___ 06:50AM BLOOD Calcium-9.0 Phos-4.9* Mg-2.2
PERTINENT IMAGING/PROCEDURES/PATH:
==================================
___ CT Abd/pelvis w/ contrast:
Minimally changed abdominopelvic lymphadenopathy with many nodes
unchanged and few nodes minimally enlarged. Splenomegaly is
slightly increased, measuring 17.7 cm and previously measuring
17.1 cm.
___ CT Chest w/o contrast:
Minimally changed supraclavicular, axillary, mediastinal, and
hilar
lymphadenopathy with many nodes unchanged and few nodes
minimally enlarged.
___ Peripheral blood cytogenetics
Pending at discharge
___ Bone marrow biopsy
Aspirate and immunophenotyping pending at discharge
Brief Hospital Course:
Mr. ___ is a ___ male with history of
recently diagnosed CLL, HIV, DM, HTN, and HLD who presents with
anemia.
ACUTE MEDICAL CONDITIONS:
=========================
# Symptomatic Anemia
Presented with several weeks of fatigue, lightheadedness, and
dyspnea on exertion found to have new profound anemia with Hgb
5.5. Iron studies were unrevealing and hemolysis labs were
negative. There were no signs of bleeding. Reticulocyte count
was inappropriately low (absolute 0.01). He described having 4
weeks of URI sxs, prompting concern that the decreased
production was due to a viral illness vs more likely, worsened
CLL. Both peripheral blood cytogenetics and a bone marrow biopsy
were done to differentiate between these two etiologies. Both
tests were pending at discharge. He ultimately received 3u pRBC
during this admission. H/H were stable at discharge.
# CLL
# Thrombocytopenia
Diagnosed with RAI stage III CLL ___ month prior to admission
and had not been on treatment as the patient had been
asymptomatic. CBC on admission showed worsening anemia and new
thrombocytopenia, consistent with RAI stage IV disease. Repeat
CT chest/abd/pelvis showed mildly worsened diffuse
lymphadenopathy. Both peripheral blood cytogenetics and bone
marrow biopsy were done to evaluate if dropping blood counts
were due to CLL vs less likely viral illness. Bone marrow biopsy
was limited- core biopsy was attempted but aborted due to pain.
Patient will follow up with Dr. ___ on ___ to discuss
possible treatment pending results.
CHRONIC MEDICAL CONDITIONS:
===========================
# Hypertension
Presented on atenolol and lisinopril at home. Lisinopril held in
the setting of anemia and normotensive pressures. Both restarted
at discharge.
DISCHARGE LABS:
===============
CBC: 49.3/8.___
TRANSITIONAL ISSUES:
=====================
[] Follow up cytogenetics and bone marrow biopsy
[] Repeat CBC at next appointment to evaluate
anemia/thrombocytopenia
[] BP stable on monotherapy here; consider stopping amlodipine
and continuing lisinopril if BP remains low as an outpatient
CODE: Full Code (confirmed)
EMERGENCY CONTACT HCP: ___ (partner) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 12.5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Atripla (efavirenz-emtricitabin-tenofov) ___ mg oral
DAILY
4. Lisinopril 20 mg PO DAILY
5. Testosterone Gel 1% 50 mg TP DAILY
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
10. Multivitamins 1 TAB PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Ascorbic Acid ___ mg PO DAILY
13. Cyanocobalamin 250 mcg PO DAILY
14. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 12.5 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Atripla (efavirenz-emtricitabin-tenofov) ___ mg oral
DAILY
6. Cyanocobalamin 250 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Testosterone Gel 1% 50 mg TP DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
#Primary:
Anemia
#Secondary:
Chronic lymphocytic leukemia
Hypertension
Diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___!
Why you were admitted to the hospital:
- You were having fatigue and lightheadedness, then lab work
showed that you were anemic (low blood counts)
What happened while you were here:
- You were given blood to replete your counts and make you feel
better
- Further tests, including a bone marrow biopsy, were done to
further evaluate the cause of the anemia
What you should do once you get home:
- Continue taking your medications as prescribed and follow up
with Dr. ___ at the appointment outlined below.
- Please call Dr. ___ your PCP if you begin having fatigue
or new symptoms
We wish you the best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19807332-DS-22
| 19,807,332 | 20,520,468 |
DS
| 22 |
2181-11-09 00:00:00
|
2181-11-11 21:45:00
|
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o male with a hx of CLL (dx
___, HIV on atriplia, DM, HTN, and HLD who presents with
fever and cough.
The patient was recently hospitalized at ___ from ___
for symptomatic anemia and thrombocytopenia. Work up was notable
for decreased reticulocyte count indicating poor production,
concerning for worsening CLL vs viral illness. Peripheral blood
flow cytometry and bone marrow biopsy were done; final read
still pending. He received 3u pRBC with plan to follow up with
Dr. ___ as an outpatient for further management.
Since discharge, the patient describes three days of mildly
productive cough, rhinorrhea, congestion, postnasal drip, and
malaise. He also reports worsening dyspnea on exertion, mild
shortness of breath at baseline, and chest pressure with deep
breaths. No chest pain or palpitations. He then had a fever to
___ last night, prompting him to come to the ED today.
Otherwise, he had two episodes of vomiting (clear liquid, no
blood) this morning without any nausea since. Also reports three
episodes of loose stools yesterday, no BMs today. No headaches,
vision changes, focal weakness, sinus pain, ear pain, sore
throat, abdominal pain, rashes or joint pain.
In the ED, vitals: Temp 102.8 BP 131/75 HR 127 RR 18 96% on RA
Labs: Cr 1.0, WBC 88.6 (94% lymph), H/H 9.___, plts 73, lactate
1.4, trop <0.01, CK 183, influenza negative
Imaging: CXR unremarkable
Given: Vancomycin, cefepime, acetaminophen and 2L NS
Consults: None
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___ - Seen in ___ clinic for leukocyte-predominant
lymphocytosis noted during annual physical exam. Noted to have
smudge cells c/w CLL
- ___ CT Chest/Abd/pelvis: Multiple pathologically enlarged
supraclavicular, subpectoral, axillary, and mediastinal lymph
nodes.
Extensive retroperitoneal, mesenteric, and pelvic
lymphadenopathy. Splenomegaly, up to 15.8 cm.
- ___ - Rai stage III CLL. Held treatment as patient
remained asymptomatic
- ___ - Admitted for symptomatic anemia and new
thrombocytopenia. Repeat imaging showed mild interval
enlargement
of lymph nodes
PAST MEDICAL/SURGICAL HISTORY:
CLL
Type II Diabetes
Hypertension
Hyperlipidemia
HIV
Bipolar Disorder
Social History:
___
Family History:
Leukemia in maternal relative. Lung cancer in grandparents who
were all smokers. Cousin with leukemia.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.6F BP 156/76 HR 114 RR 18 95% on Ra
Gen: WDWN, obese male in NAD. Ill-appearing.
HEENT: No conjunctival pallor. No icterus. MMM. OP without
erythema, exudates or ulcers. No maxillary or frontal TTP. Nares
without significant erythema. EOMI.
NECK: Supple
LYMPH: No cervical or supraclav LAD.
CV: RRR with normal S1 and S2. II/VI SEM over LLSB and apex. No
rubs or gallops.
LUNGS: Normal respiratory effort. Diffuse rhonchi and expiratory
wheezes. No crackles.
ABD: Normoactive BS. Soft, obese. Non-tender, non-distended. No
masses appreciated.
EXT: WWP. No ___ edema or erythema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3. CN II-XII intact. ___ strength throughout.
LINES: PIV c/d/I.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: Temp: 98.4 PO BP: 100/62 HR: 84 RR: 20 O2 sat: 98% O2 RA
Gen: WDWN, obese male in NAD. Lying comfortably in bed.
HEENT: No conjunctival pallor. No icterus. MMM. OP without
erythema, exudates or ulcers. Nares without significant
erythema.
NECK: Supple
CV: RRR with normal S1 and S2. II/VI SEM over LLSB and apex. No
rubs or gallops.
LUNGS: Normal respiratory effort. Diffuse expiratory wheezes and
scattered rhonchi. No crackles.
ABD: Normoactive BS. Soft, obese. Non-tender, non-distended. No
masses appreciated.
EXT: WWP. No ___ edema or erythema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3. CN II-XII grossly intact. Moves all extremities.
LINES: PIV c/d/i.
Pertinent Results:
ADMISSION LABS:
================
___ 11:15AM BLOOD WBC-88.6*# RBC-2.98* Hgb-9.4* Hct-28.0*
MCV-94 MCH-31.5 MCHC-33.6 RDW-15.3 RDWSD-50.4* Plt Ct-73*
___ 11:15AM BLOOD Neuts-3* Bands-0 Lymphs-94* Monos-2*
Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-2.66
AbsLymp-83.28* AbsMono-1.77* AbsEos-0.00* AbsBaso-0.00*
___ 11:15AM BLOOD Glucose-163* UreaN-31* Creat-1.0 Na-135
K-4.6 Cl-96 HCO3-22 AnGap-17
___ 11:15AM BLOOD ALT-25 AST-25 CK(CPK)-183 AlkPhos-106
TotBili-0.4
___ 11:29AM BLOOD Lactate-1.4
PERTINENT LABS:
=================
___ 11:15AM BLOOD WBC-88.6*# Lymph-94* Abs ___
CD3%-6 Abs CD3-4704* CD4%-3 Abs CD4-2605* CD8%-2 Abs CD8-1780*
CD4/CD8-1.46
___ 11:15AM BLOOD Lipase-21
___ 11:15AM BLOOD cTropnT-<0.01
___ 11:15AM BLOOD CK-MB-2
___ 06:35AM BLOOD Hapto-177
___ 06:35AM BLOOD IgG-608* IgA-75 IgM-72
___ 06:35AM BLOOD CMV VL-NOT DETECT
___ 06:35AM BLOOD HBV VL-NOT DETECT HCV VL-NOT DETECT
___ 06:35AM BLOOD HIV1 VL-NOT DETECT
___ 07:50AM BLOOD B-GLUCAN-PND
___ 07:50AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODIES (IGG,
IGM)-PND
DISCHARGE LABS:
================
___ 06:44AM BLOOD WBC-32.3* RBC-2.10* Hgb-6.4* Hct-20.3*
MCV-97 MCH-30.5 MCHC-31.5* RDW-15.4 RDWSD-52.4* Plt Ct-49*
___ 06:44AM BLOOD Glucose-136* UreaN-17 Creat-0.8 Na-140
K-3.7 Cl-101 HCO3-26 AnGap-13
___ 06:44AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.2
PERTINENT MICRO/PATH:
======================
___ urine legionella: Negative
___ Respiratory viral panel: POSITIVE FOR RESPIRATORY
SYNCYTIAL VIRUS (RSV).
___ MRSA screen: Negative
___ 05:47AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 02:43PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
PERTINENT IMAGING:
==================
___ CXR:
Low lung volumes. No evidence of focal consolidation or pleural
effusion.
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a hx of CLL (dx
___, HIV on atriplia, DM, HTN, and HLD who presented with
fever, cough, and rhinorrhea, diagnosed with viral URI.
#Respiratory Syncytial Virus Infection
#Viral URI
Presented with cough, congestion/postnasal drip, shortness of
breath, and malaise. Initially met ___ SIRS criteria (fever,
tachycardia) concerning for sepsis. Exam was notable for diffuse
wheezes/rhonchi. Work up included: influenza negative, CXR
unremarkable, negative urine/blood cultures, and negative urine
legionella. He received IVF and was initially treated with
vancomycin/cefepime/azithromycin for presumed HCAP; however
antibiotics were discontinued after ___ days when his symptoms
were felt due to a viral infection. Following discharge, the
respiratory panel returned positive for RSV, confirming the
above suspicions. HIV/HepB/HepC/CMV/EBV/HSV viral loads,
mycoplasma IgG/IgM, and B-glucan were pending at discharge. He
will follow up with Dr. ___ further management.
#CLL
Diagnosed in ___, initially held treatment as patient was
asymptomatic. He was recently admitted for new anemia and
thrombocytopenia, consistent with RAI stage IV disease. Repeat
CTs at that time showed mild disease progression. Bone marrow
biopsy with 93% lymphocytes and extensive CLL involvement. Flow
cytometry pending at discharge. He will follow up with Dr.
___ on ___ for further discussions and likely initiation of
chemotherapy with fludarabine and cyclophosphamide.
#Anemia/Thrombocytopenia
Admitted ___ for new symptomatic anemia/thrombocytopenia
and required 3u pRBC. Work up at that time was notable for
reduced reticulocyte count and bone marrow biopsy with extensive
CLL, consistent with inadequate production. He required one
blood transfusion during this admission, on day of discharge
(___).
# Hypertension
Presented on atenolol and lisinopril at home. Both medications
were held in the setting of infection and normal/borderline low
blood pressures.
TRANSITIONAL ISSUES:
====================
[] Will see Dr. ___ in clinic and likely start chemotherapy
on ___
[] Follow up final flow cytometry results
[] Follow up CD4 counts, HIV VL, Hep B/C VL, EBV VL, HSV VL,
mycoplasma IgG/IgM, and B-glucan
[] Atenolol/lisinopril held at discharge. Consider restarting if
he becomes hypertensive
[] Aspirin held at discharge due to thrombocytopenia
# CODE: Full (presumed)
# CONTACT: ___ (partner) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
4. Multivitamins 1 TAB PO DAILY
5. Testosterone Gel 1% 50 mg TP DAILY
6. Ascorbic Acid ___ mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atripla (efavirenz-emtricitabin-tenofov) ___ mg oral
DAILY
9. Cyanocobalamin 250 mcg PO DAILY
10. Fish Oil (Omega 3) 1000 mg PO DAILY
11. Lisinopril 20 mg PO DAILY
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Vitamin D 1000 UNIT PO DAILY
14. Atenolol 12.5 mg PO DAILY
Discharge Medications:
1. Fluticasone Propionate 110mcg 2 PUFF IH BID Duration: 5 Days
2. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
RX *codeine-guaifenesin 10 mg-100 mg/5 mL 5 ml by mouth every
six hours Disp ___ Milliliter Milliliter Refills:*0
3. Ascorbic Acid ___ mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Atripla (efavirenz-emtricitabin-tenofov) ___ mg oral
DAILY
6. Cyanocobalamin 250 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID:PRN constipation
8. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID
11. Multivitamins 1 TAB PO DAILY
12. Testosterone Gel 1% 50 mg TP DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until Instructed by your doctor
15. HELD- Atenolol 12.5 mg PO DAILY This medication was held.
Do not restart Atenolol until instructed to by your doctor
16. HELD- Lisinopril 20 mg PO DAILY This medication was held.
Do not restart Lisinopril until instructed by your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
#Primary:
Viral upper respiratory tract infection
#Secondary:
Chronic lymphocytic leukemia
Anemia ___ CLL
Thrombocytopenia
Sepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
Why you were admitted to the hospital:
- You were having fever, chills, nasal congestion, cough and
shortness of breath
What happened while you were here:
- You were briefly treated with intravenous antibiotics
- It was ultimately felt that a viral infection was causing your
symptoms
- You were given supportive measures like intravenous fluids and
cough medications and your symptoms improved
- You also received a blood transfusion due to low blood counts
from the CLL
What you should do once you return home:
- Please follow up with Dr. ___ as described below; you have
an appointment (time not yet scheduled) on ___. If you do
not receive a phone call, please call clinic at ___ to
verify your time
- You will discuss and possibly start chemotherapy at this visit
- Continue taking your medications as prescribed. Do not take
atenolol or lisinopril until you follow up with Dr. ___
___,
Your ___ Care Team
Followup Instructions:
___
|
19807987-DS-20
| 19,807,987 | 29,913,595 |
DS
| 20 |
2191-08-12 00:00:00
|
2191-08-12 17:59:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
amlodipine / pravastatin / Zocor
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary angiogram ___
History of Present Illness:
Mr. ___ is a ___ year-old male with history of
hypertension, type 2 diabetes on metformin (A1C from ___
6.6%), CKD (baseline Cr 1.2-1.4), asthma, former smoker (quit in
___) referred to the ED from his PCP office for ongoing chest
pain.
Per chart review, patient has a ___ week-history atypical of
right-sided chest pain that occurs ___ days per day and occurs
at both rest and exertion. Pain is described as achy and
radiates
to right trapizius region and right arm.
Of note, patient had a recent ED visit on ___ with similar
complaint. Stress MIBI from ___ with possible reversible,
medium size perfusion defect involving the RCA territory. Normal
left ventricular cavity size and function. LVEF 68%. Patient was
supposed to have coronary angiogram on ___ however, due to
continued chest pain was referred to the ED.
Patient denies any presyncope symptoms, shortness of breath,
PND,
orthopnea, lower extremity edema, palpitations or presyncope. He
also denies nausea, vomiting, change in bowel habit, fever or
weight loss.
In the ED: Patient reports right-sided shoulder pain with
cervical pain.
Initial vital signs were notable for:
Temp: 97.6 HR: 74 BP: 138/83 Resp: 18 O2 Sat: 98 RA
Labs were notable for:
Hb: 11.8 | WBC: 5.3 | Plt: 231
Cr: 1.4 | K: 4.8 | BG: 204
T< 0.01
Patient was seen by Atrius Attending Dr. ___ thought
that patient's symptoms might be cardiac in origin based on his
prior stress MIBI and recommended urgent coronary angiography.
Patient was shifted to cath lab.
Studies performed include:
===========================
Coronary Angiography - ___, which showed < 50% lesions in
all 3 vessels serving the inferior wall.
Consults: Cardiology
Vitals on transfer: BP : 137/80 mmHg | HR: 67 | RR: 18 | O2
SATS:
97% RA.
Upon arrival to the floor, patient confirms HPI. He endorses
trapizial discomfort and pain in the cervical spine area.
Past Medical History:
- HTN: ___ years
- DM/Pre-diabetes
- Asthma
- Obesity
- Hypercholesterolemia
- Allergic rhinitis
- Erectile dysfunction
- CKD
- Peripheral neuropathy
- Colonic polyp
Social History:
___
Family History:
Congestive heart failure Mother deceased age ___ of chf
Myocardial Infarction Mother
___ Onset Mother
___ Mother
___ Sister
Physical ___:
ADMISSION PHYSICAL EXAM:
=========================
VITALS:
BP : 137/80 mmHg | HR: 67 | RR: 18 | O2 SATS: 97% RA.
GENERAL: Alert and interactive. In no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: Thyroid is normal in size and texture, no nodules. 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: Pain and paravertebral cervical spine 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. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
DISCHARGE PHYSICAL EXAM:
=========================
VS: T 97.5, BP 101/65, HR 72, RR 18, O2 97% on RA
GEN: Well appearing, NAD
CVD: RRR, no m/r/g
PULM: CTAB
ABD: Soft, non tender, non distended
EXT: No tenderness to palpation of R shoulder joint, some
reproducible pain w/ neck rotation
Pertinent Results:
LABS
===============
___ 02:10PM BLOOD WBC-5.3 RBC-3.94* Hgb-11.8* Hct-35.0*
MCV-89 MCH-29.9 MCHC-33.7 RDW-11.3 RDWSD-36.6 Plt ___
___ 02:10PM BLOOD Neuts-50.4 ___ Monos-8.8 Eos-0.4*
Baso-0.2 Im ___ AbsNeut-2.69 AbsLymp-2.13 AbsMono-0.47
AbsEos-0.02* AbsBaso-0.01
___ 02:10PM BLOOD Glucose-204* UreaN-25* Creat-1.4* Na-138
K-4.8 Cl-103 HCO3-23 AnGap-12
___ 07:01AM BLOOD CK(CPK)-225
___ 02:10PM BLOOD cTropnT-<0.01
___ 07:01AM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:01AM BLOOD Calcium-9.7 Phos-3.8 Mg-1.8
STUDIES/IMAGING
=================
___ Coronary angiogram
Moderate severity two vessel coronary coronary artery disease.
___ TTE
Mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global biventricular systolic function. No
valvular pathology or pathologic flow identified.
___ XR Shoulder
Three views of the right shoulder are provided. No comparison.
Status post shoulder surgery with surgical material and surgical
remnants at the middle and lateral aspect of the humeral head.
The humeral acromial distance is normal. No luxation. Mild
degenerative changes at the level of the humeral glenoid joint.
No cortical discontinuity indicative of fracture.
___ XR CSpine
Three views of the cervical spine are provided. There is no
comparison.
Absence of the physiological cervical lordosis. Mild dorsal
narrowing of the disc spaces and dorsal and ventral osteophyte
formation, mild degenerative changes at the level of the
intervertebral joints. No vertebral compression fractures.
Brief Hospital Course:
TRANSITIONAL ISSUES
=====================
[] The patient's pain was felt to be secondary to
musculoskeletal etiology in the arm or shoulder. If persistent
consider advanced imaging or referral to orthopedics/pain
specialist.
[] Given findings of non obstructive CAD, recommend aggressive
primary prevention strategies, including good control of blood
pressure and diabetes. He may also benefit from carvedilol
instead of labetolol.
[] The patient was found to be slightly anemic with Hbg 10.9.
Recommend age appropriate cancer screening and further work up
if anemia worsens.
SUMMARY
=========
Mr. ___ is a ___ year-old male with history of
hypertension, type 2 diabetes on metformin (A1C from ___
6.6%), CKD (baseline Cr 1.2-1.4), asthma, former smoker (quit in
___ who presented with R sided chest and arm pain in the
setting of a recent abnormal stress test.
ACTIVE ISSUES
===============
# Chest and shoulder pain
# Stable coronary artery disease
Given a recent stress test on ___ revealing for a possible
reversible medium sized perfusion defect in the RCA territory,
the patient's presenting symptoms of chest and arm pain were
concerning for acute coronary syndrome, although troponins were
negative and EKG was non specific. He underwent urgent cardiac
catheterization which was revealing for non obstructive coronary
artery disease, with no more than 60% stenosis in all 3 major
vessels. An echo was done which showed normal global and
regional systolic function. The patient continued to have arm,
shoulder, and upper chest pain however, so xrays of the cervical
spine and shoulder joint were obtained which showed mild
degenerative changes in the spine and glenohumoral joint. Given
his prior shoulder surgery and chronic back and joint pain, it
was felt that the patient's symptoms were secondary to
musculoskeletal etiology, which was likely aggravated recently
when moving heavy boxes. The patient was given a lidocaine patch
and pain medications.
CHRONIC ISSUES
================
# Hyperlipidemia
The patient was continued on home atorvastatin 80mg daily.
# Type 2 Diabetes Mellitus
Diabetes seems to be well controlled without retinopathy. A1C
from ___ was 6.6. He was continued on metformin 500mg
daily.
# Hypertension
The patient was continued on labetalol 600 mg BID, Torsemide
20mg daily, spironolactone 25mg daily, and lisinopril 20 mg
daily.
# Anemia
of 11.8. It appears to be around his baseline in 12 range.
Patient has history of colon polyps. Recommend outpatient with
age appropriate screening.
# Chronic pain/neuropathy
The patient was continued on home gabapentin 300mg TID.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Spironolactone 25 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Gabapentin 300 mg PO TID
6. Torsemide 20 mg PO DAILY
7. Sildenafil 20 mg PO ONCE:PRN Erectile dysfunciton
8. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
9. Labetalol 600 mg PO BID
10. Vitamin D 1000 UNIT PO DAILY
11. Fluticasone Propionate 110mcg 2 PUFF IH BID
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN Asthma
13. Cyclobenzaprine 5 mg PO TID:PRN Back pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild/Fever
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN Asthma
4. Atorvastatin 80 mg PO QPM
5. Cyclobenzaprine 5 mg PO TID:PRN Back pain
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Gabapentin 300 mg PO TID
8. Labetalol 600 mg PO BID
9. Lisinopril 20 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO DAILY
11. Sildenafil 20 mg PO ONCE:PRN Erectile dysfunciton
12. Spironolactone 25 mg PO DAILY
13. Torsemide 20 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Musculoskeletal arm pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why were you admitted to the hospital?
- You were having right arm and chest pain.
What happened while you were in the hospital?
- Because you recently had an abnormal stress test, you were
taken to have a procedure called a coronary angiogram. This
showed mild narrowing of your heart arteries, but there were no
major blockages, meaning you did not have a heart attack.
- An ultra sound of your heart was done which showed normal
heart function.
- Your pain was felt to be more likely related to muscle or bone
issues. Xrays of your shoulder and neck were done and you were
treated with pain medications.
What should you do when you go home?
- Please take all your medications as prescribed.
- Follow up with your primary care doctor as discussed below.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19808040-DS-13
| 19,808,040 | 26,922,334 |
DS
| 13 |
2143-08-19 00:00:00
|
2143-08-22 22:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of Breath/Fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ yo M with h/o HTN who was refered to the ED by his
PCP ___ 1 month of fatigue and dyspnea. The patient presented to
his PCP office today as he has been feeling poorly for over a
month. Normally, he is very active, however, he began noticing
difficulty completing his workouts 1 month ago. This progressed
to increased fatigue with minimal exertion like climbing a
flight of stairs. He denies chest pain or discomfort. Over the
last few days, the patient has waking up around 5AM with acute
shortness of breath. He also has noted a mild sensation of
orthopnea. His appetite has been low and he endorses early
satiety. He has noted increased abdominal bloating, pressure,
and intermittent diarrhea since this time as well. A couple of
months ago, the patient had a self-resolving episode of deep
cough, fatigue, sore throat, but no rashes or GI symptoms. The
patient saw his PCP today and was noted to have sinus
tachycardia to 130s, so was refered for evaluation.
In the ED, the patient had a CXR with evidence of pulmonary
edema. He was peristently tachycardic. Cards was consulted and
performed a bedside TTE that showed EF 15%. The patient was
given 20mg IV lasix and was admitted for evaluation and
treatment of acute systolic heart failure.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
Borderline HTN
Social History:
___
Family History:
Parents are healthy with only hyperlipidemia, but no early CAD
or cardiomyopathy. Sister with asthma. Grandmother with "weak
heart" and passed away in her ___.
Physical Exam:
ON ADMISSION
VITALS: 98, 125/94, 112, 20, 96% RA
GENERAL: NAD
HEENT: PERRL, EOMI
NECK: JVD elevated to level of mid neck at 60 degrees, when laid
flat it increases to level of jaw
LUNGS: mild crackles at bases bilaterally
HEART: sinus tachycardia, normal S1, S2, +S3, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: Mild 1+ edema ___
NEUROLOGIC: A+OX3
ON DISCHARGE
PE
Afebrile, BP- 100-113/65, P- 86-93, RR- 18, 100%RA
I/O- 700/700
Awake, alert, walking around, NAD
HEENT- clear oropharnyx
Neck- supple, JVP 9cm
Lungs- very mild crackles at bases
Heart- S1S2, no S3, no MRG
Abd- sot, NT, ND, no hepatomegaly appreciated
Extrem- 2+ pulses, 1+ distal pitting edema
Pertinent Results:
ON ADMISSION
___ 04:46PM GLUCOSE-101* UREA N-11 CREAT-1.2 SODIUM-139
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14
___ 04:46PM cTropnT-<0.01 proBNP-2992*
___ 04:46PM WBC-6.9 RBC-4.76 HGB-15.7 HCT-45.6 MCV-96
MCH-33.0* MCHC-34.5 RDW-13.4
___ 04:46PM PLT COUNT-210
ON DISCHARGE
___ 05:50AM BLOOD WBC-7.0 RBC-4.85 Hgb-15.5 Hct-46.0 MCV-95
MCH-32.0 MCHC-33.8 RDW-13.1 Plt ___
___ 05:50AM BLOOD UreaN-26* Creat-1.1 Na-138 K-4.2 Cl-103
HCO3-26 AnGap-13
___ 05:50AM BLOOD Mg-2.4
Other Pertinent Results
___ 07:15PM BLOOD calTIBC-358 Ferritn-342 TRF-275
___ 08:00AM BLOOD TSH-2.0
___ 05:15PM BLOOD ___ dsDNA-NEGATIVE
___ 05:15PM BLOOD RheuFac-3
___ 07:15PM BLOOD HIV Ab-NEGATIVE
___ 08:20AM BLOOD CK(CPK)-41*
___ 04:46PM BLOOD ALT-82* AST-31 AlkPhos-63 TotBili-2.1*
Images
ECG
Sinus tachycardia. Marked left atrial abnormality. A-V
conduction delay
for the rate. Left ventricular hypertrophy with repolarization
changes.
Poor R wave progression across the precordium, probably related
to the
left ventricular hypertrophy. No previous tracing available for
comparison.
Echo ___
The left atrium is mildly dilated. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
There is severe global left ventricular hypokinesis (LVEF =
___. A left ventricular mass/thrombus cannot be excluded.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Dilated left ventricle with severe global systolic
dysfunction, most c/w nonischemic cardiomyopathy. Moderate
functional mitral regurgitation. Mild pulmonary hypertension.
Echo ___
IMPRESSION: Markedly dilated left ventricular cavity with severe
global hypokinesis c/w diffuse process (toxin, metabolic, etc.
The pattern is less suggestive of multivessel CAD). At least
mild-moderate mitral regurgitation. Borderline pulmonary
arterial systolic hypertension.
Compared with the findings of the prior study (images reviewed)
of ___, global left ventricular systolic function is
slightly improved and the heart rate is slower.
Cardiac MR
___
Brief Hospital Course:
___ year old M with no significant PMHx presents with 3 weeks of
worsening shortness of breath and fatigue, found to have severe
systolic heart failure.
Congestive Heart Failure
Echocardiogram revealed EF ___. The patient was initially
aggressively diuresed and begun on PO Lisinopril. After he
became more euvolemic, beta blocker therapy (metoprolol
succinate) was initiated. He was also started on spironolactone.
One evening, the patient was triggered for symptomatic
hypotension (81/59) but this quickly resolved with 200cc of NS.
Afterwards he was started on digoxin therapy as well.
The cause of the patient's systolic heart failure is unclear. He
does report alcohol use and does note that he had a viral
illness that included a sore throat in ___, but a strep test
was negative at the time. All other tests for known causes of
heart failure were negative including TSH, iron studies, HIV,
___, anti dsDNA, and RF.
Repeat echocardiogram showed no evidence of LV thrombus.
By discharge, the patient had been diuresed ___ of fluid and
was feeling well. He was seen by Social Work to help him cope
with his new diagnosis and by nutrition for diet education for
heart failure patients.
Transitional Issues
The patient will be followed closely in the ___ clinic under the
guidance of Dr ___ NP ___.
The patient had a cardiac MRI done before discharge that has yet
to be ___.
He has been instructed to weigh himself each morning after
voiding and before breakfast. If he gains more than 2 lbs in a
day or gains weight for 3 straight days he has been instructed
to call Dr ___.
He has also been instructed to avoid alcohol and caffeine. He
should not be taking any supplements or herbal medications until
they are cleared by Dr ___.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Multivitamins 1 TAB PO DAILY
2. Fish Oil (Omega 3) Dose is Unknown PO DAILY
3. Probiotic *NF* (lactobacillus rhamnosus GG) 10 billion cell
Oral Daily
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Metoprolol Succinate XL 25 mg PO DAILY
Hold for HR<55, SBP<90
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
5. Spironolactone 12.5 mg PO DAILY
Hold for SBP<90
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*15 Tablet Refills:*0
6. Fish Oil (Omega 3) 1000 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Probiotic *NF* (lactobacillus rhamnosus GG) 10 billion cell
Oral Daily
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Systolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with shortness of breath and fatigue.
An ultrasound of your heart showed that you're heart is very
weak and you have something called systolic heart failure. We
have started you on medications that have been shown to benefit
patients with your condition. In addition, we have started a
water pill that will help keep fluid out of your lungs and
improve your breathing, which can happen with heart failure. It
is vital that you take these medications every day - do not stop
any of them unless you discuss this with Dr. ___.
DO NOT start any new medications, herbs or supplements until
you consult with Dr ___. Many of these medications
can interact poorly with the medications you are already taking
and worsen your heart disease.
It is unclear what has caused your heart failure. All of the
blood tests that can detect a specific cause have been negative.
You did report you had a viral illness several months ago; this
can be a cause. In addition, alcohol consumption can cause this
as well. You must avoid ALL alcohol on discharge. Also please
avoid caffeine intake until you follow up with Dr ___
___.
You will continue to follow-up with the Heart Failure service
with Dr ___ NP ___. They will optimize your
medications and monitor your heart function.
Weigh yourself every morning after voiding, call Dr. ___
___ if your weight goes up more than 2 lbs in a day,
or you notice your weight increases by 3 pounds over 3
consecutive days.
It was a pleasure taking care of you, Mr ___.
Followup Instructions:
___
|
19808487-DS-22
| 19,808,487 | 29,124,262 |
DS
| 22 |
2162-03-01 00:00:00
|
2162-03-02 11:42:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered Mental Status, Abnormal Labs.
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ year old male with history of HIV on HAART
therapy, Afib, peripheral artery disease, hypertension, and
diabetes mellitus type II, presenting for laboratory
abnormalities at rehab concerning for acute renal failure.
Patient is being admitted to the MICU for further management of
his acute renal failure.
Patient was recently admitted for 10 day stay, and discharged
on ___ (3 days prior to his admission) to rehab. Patient was
initially admitted to the vascular surgery service for
non-healing right plantar ulcer, and underwent procedure.
During his hospital stay, patient underwent cannulation and
access of his left common femoral artery and placement of a
___ sheath, catheter placement of right external iliac
artery, abdominal aortogram, and right lower extremity
angiogram. He also underwent on ___ debridement of his
right foot with resection of the remnant ___ metatarsal, vein
graft, and full thickeness skin graft of 6x5 cm over the wound.
During the procedure, there is no notation of low blood
pressure or other hemodynamic instabilities. He underwent an ALT
flap to the right foot, FTSG to right dorsal foot surface, and
handsewn arterial anastomosis end to end to distal DP. A vein
graft required left medial thigh saphenous branch graft and two
coupled anastomoses. A dangle protocol was done and tolerated
well. During procedure, patient did have a 10 point hematocrit
drop and was transfused 1 unit pRBC. Patient also was started on
ciprofloxacin for a presumed UTI, and given MSSA and mixed
bacterial flora in the OR culture, he was seen by ID and started
on cefazolin with OPAT. Patient was also restarted on his
pradaxa on POD#4.
Patient was discharged to rehab, and patient did not have labs
drawn upon discharge for renal function. Patient was discharged
on ___, and last electrolytes obtained on ___, which showed
discharged CR BUN ___. Patient was at rehab, found to have
increasingly altered mental status, and labs initially
concerning for elevated BUN / Cr, and therefore was sent to
___ for further evaluation.
#In the ED, initial vitals: 97.8 85 93/36 18 99% RA. Patient
was then found to be hypotensive to 68/41, and was started on
IVF and norepinephrine for hypotension. Patient's initial exam
was non-focal, however patient was found to not be following
commands. Patient's labs were c/f K 5.2, BUN 113 / 8.1, CK 61,
Phosph 8.6, Mag 4.7, Calcium 7.4. INR 13.4, PTT 150. Lactate
2.4.
Patient was evaluated by renal, who advised foley catheter
placement, urine studies. Patient had initial u/a with RBC, WBC
44, Protein 30, Mod leuk, Large blood. Patient also evaluated by
vascular surgery, without acute intervention. Imaging obtained
was CT abdomen with mild fullness, mild hydronephrosis of the
right renal collecting, atrophic pancreas, no RP hematoma,
anasarca, and dilated loops of the proximal small bowel with
likely partial or early complete SBO. Patient also had a CT head
without abnromalitiy, and CXR obtained, and cultured.
Patient was given
___ 17:45 IVF 1000 mL NS
___ 18:28 IV Piperacillin-Tazobactam 4.5 g
___ 18:51 IV DRIP Norepinephrine Started 0.03 mcg/kg/min
___ 19:06 IV Vancomycin 1000 mg
___ 19:06 IV DRIP Norepinephrine Rate Changed to 0.06
mcg/kg/min
___ 19:27 IV Dextrose 50% 25 gm
___ 19:27 IVF 1000 mL NS 1000 mL
___ 19:27 IVF 1000 mL NS 1000 mL
___ 19:27 IVF 1000 mL NS 1000 mL
On transfer, vitals were: 66 86/50 17 98% RA
On arrival to the MICU, patient was alert and oriented x 2.
Patient denied any complaints at this time. He was complaining
of some leg pain where a former drain was done.
Review of systems:
(+) Per HPI
Past Medical History:
1. Atrial Fibrillation
2. Aortic Stenosis s/p AVR (bioprosthetic)
3. Hypertension
4. Dyslipidemia
5. IDDM Type II
6. HIV on HAART
7. PCP ___
8. Chronic Pancreatitis
9. Hepatitis B
PSH:
1. AVR ___ Tissue Valve).
2. Left foot podiatric Surgery.
Social History:
___
Family History:
Mother: passed at age ___, aortic aneurysm
Sister: healthy
Physical ___:
ADMISSION PHYSICAL EXAM:
Vitals: T: afebrile BP: 110s/50s P: 80s R: 18 O2: 98% on RA
GENERAL: Alert, oriented to self/place/president, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregular rhythm, regular rate, no murmurs appreciated
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: WWP, no peripheral edema, R-sided amputation.
DISCHARGE PHYSICAL EXAM
Vitals: T: 97.5 BP: 127/54 (127-153/64-95) P: 64 (64-95) R: 20
O2:99RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, PERRL, EOMI, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Irregularly irregular with systolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: no clubbing, cyanosis or edema. Pulses not palpable in
lower extremities bilaterally. RLE amputation site appears pink
and well-perfused; lower right leg shows chronic venous stasis
hyperpigmentation.
Skin: Left thigh has medial and lateral incision sites covered
with bandage. Unstageable pressure ulcer on lower middle back.
MSK: Moves all extremities. No paraspinal tenderness.
Neuro: Oriented to own name, place, date, birthday, and
situation. Diminished sensation on lower right leg compared to
left leg.
Labs: see below
Imaging and studies: see below
Pertinent Results:
ADMISSION LABS
========================
___ 05:40PM BLOOD WBC-14.3* RBC-3.06* Hgb-8.6* Hct-27.2*
MCV-89 MCH-28.1 MCHC-31.6* RDW-14.8 RDWSD-48.3* Plt ___
___ 05:40PM BLOOD Neuts-69 Bands-12* Lymphs-11* Monos-5
Eos-3 Baso-0 ___ Myelos-0 AbsNeut-11.58*
AbsLymp-1.57 AbsMono-0.72 AbsEos-0.43 AbsBaso-0.00*
___ 05:40PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-NORMAL Ovalocy-1+
___ 06:39PM BLOOD ___ PTT-150* ___
___ 09:50PM BLOOD ___ Thrombn-150*
___ 05:40PM BLOOD Glucose-62* UreaN-113* Creat-8.1*#
Na-132* K-5.2* Cl-93* HCO3-19* AnGap-25*
___ 05:40PM BLOOD ALT-1 AST-25 CK(CPK)-61 AlkPhos-107
TotBili-0.1
___ 05:40PM BLOOD Albumin-2.8* Calcium-7.4* Phos-8.6*#
Mg-4.7*
___ 09:50PM BLOOD calTIBC-208 Ferritn-181 TRF-160*
___ 09:50PM BLOOD CRP-33.4*
___ 09:50PM BLOOD Digoxin-1.3
___ 05:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:16PM URINE Color-DKMB Appear-Hazy Sp ___
___ 06:16PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
___ 06:16PM URINE RBC->182* WBC-44* Bacteri-FEW Yeast-NONE
Epi-0
SIGNIFICANT LABS
========================
___ 02:52AM BLOOD ___ PTT-144.6* ___
___ 05:50AM BLOOD ___ PTT-33.4 ___
___ 09:50PM BLOOD ___ Thrombn-150*
___ 09:50PM BLOOD Ret Aut-2.63* Abs Ret-0.0800
___ 05:40PM BLOOD Glucose-62* UreaN-113* Creat-8.1*#
Na-132* K-5.2* Cl-93* HCO3-19* AnGap-25*
___ 05:50AM BLOOD Glucose-143* UreaN-16 Creat-1.0 Na-146*
K-4.1 Cl-111* HCO3-25 AnGap-14
___ 02:52AM BLOOD ALT-0 AST-18 LD(LDH)-321* AlkPhos-94
TotBili-0.1
MICROBIOLOGY
========================
__________________________________________________________
___ 8:37 am SWAB Source: L medial thigh incision.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 9:54 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
__________________________________________________________
___ 10:10 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 2:52 am BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:00 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 6:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:16 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 5:42 pm
BLOOD CULTURE
Blood Culture, Routine (Pending):
RADIOLOGY
========================
___ CXR
IMPRESSION:
Low lung volumes with probable bibasilar atelectasis.
___ CT ABD PELVIS W/O CON
IMPRESSION:
1. Limited evaluation without IV contrast and with the patient's
arms down
causing significant streak artifact in the upper abdomen.
2. Dilated loops of proximal small bowel with apparent
transition zone in the left upper hemipelvis and relatively
collapsed loops distally. Gas and stool remains in the colon.
Findings may reflect a partial small bowel obstruction.
3. Mild hydronephrosis and proximal hydroureter on the right
without evidence of urolithiasis. This could be further
evaluated with MRU if clinically indicated.
4. The pancreas is severely atrophic with numerous scattered
calcifications compatible with chronic pancreatitis.
5. No retroperitoneal hematoma. The abdominal aorta is normal
in caliber with scattered atherosclerosis.
6. Mild anterior height loss of T12, new since at least ___.
7. Trace left pleural effusion. Anasarca.
8. Small fat and fluid containing left inguinal hernia.
DISCHARGE LABS
=========================
___ 05:46AM BLOOD WBC-11.2* RBC-2.82* Hgb-7.9* Hct-25.8*
MCV-92 MCH-28.0 MCHC-30.6* RDW-15.5 RDWSD-48.7* Plt ___
___ 05:46AM BLOOD Plt ___
___ 05:46AM BLOOD Glucose-245* UreaN-11 Creat-0.8 Na-139
K-3.7 Cl-106 HCO3-26 AnGap-11
___ 05:46AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.6
Brief Hospital Course:
In short, Mr. ___ had previously been hospitalized, d/c'd on
___ (admitted to ___ surgery) for a non-healing ulcer. During
his stay he received several procedures includign abdominal
aortogram and RLE angiogram. He also underwent surgical
debridement of his right foot with resection of the ___
metatarsal, vein graft, and full thickness skin graft 6x5 cm
over the wound on ___ the procedure was notable for a 10pt
Hct drop and was transfused 1 unit pRBC. He was subsequently
started on ciprofloxacin for a presumed UTI and cefazolin w/OPAT
after MSSA and mixed bacterial flora were seen on OR culture. He
was restarted on Pradaxa for A-fib on ___. He was discharged
to rehab on ___ (3 days prior to current admission). His last
renal function labs taken on ___ showed BUN Cr ___. Three
days later in rehab, the patient was found to have altered
mental status and labs concerning for elevated BUN/Cr (Cr
reportedly 7.5).
In the ED he was found to be hypotensive to 68/41 and was
started on IVF and norepi. Patient's neuro exam was non-focal
but he could not follow commands. Labs c/f K 5.2, BUN 113 / 8.1,
CK 61, Phosph 8.6, Mag 4.7, Calcium 7.4. INR 13.4, PTT 150.
Lactate 2.4. He was evaluated by renal, and a foley was placed
with U/A showing RBC, WBC 44, Protein 30, Mod leuk, Large blood.
CT abdomen showed mild fullness, mild hydronephrosis of the
right renal collecting, atrophic pancreas, no RP hematoma,
anasarca, and dilated loops of the proximal small bowel c/w with
likely partial or early complete SBO.
Patient was subsequently bolused ___. He was also given IV
Zosyn, Vanc, and norepinephrine (0.06). He was transferred to
the MICU, where he has been hemodynamically stable and afebrile.
His UOP has gradually increased and his Cr has fallen. On ___
his INR was found to be 17 and he was given 10mg vit K. On ___
INR had dropped to 1.6, Cr was down to 2.2 and UA was positive
for 18 WBC and >182 RBC. His pradaxa was held given his elevated
INR. The etiology of the coagulopathy is unknown, even though
pradaxa is renally excreted, it is very strange that it could
build up to high enough levels during renal failure to cause
such a profound coagulopathy. Having said this, with the
patient's normalization of his INR, his pradaxa was restarted on
___. Plastics evaluated his RLE and noted a fluid collection
in medial thigh that they opened up today at bedside today and
sent for culture. The wound sites showed no signs of infection
per their report and antibiotics were stopped on ___. Mr.
___ MICU stay has also been notable for some confusion,
loose BM starting on ___ (c.diff negative; tx w/loperamide),
and nausea (tx w/Zofran).
The patient was also found to be anemic with his baseline Hgb
reported to be around 10; his hgb is currently stable at 8.8
today (was 8.6 on admission). Anemia could be multifactorial and
related to blood loss possibly related to hematuria in setting
of coagulopathy or due to intraoperative blood loss. No evidence
of GI bleed, no RP bleed on CT. Furthermore, reticulocyte count
on ___ were c/w inadequate Epo response, possibly c/w acute
renal failure. Latest serum iron on ___ showed iron of 6 (TIBC
low at 208, transferrin low at 160, ferritin WNL) His MCV on
transfer was WNL at 93. RBC morphology studies on ___ were
WNL. His pradaxa was restarted once his renal function returned
to baseline.
Since his transfer from the MICU, the patient was never febrile
and the wound and other cultures remained negative.
# Osteomyelitis. He was continued on cefazolin for osteomyelitis
s/p amputation, and will need a 6 week course ___ -
___ (6 weeks therapy))
# ___ retention. Cr normalized to 0.8 on ___. On the
day of discharge; voiding trial was attempted, but unsuccessful.
He required replacement of his Foley. Finasteride and tamsulosin
were restarted. Patient will follow up with urology as
outpatient. During this hospitalization, his medications were
all renally dosed and then returned to his previous dossing with
normalization of the patient's GFR.
# Delirium. Mental status returned to baseline since discharge
from MICU.
# Atrial fibrillation s/p bioprosthetic AVR. Was restarted on
home digoxin and diltiazem. Dabigatran was restarted after INR
normalized.
# Hypertension. Lisinopril and furosemide were held in the
setting of hypotension; with a plan to restart as outpatient.
#HIV/AIDs on HAART. Hx of PCP ___ was continued on home
HAART therapy.
TRANSITIONAL ISSUES
[] Will require urology follow up for BPH and Foley removal
(scheduled)
[] Please check weekly CBC w/ diff, BUN, ESR/CRP while on
cefazolin
[] Please consider restarting lisinopril and furosemide
[] Metoprolol succinate was restartd at a lower dose; please
uptitrate as needed
[] Please follow up with OPAT/ID for continued surveillance of
osteomyelitis. Continue cefazolin, planned course: ___ -
___
[] Please uptitrate gabapentin to 600 TID (preadmission dose)
for control of pain, slowly as to not cause somnolence.
[] Pt's insulin dose was decreased to lantus 15u daily. This may
require continued uptitration, goal FSs 150s-200s.
Wound care:
Site: RLE
Patient may 'dangle' the RLE for 30 minutes TID. The dangle
periods may be used for bathroom use and getting OOB to chair.
Non-weight bear on RLE. Please apply aquaphor ointment to RLE
daily (over surgical sites).
.
Sacral pressure ulcer: after cleansing, cover wound with Mepilex
sacrum foam dressing. Change every three days and prn
[] CONTACT: ___ at ___; PCP ___
___ RN ___ ___ proxy is ___ in ___
also his sister
[] CODE STATUS: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 300 mg PO BID
2. Acetaminophen 650 mg PO Q6H
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 20 mg PO QPM
5. CefazoLIN 2 g IV Q8H
6. Creon 12 3 CAP PO TID W/MEALS
7. Dabigatran Etexilate 150 mg PO BID
8. Digoxin 0.25 mg PO DAILY
9. Diltiazem Extended-Release 180 mg PO BID
10. Docusate Sodium 100 mg PO BID
11. Etravirine 200 mg PO BID
12. Furosemide 40 mg PO DAILY
13. Gabapentin 600 mg PO TID
14. LaMIVudine 150 mg PO DAILY
15. Metoprolol Succinate XL 100 mg PO BID
16. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain-
moderate
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Raltegravir 400 mg PO BID
19. Senna 8.6 mg PO BID:PRN constipation
20. Simethicone 40-80 mg PO QID:PRN gas pain
21. Lisinopril 5 mg PO DAILY
22. Glargine 42 Units Breakfast
Insulin SC Sliding Scale using UNK Insulin
Discharge Medications:
1. Abacavir Sulfate 300 mg PO BID
2. Acetaminophen 650 mg PO Q6H
3. Creon 12 3 CAP PO TID W/MEALS
4. Dabigatran Etexilate 150 mg PO BID
5. Docusate Sodium 100 mg PO BID
6. Etravirine 200 mg PO BID
7. LaMIVudine 150 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Raltegravir 400 mg PO BID
10. Senna 8.6 mg PO BID:PRN constipation
11. LOPERamide 2 mg PO QID:PRN diarrhea
12. Tamsulosin 0.4 mg PO QHS
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 20 mg PO QPM
15. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain-
moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*42 Tablet Refills:*0
16. Simethicone 40-80 mg PO QID:PRN gas pain
17. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
18. CefazoLIN 2 g IV Q8H
___ - ___
19. Outpatient Lab Work
ICD-10: Acute Osteomyelitis
Draw every ___: WEEKLY: CBC with differential, BUN, Cr,
ESR/CRP, INR
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
All questions regarding outpatient parenteral antibiotics after
discharge should be directed to the ___ R.N.s at
___ or to the on-call ID fellow when the clinic is
closed.
20. Metoprolol Succinate XL 100 mg PO DAILY
21. Gabapentin 300 mg PO TID
22. Finasteride 5 mg PO DAILY
23. Digoxin 0.25 mg PO DAILY
24. Diltiazem Extended-Release 180 mg PO BID
25. Lorazepam 0.25 mg PO Q4H:PRN anxiety
RX *lorazepam 0.5 mg 0.5 (One half) tablet by mouth every four
hours Disp #*42 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Acute Renal Failure
Atrial Fibrilation
Altered Mental Status
Anemia
Secondary Diagnosis
HIV/AIDS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you while in the hospital. You
came to the hospital because of confusion. You were found to be
in kidney failure. This was attributed to an obstruction,
preventing urine from emptying out of your bladder. You required
a stay in the ICU to normalize your kidney function. During this
time, you were at very high risk of bleed and your blood
thinning medication was held. Once your kidney function returned
to normal, we restarted your medications. We also started you on
a medication to prevent your bladder from becoming obstructed.
Your medications and follow up appointments are detailed bellow.
We wish you the best!
Your ___ care team
Followup Instructions:
___
|
19808744-DS-10
| 19,808,744 | 23,495,682 |
DS
| 10 |
2180-11-03 00:00:00
|
2180-11-23 06:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with PMH as noted, with three week h/o low back pain, L
leg pain, and one week h/o L ankle pain. Pt previously treated
with several day course of oral steroids (pred 40 mg daily) with
improvement (completed ___, but since then has been managing
conservatively. She has seen ___ but has increased pain with ___.
Pain is in left lumbar region with radiation down L leg, burning
sensation. Has had increased L ankle pain for the week prior to
admission, no trauma. She has been crawling for the three days
prior to admission. On the day of admission, alarm went off -
she "dragged myself down the stairs" and police arrived. She
called her daughter, who brought her to the ED. In the ED,
neurosurgery team recommended L-spine MRI and pain control, but
patient has pacer. Pt received diazepam 5 mg with improvement,
along with acetaminophen 1000 mg. However, she states that the
diazepam made her feel unwell, and she would prefer to try
flexeril. She is hesitant to take NSAIDS given prior PUD. Her
apixaban was dosed at 3:10 pm. She was admitted for further
care.
On admission, she feels well, with no current pain. She states
that her ankle pain is the most severe pain.
Past Medical History:
Sick sinus s/p pacer
Pacer details: Date of Implant: ___
Indication: ___
Device brand/name: ___
Model Number:2240
HTN
CHF
Gastric ulcer (NSAID related)
h/o melanoma
Social History:
___
Family History:
FAMILY HISTORY: Mom with ulcers. No history of colon or other
cancer.
Physical Exam:
ADMISSION:
Physical Exam: afeb 123/74 61 18 95% (RA)
GENERAL: NAD
Mentation: Alert, speaks in full sentences
Eyes: NC/AT
Ears/Nose/Mouth/Throat: MMM
Neck: Supple
Resp: CTA bilat
CV: RRR, normal S1S2
GI: Soft, NT/ND, normoactive bowel sounds
Skin: No rash
Extremities: No edema
Neuro:
- Mental Status: Alert & oriented x3. Able to relate history
without difficulty
-Motor: Normal bulk, strength and tone throughout. No abnormal
movements noted. Able to sit up without difficulty, can bend L
knee to 100 degrees without difficult. LLE ___ strength
___
Spine - nontender
L ankle- No ecchymoses; nontender. Can flex/extend without
difficulty
DISCHARGE:
___ 0815 Temp: 98.2 PO BP: 133/70 HR: 80 RR: 18 O2 sat: 94%
O2 delivery: RA
GENERAL: NAD
Mentation: pleasant woman in NAD at rest in bed.
Eyes: NC/AT
Ears/Nose/Mouth/Throat: MMM
Neck: Supple
Resp: CTA bilat
CV: RRR, normal S1S2
GI: Soft, NT/ND, normoactive bowel sounds
Skin: No rash
Extremities: No edema
Neuro: no facial droop, ___ strength through b/l ___ including
ankle flex/dorisflex, hip flexion, knee extension, gait
deferred.
+ mild lumbar vertebral tenderness, no paraspinal muscle
tenderness.
Pertinent Results:
LABS:
====
___ 10:50AM BLOOD WBC-12.2* RBC-4.19 Hgb-13.2 Hct-39.0
MCV-93 MCH-31.5 MCHC-33.8 RDW-13.2 RDWSD-45.3 Plt ___
___ 04:55AM BLOOD WBC-7.2 RBC-3.86* Hgb-12.1 Hct-36.6
MCV-95 MCH-31.3 MCHC-33.1 RDW-13.2 RDWSD-45.6 Plt ___
___ 10:50AM BLOOD Glucose-119* UreaN-11 Creat-0.7 Na-141
K-4.1 Cl-103 HCO3-25 AnGap-13
IMAGING:
======
___ CXR
IMPRESSION:
Pacemaker leads terminate in right atrium and right ventricle.
Heart size and
mediastinum are stable. Lungs are clear. There is no
appreciable pleural
effusion. There is no pneumothorax
___ L ankle plain film
Impression:
No acute fracture or dislocation.
Brief Hospital Course:
___ with SSS s/p PPM on apixiban, ___, PUD, and known DJD who
presents with acute worsening of low back pain with radiation
down the leg.
Based on ___ CT, patient with extensive DJD at L4-S1, remains
neurologically intact but with worsening pain limiting function.
CT noted lateral disc protusion with compression of L5,
consistent with patient's distribution of pain. Additionally, CT
noted perineural S2 lesion likely cyst but cannot exclude nerve
sheath tumor and thus MRI recommended. She was seen by Spine
surgery who felt there was no emergent process warranting urgent
surgical intervention. Recommended MRI. Due to PPM, clearance
was obtained from Cardiology. Unfortunately, unable to get MRI
___. After discussing with patient and family, plan for
ongoing conservative management with symptom control, outpatient
pain clinic, and outpatient scheduled MRI. Outpatient providers
contacted via email to coordinate ongoing care.
TRANSITIONAL ISSUES:
=================
Recommend MRI to further evaluate perineural S2 lesion, likely
cyst but cannot exclude neural sheath tumor.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Atorvastatin 20 mg PO QAM
3. Metoprolol Succinate XL 50 mg PO BID
4. Omeprazole 40 mg PO QHS
5. Torsemide 60 mg PO QAM
6. Verapamil SR 240 mg PO QAM
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Cyclobenzaprine 10 mg PO HS:PRN moderate pain
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth at bedtime Disp
#*20 Tablet Refills:*0
3. TraMADol ___ mg PO Q6H:PRN Pain - Severe
RX *tramadol 50 mg 0.5 to 1 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
4. Apixaban 5 mg PO BID
5. Atorvastatin 20 mg PO QAM
6. Metoprolol Succinate XL 50 mg PO BID
7. Omeprazole 40 mg PO QHS
8. Torsemide 60 mg PO QAM
9. Verapamil SR 240 mg PO QAM
Discharge Disposition:
Home
Discharge Diagnosis:
# Lumbar radiculopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege to care for you at the ___
___. You were admitted with back and leg pain that is
due to a herniated disc in your spine. You were evaluated by our
spine surgeons who luckily feel that there is no emergency
requiring surgical intervention. It is very reasonable to try a
conservative management approach. This will including giving you
medications to treat your symptoms, seeing the Pain doctors on
___, and coordinating an outpatient MRI in case this approach
does not work and you need further evaluation by the Spine team.
Please only take the flexeril at night as this can make you very
sleepy. You are also being provided a prescription for a
medication called tramadol that you can take in the daytime for
pain, but this sometimes makes people drowsy as well. Please
make sure you are very cautious until you know how these
medications affect you.
Following discharge I will be reaching out to Dr. ___ to
coordinate the next steps. Again, it is very important to go to
your visit with her on ___ ___s visit the pain clinic
visit arranged for ___ as well.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19809002-DS-6
| 19,809,002 | 22,341,699 |
DS
| 6 |
2164-02-24 00:00:00
|
2164-02-27 06:46:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
___ with a history of reflux who
presents with RUQ pain which started at 1 am this morning. The
pain was sharp and associated with nausea and non-bloody emesis
x4. He initially tried tums and went back to sleep but again
awoke with severe pain. He has been having issues with
constipation for the past several days but did have a small
bowel
movement this morning. He last ate last night.
At the time of my evaluation he says his pain is improved, but
is
still present. He has no nausea at this time. He has no fevers
or
chills.
Past Medical History:
Past Medical History:GERD
Past Surgical History:None
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: 96.6 69 128/85 18 98RA
GEN: A&O, NAD
CV: RRR, No M/G/R
PULM: non-labored on RA
ABD: Soft, mildly distended. Mildly TTP RUQ.
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.2, 153/91, 89, 18, 94%RA
Gen: A&O x3, lying comfortably in bed
CV: HRR
Pulm: LS ctab
Abd: soft, appropriately TTP around incisions. Lap sites CDI.
Ext: WWP no edema
Pertinent Results:
Laboratory:
___ 05:12AM BLOOD WBC: 11.2* RBC: 4.60 Hgb: 14.3 Hct: 41.2
MCV: 90 MCH: 31.1 MCHC: 34.7 RDW: 11.8 RDWSD: 37.___
___ 05:12AM BLOOD Glucose: 126* UreaN: 16 Creat: 0.9 Na:
142
K: 4.3 Cl: 105 HCO3: 23 AnGap: 14
___ 05:12AM BLOOD ALT: 30 AST: 24 AlkPhos: 76 TotBili: 0.3
___ 05:12AM BLOOD Albumin: 5.2 Calcium: 10.3 Phos: 3.3 Mg:
2.0
Post-Op Labs:
___ 07:10AM BLOOD WBC-11.5* RBC-4.42* Hgb-13.7 Hct-39.9*
MCV-90 MCH-31.0 MCHC-34.3 RDW-12.1 RDWSD-39.2 Plt ___
___ 07:10AM BLOOD Glucose-96 UreaN-10 Creat-0.9 Na-145
K-4.2 Cl-104 HCO3-25 AnGap-16
___ 07:10AM BLOOD ALT-79* AST-47* AlkPhos-75 TotBili-0.7
___ 07:10AM BLOOD Calcium-9.7 Phos-4.4 Mg-2.0
Imaging:
US:
IMPRESSION:
Cholelithiasis without evidence of acute cholecystitis. Of note,
there is a 1.7 cm stone at the gallbladder neck.
Brief Hospital Course:
The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound revealed cholelithiasis without
evidence of acute cholecystitis. The patient underwent
laparoscopic cholecystectomy, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating liquids, on IV fluids,
and oral analgesia for pain control. The patient was
hemodynamically stable.
Pain was well controlled. POD1, the patient experienced an
episode of intense abdominal muscle spasms that were relieved
with flexeril and Ativan. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient and his wife received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Cyclobenzaprine 10 mg PO ONCE Duration: 1 Dose
RX *cyclobenzaprine 10 mg 1 tablet(s) by mouth once a day Disp
#*1 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
4. LORazepam 0.5 mg PO ONCE Duration: 1 Dose
RX *lorazepam 0.5 mg 1 tab by mouth once a day Disp #*1 Tablet
Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*5 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*14 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Cholelithiasis
Biliary colic
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 biliary colic. 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:
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:
___
|
19809073-DS-21
| 19,809,073 | 22,480,977 |
DS
| 21 |
2196-02-18 00:00:00
|
2196-02-18 16:40:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, respiratory symptoms
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with hx of AML s/p chemo and allo SCT ___ years c/b GVHD of
lungs and liver which have resolved with immunosuppresion
presents with fever, rash, URI symptoms.
Reports that starting two months ago, he has had on and off URI
symptoms (chest and nasal congestion). On ___, he was returning
home from dinner and felt lightheaded with 'spotted' vision,
diaphoresis, and slowly fell to the floor. No trauma and no LOC.
He crawled into the house and the symptoms resolved after ___
minutes. No cp, palpitations, confusion, urine/bowel
incontinence. Reports feeling dehydrated especially because he
played hockey for 90 minutes the night before. His wife took him
to ___ where he had an extensive
evaluation including CTA, EKG, CXR, heart monitor which were all
normal. He was discharged on ___. On ___, he also had chest
congestion, nasal congestion, rhinorrhea, mild sore throat and
bilateral eye erythema with yellowish discharge. On ___, he
developed a cough with productive green phlegm. He also noted a
rash on ___ around his bilateral ankle that was non-pruritic
and non-tender. Also developed a fever to 102 and went to see
his PCP. Patient was started on azithromycin which he took for
one days. He called Dr. ___ on ___ regarding his
symptoms and was instructed to come in to the ED.
In the ED, initial vitals were 97, 124/68, 80, 16, 95% RA. He
had a CXR which showed RLL pneumonia and he was started on
levofloxacin. He was admitted for further evaluation.
This morning, he continues to complain of chest, nasal
congestion, productive sputum, and rhinorrhea. No eye
pain/pruritus, loss of vision, neck pain, penile discharge, sob,
cp. +waking up with his eyes glued shut. +mild sore throat. No
recent travel. Two cats at home and no other pets. Does part
time writing and works with elementary school children. Up to
date with his vaccines post allo SCT.
Review of Systems:
(+) Per HPI.
Denies chills, night sweats, headache, vision changes, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
-AML diagnosed ___ s/p M6-FAB, s/p induction chemotherapy with
3 days of idarubicin and seven days of continuous infusion of
ARA-C, then s/p allogeneic transplant from a sibling donor with
busulfan and Cytoxan conditioning in ___. His course was
complicated by presumed graft versus host disease of the lung
and liver, both of which resolved with immune suppression.
-AAA, stable at 4.2 cm
-attention symptoms
-degenerative disk disease
-right inguinal hernia
-tonsillectomy as a child
Social History:
___
Family History:
Mother w/blood disease (not cancer) and followed by a
hemato___. Also with atrial fibrillation. Father died in a
plane crash at age ___. His grandfather died of leukemia in his
___.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS - 98.9, 125/81, 80, 17, 94% RA, weight 166.4 lbs
General: well appearing male, NAD, pleasant
HEENT: PERRL, EOMI, conjunctiva with diffuse erythema and yellow
discharge/crusting, no photophobia. Dried mucus noted on nasal
passages. OP clear. Mild sinus tenderness R>L.
Neck: supple, no LD, no thyromegaly, no meningeal signs
Lungs: R basilar crackles, no accessory muscle use, no
wheezes/rhonchi
CV: RRR, no m/g/r
Abdomen: +BS, soft, NT, ND, no hepatomegaly appreciated
Ext: wwp, 2+ pedal pulses. Petechial, non-blanchable rash in b/l
medial side of ankles with some lesions spreading to the
leg/feet. Non-tender to palpation. no c/c/e. Negative kernig and
brudzinski.
Neuro: A&Ox3, CN II-XII grossly intact
DISCHARGE PHYSICAL EXAM
VITALS - Tm 98.1, Tc 97.8, 118/84 (118-131/73-84), 68 (66-79),
18, 95-97% RA, weight 166.4
General: well appearing male, NAD, pleasant
HEENT: conjunctiva with much improved diffuse erythema without
discharge/crusting, no photophobia. OP clear. Mild sinus
tenderness R>L
Lungs: R basilar crackles stable from yesterday, no accessory
muscle use, no wheezes/rhonchi
CV: RRR, no m/g/r
Abdomen: +BS, soft, NT, ND, no hepatomegaly appreciated
Ext: wwp, 2+ pedal pulses. Petechial, non-blanchable rash in b/l
medial side of ankles with some spread to mid-leg and b/l feet.
Non-tender to palpation. no c/c/e.
Neuro: A&Ox3, CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS
___ 07:20PM BLOOD WBC-12.4*# RBC-4.29* Hgb-15.2 Hct-44.6
MCV-104* MCH-35.4* MCHC-34.1 RDW-12.3 Plt ___
___ 07:20PM BLOOD Neuts-82.6* Lymphs-9.8* Monos-6.1 Eos-0.3
Baso-1.2
___ 07:20PM BLOOD Glucose-98 UreaN-21* Creat-1.0 Na-139
K-4.2 Cl-98 HCO3-25 AnGap-20
___ 06:40AM BLOOD ALT-55* AST-41* AlkPhos-93 TotBili-0.6
___ 07:20PM BLOOD Calcium-9.8 Phos-3.1 Mg-2.1
___ 07:34PM BLOOD Lactate-1.1
DISCHARGE LABS
___ 07:20AM BLOOD WBC-6.8 RBC-3.67* Hgb-13.0* Hct-37.6*
MCV-102* MCH-35.3* MCHC-34.6 RDW-12.7 Plt ___
___ 07:20AM BLOOD Neuts-73.9* ___ Monos-5.2 Eos-1.5
Baso-0.7
___ 07:20AM BLOOD Glucose-101* UreaN-17 Creat-0.9 Na-140
K-4.2 Cl-104 HCO3-28 AnGap-12
___ 07:20AM BLOOD ALT-58* AST-37 LD(LDH)-135 AlkPhos-89
TotBili-0.5
___ 07:20AM BLOOD Calcium-9.2 Phos-3.0 Mg-1.9
___ 07:20AM BLOOD VitB12-1337* Folate-15.6
___ 06:40AM BLOOD IgG-834
PENDING LABS
___ 07:40AM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODIES (IGG,
IGM)-PND
___ 04:45PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODIES (IGG,
IGM)-PND
URINE
___ 07:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:30PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 07:30PM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
MICRO
___ 5:12 pm SPUTUM Site: INDUCED Source: Induced.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 7:58 pm URINE Site: CLEAN CATCH Source: ___.
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
___ 4:00 pm THROAT FOR STREP
R/O Beta Strep Group A (Final ___:
NO BETA STREPTOCOCCUS GROUP A FOUND.
___ 4:45 pm IMMUNOLOGY N.
HIV-1 Viral Load/Ultrasensitive (Final ___:
HIV-1 RNA is not detected.
___ MONOSPOT (Final ___:
NEGATIVE by Latex Agglutination.
___ 2:40 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Inadequate specimen for respiratory viral culture.
PLEASE SUBMIT ANOTHER SPECIMEN.
Respiratory Viral Antigen Screen (Final ___:
Greater than 400 polymorphonuclear leukocytes;.
Specimen inadequate for detecting respiratory viral
infection by DFA
testing.
PENDING MICRO
___ 4:00 pm SWAB
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Pending):
Chlamydia trachomatis, Nucleic Acid Probe, with Amplification
(Pending):
___ BLOOD CULTURE Blood Culture, Routine-PENDING
___ BLOOD CULTURE Blood Culture, Routine-PENDING
IMAGING
___ CXR
The lungs are hyperinflated with flattening of the diaphragms
suggestive of COPD. Heart size is normal. The aorta remains
aneurysmally dilated and tortuous, unchanged. Pulmonary
vascularity is not engorged. Ill-defined patchy opacity within
the right lower lobe is concerning for pneumonia, and is new
compared to the prior exam. Left lung is clear. No pleural
effusion or pneumothorax is identified. Posttraumatic changes
of the right acromioclavicular joint are re- demonstrated.
There are no acute osseous abnormalities.
IMPRESSION:
Right lower lobe pneumonia. Follow up radiographs after
treatment are
recommended to ensure resolution of this finding.
Brief Hospital Course:
___ M with hx of AML s/p allogeneic stem cell transplant ___
years ago c/b GVHD of liver and lung that resolved with
immunosuppresion presents with URI symptoms, fever, rash, and
conjunctivitis for 5 days and found to have RLL pneumonia.
# RLL pneumonia: most likely CAP as he is not neutropenic and
only spent one day at an OSH hospital. O2 saturations are high
___ at RA and remained afebrile throughout his hospitalization.
He had mild leukocytosis on admission that resolved by
discharge. Legionella antigen negative. Mycoplasma antibodies
pending. Treated with levofloxacin for a 7 day course.
# Viral syndrome: Likely explains the conjunctivitis, sinusitis,
URI symptoms and petechial rash. Per report, he has had multiple
viral infections recently. HIV viral load was negative. He had
mild transaminases on admission that trended down by discharge.
A monospot to test for mononucleosis was negative. Strep test
was negative. Urine and blood cultures with no growth to date. A
nasopharyngeal viral swab was ordered but was unable to be
interpreted. GC/chlamydia swab pending at discharge.
# viral conjunctivitis: most likely viral given that is
bilateral with no photophobia, pain, pruritus, or visual loss.
Improving by discharge.
# Petechial rash on b/l lower extremity: likely secondary to
viral syndrome. Platelets are normal. GVHD would be less likely
given that he is ___ years from his transplant.
# presyncope: per patient, workup at OSH (CTA, EKG, heart
monitor) was negative. Probably vasovagal in the setting of
recent dehydration after playing hockey as patient had prodrome
without LOC or cardiac symptoms. Monitored on telemetry without
any events. EKG at baseline.
# mild anemia: hct dropping from 44.6 on admission to 37.6 at
discharge with elevated MCV. LDH is normal and thus unlikely to
be hemolysing. Stools were guaic negative. Folate and vitamin
B12 were checked and were in appropriate range.
CHRONIC
# Attention symptoms: reports that he has not taken amphetamine-
dextroamphetamine in a couple of weeks. This medication was held
during his hospitalization.
#AML s/p allogeneic stem cell transplant ___: from a sibling
donor. His disease has been in remission. Has follow up with
Dr. ___ on ___.
TRANSITIONAL ISSUES
-discharged with 7 day course of levofloxacin. Please repeat CXR
in 2 weeks to ensure resolution of pna
-mild anemia with elevated CMV and normal vitB12 and folate,
please recheck CBC
-please follow up with pending blood cxs, mycoplasma antibodies,
GC/chlamydia PCR
-has f/u with PCP ___ ___
# CODE: Full
# EMERGENCY CONTACT: ___ (wife): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amphetamine-dextroamphetamine *NF* 5 mg Oral qAM
2. amphetamine-dextroamphetamine *NF* 10 mg Oral noon
3. budesonide *NF* 180 mcg/actuation Inhalation BID
4. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
5. Multivitamins 1 TAB PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. budesonide *NF* 180 mcg/actuation Inhalation BID
2. Fish Oil (Omega 3) 1000 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. amphetamine-dextroamphetamine *NF* 5 mg Oral qAM
6. amphetamine-dextroamphetamine *NF* 10 mg ORAL NOON
7. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
8. Levofloxacin 750 mg PO DAILY
take for four more days (last day on ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-community acquired pneumonia
-viral illness
-presyncope
SECONDARY:
AML s/p allogeneic SCT
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 stay at ___
___. You were admitted to the
hospital because of pneumonia and a viral illness. You improved
with antibiotics. Please continue to take the antibiotic for 4
more days (last day on ___ and follow up with Dr. ___ Dr.
___.
Please make sure you keep yourself hydrated to prevent feeling
lightheaded. In addition, you should hold off playing hockey
until your symptoms resolve.
Followup Instructions:
___
|
19809088-DS-13
| 19,809,088 | 29,454,852 |
DS
| 13 |
2116-07-13 00:00:00
|
2116-07-13 15:34:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / morphine / Asacol
Attending: ___.
Chief Complaint:
Wound infection s/p ventral hernia repair with mesh 6 months
ago
Major Surgical or Invasive Procedure:
___: Ultrasound guided drainage of fluid collection in the
anterior abdominal wall. 8 ___ catheter was placed to
a JP bulb.
History of Present Illness:
Ms. ___ is a ___ with Past Surgical History notable for
total colectomy ___ years ago, with Lysis of Adhesions for small
bowel obstruction,
8 months ago, complicated by ventral hernia, repaired with mesh
(physio mesh and composite type mesh polypropylene w/Monocryl
coating) 6 months ago at ___. Patient reports that
has required aspiration and drain placement x4, with most
recent drain removed on ___ of last week. On ___
patient spiked fever to 102 and was placed on ciprofloxacin
250mg BID. She has remained afebrile since ___. On ___
patient appreciated erythema and warmth of abdomen as well as
swelling around her incision. Describes buring sensation around
incision, at worst ___ on pain scale, curently ___. Pain
alleviated by lying down, exacerbated by movement. On Review of
systems:
patient denies changes in bowel movements, nausea, vomiting,
shortness of breath
chest pain.
Past Medical History:
Past Medical History:
Collagenous colitis s/p total colectomy
GERD
Post-operative ileus
Arthritis
Asthma (Improved since quitting smoking)
Paroxysmal atrial tachycardia
Hypercholesterolemia
HTN
Past Surgical History:
Total colectomy with end ileostomy and subsequent takedown and
J-Pouch formation ___ years ago. Laparotomy and lysis of
adhesions
for small bowel obstruction- ___
Symptomatic incarcerated abdominal incisional hernia repair with
physio mesh and composite type mesh polypropylene w/Monocryl
coating - ___
Appendectomy (Childhood)
Tonsillectomy
Adenoidectomy
L knee replacement
R ACL repair
Carpal Tunnel release
Social History:
___
Family History:
Sister died of lung cancer
Physical Exam:
Upon Admisson:
Vitals: T 97.2, P 83, BP 152/82, RR 18, SpO2 100%RA
GENERAL: awake and alert.
HEENT: No scleral icterus
CV: Regular sinus rhythm.
PULM: Clear to auscultation bilterally.
ABDOMEN: Midline incision with swelling at distal aspect. Lower
abdomen tender to palpation, two drain sites healing
DRE: Deferred
Extremities: no upper or lower extremity edema. Extremities,
warm and well perfused
Upon discharge:
VITALS: 98.0 84 139/69 20 98RA
GENERAL: Awake and alert.
HEART: Regular sinus rhythm.
LUNGS:no respiratory distress, clear bilaterally.
ABDOMEN:soft, NT, ND, midline incision scar, JP in place with
serosang output
EXTREMITIES: warm well perfused
Pertinent Results:
___ 07:20AM BLOOD WBC-7.4 RBC-4.44 Hgb-13.2 Hct-39.2 MCV-88
MCH-29.8 MCHC-33.7 RDW-12.1 Plt ___
___ 09:35AM BLOOD ___ PTT-30.6 ___
___ 07:20AM BLOOD Glucose-90 UreaN-5* Creat-0.5 Na-143
K-4.2 Cl-106 HCO3-25 AnGap-16
___ 07:20AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.0
___ CT abdomen/pelvis
1. 3.3 x 10.2 x 16.5 cm fluid collection measuring up to 11
Hounsfield units with minimal surrounding stranding in the
anterior abdominal wall, concerning for a seroma, however an
underlying infectious process/abscess cannot be entirely
excluded.
2. Status post colectomy. Multiple dilated loops of small bowel
in the right abdomen with no definite transition point
identified, could relate to post surgical findings.
___ ___ drain placement
An 8 ___ ___ catheter was advanced into the fluid
collection under
ultrasound guidance. Once adequate positioning was confirmed,
the catheter was deployed and the pigtail was formed. 220 cc of
serosanguinous fluid was aspirated. 8 cc of fluid was sent for
microbiology. The drain was placed to a JP bulb, secured to the
skin with a Stat Lock, and sterile dressings were applied.
Brief Hospital Course:
The patient is a ___ year old female who was admitted to the
Acute Care Surgery service with a fluid collection in her
abdominal wall. She was made NPO and was continued on a course
of ciprofloxacin started by her PCP. On Hospital day 2
she had a JP drain placed under ultrasound by interventional
radiology who aspirated 220 cc of serosanguinous fluid. Gram
stain and cultures were sent. That evening, she was advanced to
a regular diet, which she tolerated well. On Hospital day 3 her
antibiotics were changed from ciprofloxacin
to oral clindamycin. Her cultures came back showing
Staphylococcus aureus coagulase positive. At the time of
discharge she was in stable condition. She was advised to follow
up with Dr. ___ in the ___ clinic on ___. She was
given a prescription for a 14 day course of clindamycin.
Medications on Admission:
1. Amitriptyline 50 mg PO HS sleep
2. Bismuth Subsalicylate Chewable 2 TAB PO QID:PRN diarrhea
3. LOPERamide 4 mg PO QID:PRN diarrhea
Discharge Medications:
1. Amitriptyline 50 mg PO HS sleep
2. Bismuth Subsalicylate Chewable 2 TAB PO QID:PRN diarrhea
3. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times a
day Disp #*56 Capsule Refills:*0
4. LOPERamide 4 mg PO QID:PRN diarrhea
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fluid collection in abdominal wall
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Acute Care Surgery service with a
subcutaneous fluid collection. You had a drain placed in ___,
and you were started on antibiotics. You are now ready to
complete your recovery at home. Please follow the instructions
below:
-You have one JP drain in place. Continue to empty this drain
as taught during your hospital stay. Please record fluid
appearance and total output daily.
-You are being given a prescription for an antibiotic. Please
complete entire 14 day course of this antibiotic.
-You may resume all home medications.
-You may resume a normal diet as tolerated.
-You may resume normal activity as tolerated. You may shower
with the JP drain in place.
-You have a follow up appointment with Dr. ___ on ___
at 1:45PM. If you need to change this appointment, please call
the ACS office at ___.
-If you experience severe abdominal pain, fever>101, or anything
else that concerns you, please call the ACS office or go the
closest emergency room.
Followup Instructions:
___
|
19809088-DS-14
| 19,809,088 | 22,119,326 |
DS
| 14 |
2116-09-22 00:00:00
|
2116-09-27 23:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / morphine / Asacol
Attending: ___.
Chief Complaint:
Abdominal wound infection
Major Surgical or Invasive Procedure:
PROCEDURE:
1. Exploratory laparotomy.
2. Excision of ventral hernia mesh.
3. Lysis of adhesions.
History of Present Illness:
Ms. ___ is a ___ with multiple abdominal surgeries and
ventral hernia s/p mesh repair (___) complicated by multiple
wound infections, most recently requiring ___ drainage at ___
on
___, now presenting with abdominal wall erythema extending
across her incision. Her ___ drain was removed on ___, and
she
has since been doing well aside from reporting loose stools ___
times daily. Two weeks ago, she noted an approximate quarter
size
erythematous area to the right of her midline incision about 8cm
above her umbilicus. This area remained unchanged over two weeks
and she had no associated symptoms. However, on the day of
presentation, she reports feeling 'achy' in her abdomen all day
with decreased appetite, fatigue, and pain 'around my mesh,' but
without nausea, vomiting, fevers, or chills. She reports
increased flatus and ongoing loose brown stools. When she
arrived
home from work, she additionally felt that her abdomen was
distended 'as though pregnant.' She noted that the skin on her
abdomen was warm and the redness had spread to the left side of
her abdomen as well. Given the abdominal distention and
worsening
erythema having had multiple wound infections in the past, she
came into ___ ED for evaluation.
Past Medical History:
Past Medical History:
Collagenous colitis s/p total colectomy
GERD
Post-operative ileus
Arthritis
Asthma (Improved since quitting smoking)
Paroxysmal atrial tachycardia
Hypercholesterolemia
HTN
Past Surgical History:
Total colectomy with end ileostomy and subsequent takedown and
J-Pouch formation ___ years ago. Laparotomy and lysis of
adhesions
for small bowel obstruction- ___
Symptomatic incarcerated abdominal incisional hernia repair with
physio mesh and composite type mesh polypropylene w/Monocryl
coating - ___
Appendectomy (Childhood)
Tonsillectomy
Adenoidectomy
L knee replacement
R ACL repair
Carpal Tunnel release
Social History:
___
Family History:
Sister died of lung cancer
Physical Exam:
Admission:
Vitals: T 97.7 HR 84 BP 124/76 RR 16 O2sat 96%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Large healed midline incision with multiple drain scars.
Erythema (blanching) on either side of midline scar about 6cm
above umbilicus, warm to touch L>R. Abdomen soft, distended,
non-tender, no rebound tenderness or voluntary guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Discharge:
GEN: NAD
HEENT: WNL
PULM: nonlabored on RA, CTAB
CV: RRR, no M/R/G
ABD: Soft, appropriately tender, incision C/D/I. JP removal site
well healed.
EXT: WWP, no edema
Pertinent Results:
___ WBC-11.5*# RBC-4.40 Hgb-13.3 Hct-40.1 Plt ___
___ WBC-11.4* RBC-4.09* Hgb-12.6 Hct-38.0 Plt ___
___ WBC-9.3 RBC-3.93* Hgb-11.8* Hct-37.0 Plt ___
___ WBC-8.7 RBC-3.76* Hgb-11.7* Hct-35.4* Plt ___
___ WBC-7.5 RBC-3.83* Hgb-11.8* Hct-35.2* Plt ___
___ WBC-9.1 RBC-4.15* Hgb-12.6 Hct-38.5 Plt ___
___ Glucose-118* UreaN-13 Creat-0.6 Na-142 K-3.9 Cl-104
HCO3-26 ___ Glucose-121* UreaN-7 Creat-0.6 Na-142 K-4.2
Cl-103 HCO3-28 ___ Glucose-153* UreaN-6 Creat-0.6 Na-135
K-4.1 Cl-101 HCO3-27 ___ Glucose-118* UreaN-7 Creat-0.7
Na-137 K-4.6 Cl-102 HCO324 ___ Glucose-112* UreaN-4*
Creat-0.6 Na-141 K-4.0 Cl-103 HCO3-32 ___ Glucose-106*
UreaN-7 Creat-0.8 Na-140 K-3.9 Cl-102 HCO3-26
TISSUE (Final ___:
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
IMAGING:
Abdominal Ultrasound ___:
FINDINGS:
Focal transverse and sagittal grayscale and color ultrasound
images were
obtained of the anterior abdominal wall. A thin fluid collection
is seen
within the mid portion of the anterior abdominal wall, measuring
7.2 cm in width and only 0.6 cm in anteroposterior dimension.
There is a trace amount of fluid extending towards the left
abdominal wall and anterior to the periumbilical region.
CT abd/pelvis ___:
IMPRESSION:
1. Status post colectomy with distended segments of small bowel
in the right abdomen, similar to ___. No clear
transition point is identified and findings are most consistent
with dysmotility or functional ileus.
2. Anterior abdominal wall low-density fluid collection has
decreased in size since the prior exam but is now thick-walled
with mild surrounding soft tissue stranding. Findings may
represent a resolving seroma but superinfection cannot be
excluded on the basis of imaging.
Brief Hospital Course:
Patient was admitted to the Acute Care Surgery Service from the
Emergency Department. Please refer to the HPI for details of her
initialy presentation.
An abdominal ultrasound showed thin fluid collection within the
mid portion of the anterior abdominal wall, measuring 7.2 cm
width and only 0.6 cm in anteroposterior dimension. Given
patient's prior extensive infectious history with her hernia
mesh, she was started on empiric IV-Vancomycin therapy. She was
made NPO with IVFs. A CT scan was obtained which showed anterior
abdominal wall low-density fluid collection which has decreased
in size since the prior exam but now thick-walled with mild
surrounding soft tissue stranding suspicious for an infection.
Patient was taken to the operating room by Dr. ___ on ___
and underwent exploratory laparotomy.
excision of ventral hernia mesh and lysis of adhesions and
primary closure. Two ___ drains were placed in the
subcutaneous space to prevent reaccumulation of seroma. The
operation was without complications and she tolerated the
procedure well. She was extubated immediately postoperatively
and was transferred to the floor in a stable condition. Given
the extensive amount of lysis of adhesions she underwent, she
was kept NPO with a nasogastric tube in place. She was kept on
IV-vancomycin. On POD1, the NGT was discontinued. Her foley
catheter was removed without difficulty. On POD3, patient's JP
drains were removed without event. Her intraoperative cultures
speciated as Methicillin resistant Staph aureus with
sensitivites shown above. Patient remained NPO with IVFs due to
lack of return of bowel function, however she remained without
any nausea or significant abdominal distension. On POD 5,
patient had return of bowel function with multiple bowel
movements. She was advanced to a regular diet without any event.
Her IV-vancomycin was changed to Bactrim based on her culture
data. By the time of discharge, patient was tolerating a regular
diet with normal bladder and bowel function. She remained
afebrile with normal vital signs and laboratory values. She was
ambulating without difficulty and her incisions were well
healing. Patient reported full comfort to continue her recovery
at home. She is to follow up with us in ___ clinic as shown in
her discharge instructions.
Medications on Admission:
Lo-Peramide 4mg QAM and 2mg QHS, Peptobismol 3 tablets daily,
Vitamin B12 1,000mcg daily, albuterol inhaler prn, Amitriptyline
50mg QHS, Vit D3 1000U daily, Gabapentin 900 mg QHS, Pravastatin
40mg daily, Rabeprazole 20mg QHS, Verapamil 180mg QHS
Discharge Medications:
1. Amitriptyline 50 mg PO HS
2. Gabapentin 900 mg PO HS
3. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hrs prn Disp #*30
Tablet Refills:*0
4. Pravastatin 40 mg PO DAILY
5. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth twice a day Disp #*16 Tablet Refills:*0
6. Verapamil SR 180 mg PO Q24H
7. Acetaminophen 650 mg PO Q6H:PRN fever/headache
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth q6hrs prn Disp #*30 Tablet
Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent infections of abdominal wall mesh
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with a wound infection and abdominal
pain. An ultrasound showed you had a fluid collection around the
mesh in your abdomen and an x-ray showed you had a partial small
bowel obstruction. The decision was made to take you to the
operating room to remove the infected mesh. You had an extensive
lysis of adhesions and removal of mesh done on ___. You
tolerated the procedure well and post operatively you were kept
nothing by mouth with IV fluids and IV antibiotics for several
days until you had return of bowel function. You are now
tolerating a regular diet and your pain is well controlled with
oral pain medicine. You are ready to go home to continue your
recovery. You will complete a course of antibiotics by mouth.
Please follow up with the ___ clinic at the appointment listed
below.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
19809155-DS-2
| 19,809,155 | 20,196,399 |
DS
| 2 |
2171-08-15 00:00:00
|
2171-08-15 10:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
amoxicillin / Iodinated Contrast- Oral and IV Dye / lisinopril
Attending: ___.
Chief Complaint:
acute worsening of chronic low back pain
Major Surgical or Invasive Procedure:
T10-T12 DECOMPRESSION
History of Present Illness:
___ female history of hypertension, depression who
presents with acute worsening of chronic low back pain over the
last 2 weeks. She also endorses radicular pain down the anterior
thighs bilaterally, frequent episodes of urinary incontinence
without awareness over the last 3 months, and new complaint of
her left knee giving out over the last 2 weeks. She does walk
with a walker at baseline for over the past year due to her low
back pain. Patient otherwise denies numbness, tingling,
weakness, saddle anesthesia, loss of bowel function.
Past Medical History:
PMH/what PSH:
HTN
Obesity
Depression
Anxiety
MEDS:
Antihypertensives
Paxil
Bupropion
Ativan
Social History:
Occasional tobacco
No active EtOH
Daily marijuana
Physical Exam:
PE:
VS ___ 2342 Temp: 97.5 PO BP: 151/82 L Lying HR: 78 RR: 20
O2 sat: 97% O2 delivery: Ra
NAD, A&Ox4
nl resp effort
RRR
incisional vac in place with good suction
Sensory:
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Pertinent Results:
___ 06:47AM BLOOD WBC-16.6* RBC-3.84* Hgb-11.0* Hct-35.7
MCV-93 MCH-28.6 MCHC-30.8* RDW-17.7* RDWSD-59.7* Plt ___
___ 07:36AM BLOOD WBC-18.3* RBC-4.17 Hgb-12.0 Hct-37.7
MCV-90 MCH-28.8 MCHC-31.8* RDW-17.2* RDWSD-57.4* Plt ___
___ 02:00AM BLOOD WBC-13.2* RBC-4.44 Hgb-12.7 Hct-39.9
MCV-90 MCH-28.6 MCHC-31.8* RDW-17.2* RDWSD-57.0* Plt ___
___ 02:00AM BLOOD Neuts-60.6 ___ Monos-7.3 Eos-3.0
Baso-0.5 Im ___ AbsNeut-8.00* AbsLymp-3.73* AbsMono-0.97*
AbsEos-0.39 AbsBaso-0.07
___ 06:47AM BLOOD Plt ___
___ 07:36AM BLOOD Plt ___
___ 10:24AM BLOOD ___ PTT-25.6 ___
___ 02:00AM BLOOD Plt ___
___ 06:47AM BLOOD Glucose-112* UreaN-12 Creat-0.7 Na-142
K-4.6 Cl-104 HCO3-27 AnGap-11
___ 07:36AM BLOOD Glucose-119* UreaN-16 Creat-1.2* Na-140
K-4.5 Cl-101 HCO3-26 AnGap-13
___ 07:36AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.6
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 ___ were used for postoperative
DVT prophylaxis.Intravenous antibiotics were continued for 24hrs
postop per standard protocol.Initial postop pain was controlled
with oral and IV pain medication.Diet was advanced as
tolerated.Foley was removed on POD#2. Physical therapy and
Occupational therapy were consulted for mobilization OOB to
ambulate and ADL's.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 may be inaccurate and requires
futher investigation.
1. Gabapentin 1200 mg PO QHS
2. Nabumetone 750 mg PO DAILY
3. ALPRAZolam 1 mg PO DAILY:PRN anxiety, insomnia
4. BuPROPion 100 mg PO DAILY
5. CloNIDine 0.1 mg PO QHS
6. Labetalol 200 mg PO BID
7. PARoxetine 60 mg PO DAILY
8. Prazosin 2 mg PO QHS
9. Sumatriptan Succinate 50 mg PO Q3H:PRN migraine
10. TraZODone 50 mg PO QHS:PRN insomnia
11. Verapamil SR 120 mg PO Q24H
12. Gabapentin 800 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Heparin 5000 UNIT SC BID prevent blood clots
4. Miconazole Powder 2% 1 Appl TP QID:PRN skin folds
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
6. Senna 8.6 mg PO BID
7. ALPRAZolam 1 mg PO DAILY:PRN anxiety, insomnia
8. BuPROPion 100 mg PO DAILY
9. CloNIDine 0.1 mg PO QHS
10. Gabapentin 800 mg PO BID
11. Gabapentin 1200 mg PO QHS
12. Labetalol 200 mg PO BID
13. Nabumetone 750 mg PO DAILY
14. PARoxetine 60 mg PO DAILY
15. Prazosin 2 mg PO QHS
16. Sumatriptan Succinate 50 mg PO Q3H:PRN migraine
17. TraZODone 50 mg PO QHS:PRN insomnia
18. Verapamil SR 120 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Thoracic spinal stenosis.
2. Thoracic myelopathy.
3. Lower extremity dysfunction, with bladder dysfunction.
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:
Thoracic Decompression Without Fusion
You have undergone the following operation: Thoracic
Decompression Without Fusion
Immediately after the operation:
Activity:You should not lift anything greater
than 10 lbs for 2 weeks.You will be more comfortable if you do
not sit or stand more than~45 minutes without moving around.
Rehabilitation/ Physical ___ times a
day you should go for a walk for ___ minutes as part of your
recovery.You can walk as much as you can tolerate.Limit any kind
of lifting.
Diet:Eat a normal healthy diet.You may have
some constipation after surgery.You have been given medication
to help with this issue.
Brace:You may have been given a brace.If you
have been given a brace, this brace is to be worn when you are
walking.You may take it off when sitting in a chair or lying in
bed.
Wound Care: Keep the incision covered with a
dry dressing on until your follow up appointment. If the
incision is draining cover it with a new sterile dressing and
keep it covered until your follow up appointment. Do not soak
the incision in a bath or pool.If the incision starts draining
at anytime after surgery,do not get the incision wet.Cover it
with a sterile dressing and call the office.
You should resume taking your normal home
medications.
You have also been given Additional Medications
to control your pain.Please allow 72 hours for refill of
narcotic prescriptions,so please plan ahead.You can either have
them mailed to your home or pick them up at the clinic located
on ___.We are not allowed to call in or fax narcotic
prescriptions(oxycontin,oxycodone,percocet) to your pharmacy.In
addition,we are only allowed to write for pain medications for
90 days from the date of surgery.
Follow up:
___ Please Call the office and make an
appointment for 2 weeks after the day of your operation if this
has not been done already.
___ At the 2-week visit we will check your
incision, take baseline X-rays and answer any questions.We may
at that time start physical therapy.
___ We will then see you at 6 weeks from the
day of the operation and at that time release you to full
activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
1)Weight bearing as tolerated.2)Gait,balance training.3)No
lifting >10 lbs.4)No significant bending/twisting.
Treatments Frequency:
Keep the incision covered with a dry dressing on until your
follow up appointment. If the incision is draining cover it with
a new sterile dressing and keep it covered until your follow up
appointment. Do not soak the incision in a bath or pool.If the
incision starts draining at anytime after surgery,do not get the
incision wet.Cover it with a sterile dressing and call the
office.
Followup Instructions:
___
|
19809180-DS-9
| 19,809,180 | 26,556,275 |
DS
| 9 |
2120-04-06 00:00:00
|
2120-04-07 11:26:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / iodine / Levaquin
Attending: ___.
Chief Complaint:
throat foreign body
Major Surgical or Invasive Procedure:
EGD with foreign body removal
History of Present Illness:
___ with history of GERD presents to ED with esophageal foreign
body. She ate homemade chicken soup ___ but then felt
something lodge in esophagus. She went to her PCP ___, had
CXR showing no FB, so was given symptomatic treatment with
viscous Xylocaine. Then, due to persistence of symptoms, she
returned to ___ who ordered CT scan which showed 18 x 16 x 3 mm
foreign body in the cervical esophagus. She was then
transferred
to ___ for further care.
Past Medical History:
Vit D deficiency
Depression
GERD
Social History:
___
Family History:
No FH of GI strictures or autoimmune conditions.
Physical Exam:
ADMISSION PHYSICAL:
VITALS: 98.0 123/73 78 15 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: 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.
DISCHARGE PHYSICAL:
General: NAD, laying back in bed
HEENT: EOMI, AT/NC, no JVD, no tracheal deviation, no LAD
Cardiac: RRR, s1+s2 normal, no m/g/r appreciated
Lungs: CTAB
Abd: +BS, non-tender, non-distended, no organomegaly appreciated
Ext: Pulses present, no edema
Skin: No lesions identified
Neuro: No motor/sensory deficits elicited
Pertinent Results:
ADMISSION LABS:
___ 05:05PM URINE HOURS-RANDOM
___ 05:05PM URINE UHOLD-HOLD
___ 05:05PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-8* PH-6.5
LEUK-NEG
___ 04:00PM GLUCOSE-86 UREA N-7 CREAT-0.8 SODIUM-139
POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-26 ANION GAP-14
___ 04:00PM estGFR-Using this
___ 04:00PM CALCIUM-9.9 PHOSPHATE-3.6 MAGNESIUM-2.0
___ 04:00PM WBC-10.7* RBC-4.05 HGB-12.6 HCT-38.3 MCV-95
MCH-31.1 MCHC-32.9 RDW-13.1 RDWSD-45.3
___ 04:00PM NEUTS-75.4* LYMPHS-15.9* MONOS-7.0 EOS-1.2
BASOS-0.2 IM ___ AbsNeut-8.04* AbsLymp-1.69 AbsMono-0.75
AbsEos-0.13 AbsBaso-0.02
___ 04:00PM PLT COUNT-297
___ 04:00PM ___ PTT-33.6 ___
DISCHARGE LABS:
___ 05:37AM BLOOD WBC-9.8 RBC-3.78* Hgb-11.5 Hct-34.9
MCV-92 MCH-30.4 MCHC-33.0 RDW-13.2 RDWSD-44.6 Plt ___
___ 05:37AM BLOOD Plt ___
___ 05:37AM BLOOD Glucose-87 UreaN-6 Creat-0.7 Na-141 K-4.0
Cl-102 HCO3-24 AnGap-15
___ 05:37AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.7
IMAGING:
___ CT Neuro ___ opinion:
IMPRESSION:
A radiopaque curvilinear structure is lodged in the upper
esophagus slightly below the cricopharyngeus, and just above the
level of the thoracic inlet, compatible with known foreign body.
There is circumferential esophageal wall thickening and
inflammatory changes, but no definite perforation or
pneumomediastinum.
MICRO:
___ Urine Cx: NEG
Brief Hospital Course:
___ with history of GERD presents to ED with esophageal foreign
body (chicken bone). Following chicken soup ___, she felt
something lodge, had CXR ___ showing no FB, given
symptomatic treatment with viscous Xylocaine. Persistence of
symptoms, prompted CT scan showing 18 x 16 x 3 mm foreign body
in the cervical esophagus. Transferred to ___, where she
underwent EGD and removal of the bone on ___. They visualized
erosive disease to the esophagus, for which she would benefit
from 5 days of amoxicillin. She was maintained on her home oral
PPI BID. Gastrografin swallow study ___ yielded no leakage. She
tolerated soft diet prior to discharge. Remained clinically
stable.
ACUTE ISSUE:
#Foreign body:
After eating chicken soup s/p removal via EGD and visualization
of erosive damage to esophagus. Gastrograffin study to check for
leak was negative. Started on clears diet, and advanced to softs
to stay for 5 days prior to regular diet. Continued viscous
lidocaine for pain. Transitioning with Amoxicllin for 5 days
given esophageal injury.
CHRONIC ISSUES:
#GERD: continued lansoprazole
#Depression: no meds at home
#Vit D deficiency: on no meds, outpt issue
TRANSITIONAL ISSUES:
#Discharged with 5 day course of amoxicillin for infection
prophylaxis given esophageal injury
#Patient to schedule follow-up in ___ clinic in ___ weeks after
discharge.
#Soft diet for 5 days before advancing to regular diet; can use
viscous lidocaine for ongoing pain
#Patient to follow-up with outpatient GI doctor Dr. ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine Viscous 2% 15 mL PO TID:PRN sore throat
2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
Discharge Medications:
1. Amoxicillin 500 mg PO Q8H
RX *amoxicillin 500 mg 1 capsule(s) by mouth every 8 hours Disp
#*15 Capsule Refills:*0
2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
3. Lidocaine Viscous 2% 15 mL PO TID:PRN sore throat
Discharge Disposition:
Home
Discharge Diagnosis:
Food particle esophageal impaction
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 hospitalized for the removal of a piece of food
that was impacted in the tube that connects your mouth to
stomach.
What was done while I was in the hospital?
- Pictures were taken that showed the piece of food stuck.
- A camera was inserted to see the piece and remove it.
- Pictures were taken to make sure you had no leak after the
piece was removed.
What should I do when I go home?
- It is very important that you take your prescribed
medications.
- Please go to your scheduled appointment with your primary
doctor.
- If you have any fevers or chest pain, please tell your
primary doctor or go to the emergency room.
Best wishes,
Your ___ team
Followup Instructions:
___
|
19809456-DS-17
| 19,809,456 | 28,298,444 |
DS
| 17 |
2175-10-16 00:00:00
|
2175-10-16 17:04:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Celebrex / Norvasc
Attending: ___.
Chief Complaint:
Hypoxia and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with hx. COPD on home ___, pulmonary HTN,
hypertrophic obstructive cardiomyopathy, aortic aneurysm s/p
repair presenting with c/o weakness.
Patient reports fatigue and weakness starting 1 week ago. Says
has been going on gradually but worsened over last week. For
the last 2 weeks she has increased ___ oxygen use - used to be
only at night now pretty much all the time. Has had associated
increase in clear sputum production, mostly in the AM. Denies
fevers or chills, no sick contacts. No chest pain or
palpitations. No weight gain, denies orthopnea or PND. At ___
baseline she could walk to ___ car from ___ house without
oxygen, but now is too fatigued to complete even simply
activities.
In the ED, initial vitals: 98.6 65 147/87 16 81% RA. Labs were
notable for a CBC with WBC 3.2, plt 88, nl trop/BNP, chem-7 with
Cl 95, Bicarb 44. CXR showed cardiomegaly and no signs of
pneumonia. Patient was given duonebs, methylpred 125mg IV, as
well as full dose aspirin.
Upon arrival to the floor patient says she feels better. Denies
dyspnea, wheezing, or chest pain. No other complaints.
Past Medical History:
1. Aneurysm of ascending aorta and aortic arch, s/p repair ___
2. Tortuous dilated thoracic aorta.
3. HOCM - LVOT 10mmHg cath ___ TTE: LVOT 19mmHg, 1+AR,
1+MR
5. L vocal cord dysphagia- ___
6. Hypertension.
7. Hypercholesterolemia.
8. Diabetes mellitus, type 2.
9. Hypothyroidism.
10. Glaucoma.
11. Osteoarthritis.
12. Osteopenia
13. Status post total abdominal hysterectomy.
14. Status post colonic polypectomy.
15. h/o Left Nasolabial abscess, s/p excision. (___)
16. Status post thoracic aortic stent graft repair for posterior
penetrating ulcer.
17. Euthyroid multinodular goiter (left-sided dominant ~3cm
solid nodules FNA negative for malignancy).
18. ? h/o asthma
19. ? h/o Tb work-up
Social History:
___
Family History:
Father, deceased, possibly due to cancer. Mother, deceased, died
during childbirth when Ms. ___ was approximately ___ years old.
Reports that family members on maternal side have
characteristically "died young." Sister with ___, and another
sister who died in ___ ___ of cancer, though she does not recall
the type.
Physical Exam:
ADMISSION EXAM
Vitals- 98.2 159/57 hr 78 17 96% 2L
General- awake, alert, in NAD but mildly tachypneic
HEENT- PERRLA, EOMI, OMM no lesions
Neck- supple, JVD elevated to manible at 30 degrees
Lungs- expiratory wheezing b/l, no crackles
CV- RRR, 2+ systolic murmur RUSB
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, strength ___ in UE and ___ b/l
DISCHARGE EXAM
Vitals- 99 120/51 69 18 96% 2L
General- awake, alert, NAD, mildly tachypneic
HEENT- PERRLA, EOMI, OMM no lesions
Neck- supple, JVD elevated to manible at 30 degrees
Lungs- mild expiratory wheezing b/l, no crackles
CV- RRR, 2+ systolic murmur RUSB
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or
guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- grossly intact
Pertinent Results:
___ LABS
___ 06:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-LG
___ 06:00PM URINE RBC-3* WBC-16* BACTERIA-FEW YEAST-NONE
EPI-1
___ 03:20PM BLOOD WBC-3.2* RBC-4.59 Hgb-12.6 Hct-40.7
MCV-89 MCH-27.5 MCHC-31.0 RDW-16.2* Plt Ct-88*
___ 03:20PM BLOOD Plt Smr-LOW Plt Ct-88*
___ 03:20PM BLOOD Glucose-112* UreaN-14 Creat-0.8 Na-145
K-4.2 Cl-95* HCO3-44* AnGap-10
___ 03:20PM BLOOD Calcium-9.8 Phos-3.2 Mg-2.0
___ 03:53PM BLOOD ___ Temp-36.6 pO2-43* pCO2-86*
pH-7.37 calTCO2-52* Base XS-19 Intubat-NOT INTUBA
___ 03:53PM BLOOD Lactate-1.3
PERTINENT LABS
___ 03:20PM BLOOD proBNP-554
___ 03:20PM BLOOD cTropnT-<0.01
DISCHARGE LABS
___ 06:35AM BLOOD WBC-5.3# RBC-4.14* Hgb-11.5* Hct-36.5
MCV-88 MCH-27.7 MCHC-31.4 RDW-16.4* Plt Ct-90*
___ 06:35AM BLOOD Glucose-78 UreaN-13 Creat-0.7 Na-147*
K-3.6 Cl-98 HCO3-46* AnGap-7*
___ 06:35AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.0
MICRO
NONE
REPORTS
___ Imaging CHEST (PORTABLE AP)
IMPRESSION: No definite acute cardiopulmonary process.
Brief Hospital Course:
___ year old female with hx. COPD on home ___, pulmonary HTN,
hypertrophic obstructive cardiomyopathy, aortic aneurysm s/p
repair presenting with c/o weakness
#Hypoxia: Ms. ___ was hypoxic to low ___ on arrival to ED and
mid ___ on home 2L on arrival to floor. Given progressive
requirement in home oxygen, likely etiology is acute on chronic
COPD. There was low concern for pulmonary embolism given
gradual onset and lack of tachycardia or heart failure (normal
BNP). She was treated with albulterol and ipratropium
nebulizers, prednisone 40mg x5 days (last day ___, and
azithromycin x5 days (last day ___. On day of discharge, ___
breathing was subjectively returned to baseline and O2
saturation was mid-90s on home O2 (2L).
#Acute on chronic COPD exacerbation: Patient has severe baseline
COPD. Given ___ increased O2 requirement and sputum production
at time of admission, she was treated for COPD exacerbation as
outlined under Hypoxia. Supplemental O2 was continued to reach
goal saturation of low to mid-90s.
#Fatigue/weakness: Likely etiology of patient's fatigue and
weakness is COPD exacerbation. TSH was recently normal in
___ and she had no signs or symptoms of acute coronary
syndrome or acute blood loss. She was treated for COPD
exacerbation as outlined above.
#Alkalosis: Patient's alkalosis is likely chronic in setting of
severe COPD. VBG was indicative of CO2 retention (pCO2 86) that
is worse than prior. Contraction alkalosis was also considered
but was less likely. She was treated for COPD as above.
#Pulmonary HTN: Patient had an ECHO in ___ that demonstrated
mild-moderate mitral regurgitation, moderate tricuspid
regurgitation, and moderate pulmonary arterial systolic HTN.
Etiology is likely multifactorail in setting of cardiac and lung
disease. Patient had signs of TR on exam (JVP elevated to level
of mandible), but no peripheral edema to suggest right sided
heart failure. ___ cardiac status was monitored by physical
exam.
#Aortic aneurysm/ulcer: Patient is s/p ascending aortic
replacement and graft stent repair for penetrating ulcer. CXR on
admission demonstrated stable cardiomegaly.
#Leukopenia, thrombocytopenia: Etiology for these is unclear.
She has had thrombocytopenia in the past. This could represent
MDS. ___ blood counts were monitored as an inpatient. WBC count
normalized from 3.2 to 5.3 on day of discharge and platelet
count remained stable in ___.
TRANSITIONAL ISSUES
# will complete course of antibiotics and prednisone, total 5d
each
# CODE STATUS: DNR/DNI
# CONTACT: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. Amlodipine 5 mg PO DAILY
3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. Vitamin D 50,000 UNIT PO 2X/MONTH
6. HydrALAzine 50 mg PO BID
7. Ipratropium Bromide MDI 2 PUFF IH QID
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Metoprolol Tartrate 50 mg PO BID
10. Pilocarpine 1% 1 DROP BOTH EYES Q8H
11. Travatan Z (travoprost) 0.004 % ophthalmic QHS
12. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. HydrALAzine 50 mg PO BID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Metoprolol Tartrate 50 mg PO BID
7. Pilocarpine 1% 1 DROP BOTH EYES Q8H
8. Azithromycin 250 mg PO Q24H Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
9. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
11. Ipratropium Bromide MDI 2 PUFF IH QID
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
13. Travatan Z (travoprost) 0.004 % ophthalmic QHS
14. Vitamin D 50,000 UNIT PO 2X/MONTH
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
for shortness of breath and increased oxygen requirement, likely
due to COPD exacerbation. You were treated with nebulizers,
steroids, and antibiotic medication (azithromycin), supplemental
oxygen, and improved.
Followup Instructions:
___
|
19809456-DS-18
| 19,809,456 | 20,745,313 |
DS
| 18 |
2175-11-12 00:00:00
|
2175-11-22 16:55:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Celebrex / Norvasc
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ with history of COPD on 2L home O2 with
recent admit this month, pulmonary hypertension, HOCM, aortic
aneurysm, HTN, HLD, MDM, hypothyroidism, OA, ostoepenia and
other issues who presents with fatigue and SOB. The patient's
symptoms began the day prior to presentation. She noted fatigue
> SOB after climbing a flight of stairs at home, which is
unusual for her. She denies fever or chills, she denies cough
or sputum production. She denies N/V/D, dysuria, abdominal
pain, melena or hematochezia. She reports good PO intake.
In the ED, initial VS were 98.2 65 169/59 20 87% 2L. Labs were
notable for lactate 1.4, normal UA, normal chem panel (other
than hemolysed K), normal lfts/cbc. Exam was notable for AOX3,
dyspnea on exertion. Imaging was notable for CXR which showed
slight opacification in RLL which could not rule out PNA.
Received nebs/IV vanco, cefepime, azithro for
pneumonia/solumedrol 80 mg. Admitted to medicine for further
management. On arrival to the floor, patient reports that she
feels at her baseline in terms of her breathing; her main
complaint is fatigue with activity.
REVIEW OF SYSTEMS:
As per HPI
Past Medical History:
1. Aneurysm of ascending aorta and aortic arch, s/p repair ___
2. Tortuous dilated thoracic aorta.
3. HOCM - LVOT 10mmHg cath ___ TTE: LVOT 19mmHg, 1+AR,
1+MR
5. L vocal cord dysphagia- ___
6. Hypertension.
7. Hypercholesterolemia.
8. Diabetes mellitus, type 2.
9. Hypothyroidism.
10. Glaucoma.
11. Osteoarthritis.
12. Osteopenia
13. Status post total abdominal hysterectomy.
14. Status post colonic polypectomy.
15. h/o Left Nasolabial abscess, s/p excision. (___)
16. Status post thoracic aortic stent graft repair for posterior
penetrating ulcer.
17. Euthyroid multinodular goiter (left-sided dominant ~3cm
solid nodules FNA negative for malignancy).
18. ? h/o asthma
19. ? h/o Tb work-up
Social History:
___
Family History:
Father, deceased, possibly due to cancer. Mother, deceased, died
during childbirth when Ms. ___ was approximately ___ years old.
Reports that family members on maternal side have
characteristically "died young." Sister with ___, and another
sister who died in her ___ of cancer, though she does not recall
the type.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS - 99.4 154/66 60 20 95% on 3L NC
General: NAD, thin woman, breathing comfortably
HEENT: MMM, OP clear
Neck: Supple, no JVD
CV: RRR, loud III/VI early systolic murmur loudest at apex, loud
P2
Lungs: Moderate air movement throughout, prolonged expiratory
phase but no wheezing or crackles
Abdomen: Soft, NT ND +BS
GU: Deferred
Ext: 1+ pitting edema to mid-shin on R, none on L
Neuro: CN II-XI intact
Skin: No rash
DISCHARGE PHYSICAL EXAM:
========================
Pertinent Results:
ADMISSION LABS:
===============
___ 03:15PM BLOOD WBC-3.9* RBC-4.48 Hgb-12.7 Hct-40.5
MCV-90 MCH-28.4 MCHC-31.4 RDW-16.7* Plt ___
___ 03:15PM BLOOD Neuts-73* Bands-1 ___ Monos-6 Eos-0
Baso-0 ___ Myelos-0 Other-1*
___ 03:15PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Target-2+
___ 03:15PM BLOOD Glucose-121* UreaN-14 Creat-0.6 Na-142
K-5.5* Cl-96 HCO3-37* AnGap-15
___ 03:15PM BLOOD ALT-19 AST-38 AlkPhos-56 TotBili-0.5
___ 03:15PM BLOOD Albumin-4.4
___ 03:18PM BLOOD Lactate-1.4 K-4.7
___ 03:20PM URINE Color-Straw Appear-Clear Sp ___
___ 03:20PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 03:20PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 03:20PM URINE Mucous-RARE
PERTINENT LABS:
===============
___ 06:12AM BLOOD TSH-0.31
PERTINENT IMAGING:
==================
ECG ___:
Sinus rhythm. Compared to the previous tracing of ___ no
change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
61 138 92 396/397 71 72 70
CXR ___:
IMPRESSION: Probable mild pulmonary edema with bilateral lower
lobe
opacities, which could represent an early pneumonia. Small
bilateral
effusions, right greater than left. Stable cardiomegaly and
post-surgical changes in the descending thoracic aorta.
RLE US ___:
IMPRESSION:
No evidence of a DVT in the right lower extremity.
PERTINENT MICRO:
================
___ 3:15 pm BLOOD CULTURE #1 SOURCE:VENIPUNCTURE.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS:
===============
___ 06:12AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.9
___ 06:12AM BLOOD Glucose-70 UreaN-14 Creat-0.6 Na-146*
K-4.0 Cl-98 HCO3-44* AnGap-8
___ 06:12AM BLOOD WBC-4.2 RBC-3.98* Hgb-11.2* Hct-35.4*
MCV-89 MCH-28.1 MCHC-31.6 RDW-16.8* Plt ___
Brief Hospital Course:
Ms. ___ is an ___ with history of COPD on 2L home O2 (with
recent admission ___ for SOB/weakness), pulmonary
hypertension, HOCM, aortic aneurysm, HTN, HLD, MDM,
hypothyroidism, OA, ostoepenia and other issues who presents
with fatigue and SOB.
ACTIVE ISSUES:
==============
# Fatigue / Shortness of breath:
This was felt to be most consistent with her baseline COPD in
the setting of running out of her tiotropium inhaler.
Deconditioning may also be contributing. Soon after having her
medications restarted, the patient reported that her respiratory
status currently close to baseline. COPD exacerbation was felt
to be unlikely given no cough or fever, PNA also felt unlikely
but given comorbidities, recent hospitalization, and worsening
hypoxemia in ED, she was briefly on vanc/levofloxacin for HCAP
and received 1 dose of Solumedrol in ED. TSH was normal.
Antibiotics and steroids were discontinued and she continued to
do well. She was discharged home without antibiotics or
steroids with instructions to call her PCP if she felt worse.
Her prescriptions were renewed.
# RLE edema:
Per patient, asymmetric RLE edema is a chronic problem for her,
but given no Hx of vascular surgery on this leg and asymmetric
swelling, ___ was performed to r/o DVT. This was negative.
CHRONIC ISSUES:
===============
# HOCM:
This was not an active issue during this hospitalization. She
was continued on her home Metoprolol and Aspirin.
# HTN:
Continued home Hydralazine, Metoprolol, and Amlodipine.
# DM2:
The patient is noton oral hypoglycemics or insulin at home. She
was maintained on a gentle ISS while in-house.
# Hypothyroidism:
The patient was continued on her home synthroid. TSH this
admisison was 0.3.
# Glaucoma:
The patietn was continued on her home eye drops.
# ?h/o asthma
The patient received advair while in-house (symbicort
non-formulary) and was continued on albuterol and ipratropium.
# CODE: Full (presumed)
# EMERGENCY CONTACT HCP: Sister ___ ___ and
Brother ___ ___
TRANSITIONAL ISSUES:
====================
- Patient provided with prescriptions for all inhalers to ensure
she has access to these meds after discharge.
- Patient instructed to call her primary care physician to
___ an appointment to be seen early next week
- Patient with asymmetric RLE edema, per patient this is
chronic, there was no DVT on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. HydrALAzine 50 mg PO BID
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Metoprolol Tartrate 50 mg PO BID
7. Pilocarpine 1% 1 DROP BOTH EYES Q8H
8. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
9. Ipratropium Bromide MDI 2 PUFF IH QID
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
11. Travatan Z (travoprost) 0.004 % ophthalmic QHS
12. Vitamin D 50,000 UNIT PO 2X/MONTH
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. HydrALAzine 50 mg PO BID
5. Ipratropium Bromide MDI 2 PUFF IH QID
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 puffs
four times a day Disp #*1 Inhaler Refills:*0
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Metoprolol Tartrate 50 mg PO BID
8. Pilocarpine 1% 1 DROP BOTH EYES Q8H
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs every six (6)
hours Disp #*1 Inhaler Refills:*0
10. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
RX *budesonide-formoterol [Symbicort] 160 mcg-4.5 mcg/actuation
1 puff twice a day Disp #*1 Inhaler Refills:*0
11. Travatan Z (travoprost) 0.004 % ophthalmic QHS
12. Vitamin D 50,000 UNIT PO 2X/MONTH
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Shortness of breath, fatigue
Secondary: Chronic obstructive pulmonary disease, pulmonary
hypertension, hypertrophic obstructive cardiomyopathy,
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure caring for you at ___
___. You were admitted to the hospital for shortness
of breath and fatigue. We looked for evidence of pneumonia and
did not find any. Your breathing and oxygen levels were
unchanged from your baseline. It is likely that your shortness
of breath and fatigue were related to running out of your
Tiotropium inhalers, as well as possibly a viral respiratory
illness that resolved on its own. Because of swelling in your R
leg, we did an ultrasound to look for a blood clot and did not
find any. Because your breathing was at your baseline and you
showed no signs of infection, you were discharged home.
It is very important that you call your primary care doctor
early this week to schedule an appointment to be seen. If you
continue to feel poorly when you go home, or if your breathing
gets worse, you should call your primary care doctor to receive
a prescription for Azithromycin and Prednisone.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19809456-DS-20
| 19,809,456 | 25,637,611 |
DS
| 20 |
2176-09-05 00:00:00
|
2176-09-06 09:09:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Celebrex / Norvasc
Attending: ___.
Chief Complaint:
Epistaxis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Primary Care Physician: ___
CHIEF COMPLAINT: Nosebleed
HISTORY OF PRESENT ILLNESS:
___ with PMH of COPD (FEV1 43%, 2L home O2), pHTN, HOCM, aortic
aneurysm, HTN, HLD, hypothyroidism, OA, and multiple
hospitalization for hypercarbic respiratory failure who is
presenting with a nosebleed since ___. She reports no real
history of nosebleeds and says that it stopped on its own. She
is also reports mild difficulty with swallowing and having a
globus sensation. With regard to her COPD, she denies any change
in breathing or cough and no increased or change in quality in
her sputum production. Her PCP noted her to be hypoxic in clinic
and increased baseline 2L home O2 to 4L. She denies ___ edema.
Vitals in the ED: 99.0 66 185/79 18 94% 4L NC
Labs notable for: WBC 3.0, Hgb 12.5, Hct 40.0, Plt 75, HCOe 43,
proBNP 437, TnT 0.01, UA with 32 RBC 1 WBC neg ___ and nitrates.
VBG notable for pCO2 of 108 but pH was 7.32 with HCO3. Repeat
VBG was pCO2 91, pH 7.37.
Imaging: CT Head without any intracranial process, but opacity
within the right maxillary sinus. Parietal scalp lesion. CXR
without opacity or edema.
Patient given: Azithromycin 500mg PO and Prednisone 40mg daily
and was admitted for possible COPD exacerbation(?).
Vitals prior to transfer: 80 164/70 26 97% Nasal Cannula.
On the floor, patient is resting comfortably in her bed without
any ongoing complaints. Denies any worsening SOB or cough and
does not have a current nosebleed. Later in morning, patient
felt overall at her baseline and denied swallowing difficulty
aside from globus sensation which she pondered but later
retracted (I ___ really have an issue with food). She had
only gotten her blood pressure medications shortly after
discussion.
Review of Systems:
(+) per HPI, epistaxis, possible dysphagia
(-) She denies chest pain, fevers, chills, nausea, vomiting and
diarrhea. She denies abdominal pain, back pain, bleeding.
9-point ROS otherwise negative.
Past Medical History:
- Severe COPD with hypercapnia and hypoxemia, on home O2
(possible asthma)
- Moderate-to-severe pHTN
- HOCM - LVOT 10mmHg cath ___ TTE: LVOT 19mmHg, 1+AR,
1+MR
- S/p endovascular repair of ruptured thoracic aorta and status
post ascending aortic replacement
- Tortuous dilated thoracic aorta.
- L vocal cord dysphagia- ___
- Hypertension.
- Hypercholesterolemia
- Diabetes Mellitus Type II
- Hypothyroidism.
- Glaucoma.
- Osteoarthritis.
- Osteopenia
- Status post total abdominal hysterectomy.
- Status post colonic polypectomy.
- h/o Left Nasolabial abscess, s/p excision. (___)
- Euthyroid multinodular goiter (left-sided dominant ~3cm solid
nodules FNA negative for malignancy).
- Possible TB workup
Social History:
___
Family History:
Father, deceased, possibly due to cancer. Mother, deceased, died
during childbirth when Ms. ___ was approximately ___ years old.
Reports that family members on maternal side have
characteristically "died young." Sister with ___, and another
sister who died in her ___ of cancer.
Physical Exam:
ADMISSION/DISCHARGE PHYSICAL EXAMINATION:
VITALS: 98.3, 65-72, ___ (improved to SBP 150s when
home antihypertensives administered), 18, 96-100% on ___
Pain/Dyspnea, Ins 180, Outs 530
GENERAL: NAD, pleasant and conversant
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, no active epistaxis or crusted blood
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, ___ systolic murmur at RUSB and at apex
radiating to the axilla.
LUNG: CTAB with prolonged expiratory phase. Minimal rales. Short
of breath with speaking.
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 II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS:
___ 02:11PM BLOOD WBC-3.0* RBC-4.64 Hgb-12.5 Hct-40.0
MCV-86 MCH-27.0 MCHC-31.3 RDW-16.8* Plt Ct-75*
___ 07:52AM BLOOD WBC-4.1 RBC-4.49 Hgb-12.3 Hct-36.5
MCV-81* MCH-27.4 MCHC-33.7 RDW-16.9* Plt Ct-74*
___ 07:52AM BLOOD Neuts-47.8* ___ Monos-9.9 Eos-1.0
Baso-0.5
___ 02:11PM BLOOD ___ PTT-30.5 ___
___ 07:52AM BLOOD Ret Aut-0.9*
___ 02:11PM BLOOD Ret Aut-1.0*
___ 02:11PM BLOOD Glucose-103* UreaN-10 Creat-0.6 Na-143
K-4.2 Cl-92* HCO3-43* AnGap-12
___ 07:52AM BLOOD Glucose-73 UreaN-11 Creat-0.6 Na-144
K-3.9 Cl-94* HCO3-46* AnGap-8
___ 07:52AM BLOOD ALT-11 AST-14 LD(LDH)-193 AlkPhos-61
TotBili-0.4
___ 02:11PM BLOOD cTropnT-<0.01
___ 02:11PM BLOOD proBNP-437
___ 07:52AM BLOOD Albumin-3.7 Calcium-9.4 Phos-3.7 Mg-1.9
___ 02:11PM BLOOD TSH-1.2
___ 03:03PM BLOOD ___ pO2-58* pCO2-108* pH-7.32*
calTCO2-58* Base XS-22
___ 04:10PM BLOOD ___ O2 Flow-1 pO2-57* pCO2-91*
pH-7.37 calTCO2-55* Base XS-21
___ 08:49AM BLOOD ___ pO2-73* pCO2-91* pH-7.38
calTCO2-56* Base XS-23 Comment-GREEN TOP
___ 04:10PM BLOOD Lactate-0.7
___ 04:10PM BLOOD freeCa-1.19
___ 02:50PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
___ 02:50PM URINE RBC-32* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
___ 02:50PM URINE Color-Straw Appear-Clear Sp ___
STUDIES:
# Blood Cx: NGTD
# Urine Cx: Mixed bacterial flora from GI contamination
# CXR (___): The lungs are well-expanded. There is no focal
consolidation, pleural effusion or pneumothorax. Again seen is a
markedly tortuous dilated aorta with a stent graft unchanged in
size and configuration since prior studies. The
cardiomediastinal silhouette is unchanged. IMPRESSION: No acute
cardiopulmonary process or change from the prior study.
# CT HEAD (___): 1. No acute intracranial process. 2.
Complete opacification of the right maxillary sinus. 3.
Unchanged right parietal scalp lesion, possibly a sebaceous cyst
or other benign etiology.
# EKG: NSR with LVH and repol abnormality. No concerning ST/TW
changes.
Brief Hospital Course:
___, an ___ yo F PMHx COPD Gold III on home oxygen and
multiple hospitalizations for respiratory failure presented with
self-limited epistaxis and concern of fatigue and globus
sensation in ___ ED. Patient's dyspnea/cough were unchanged
from baseline and hypoxemia/hypercarbia were unchanged from
baseline with normal pH and no new symptoms. However patient was
noted to have leukopenia/thrombocytopenia that was worst that
prior baseline as well as hematuria without evidence of
nephrolithiasis. Patient was discharged to outpatient followup
as she was feeling at her baseline.
# COPD without Exacerbation: Patient with known COPD with
Chronic Hypercapnia on Home Oxygen, with GOLD III disease last
PFTs ___ with FEV1 43%. Patient has stable symptoms with no
change in dyspnea or cough. Patient has elevated pCO2 but
normal pH indicated stable compensation. Patient also has
normal troponin and BNP. Patient does not meet criteria for
active flare and therefore has no indication for antibiotics or
systemic corticosteroids. Her SaO2 was at baseline. She was
maintained on fluticasone-salmeterol inhaler during her
hospitalization due to ___ formulary.
# Hypertensive Crisis: Patient with known HTN on 3
antihypertensives was not given any antihypertensive in the ED
after presenting with SBP>180 and continued to be >180 on
arrival to ___; patient was subsequently given home
antihypertensives. Patient denies headache, visual changes,
chest pain, change in dyspnea, focal weakness or numbness, and
lower extremity swelling. Her SBP improved to 150s when she was
given her home amlodipine, metoprolol, and hydralazine.
# Leukopenia / Thrombocytopenia: Patient has thrombocytopenia
dating back to ___ (maybe worse in setting of mild consumption)
and leukopenia intermittently during the same time period with
unremarkable differential (not neutropenic). Differential
includes poor bone marrow production (possible MDS),
hypersplenism (given thrombocytopenia), immune destruction, and
acute viral infection (less likely given lack of acute
symptoms). Patient reticulocyte count was low but her WBC was
low-normal on day of discharge.
# Epistaxis: Patient on no anticoagulation aside from aspirin
presented with several days of intermittent slow epistaxis
versus far less likely hemoptysis with resolved symptoms, normal
vitals, stable respiratory status, and stable Hgb. Patient had
no remaining evidence of epistaxis on admission and was
discharged with saline nasal spray to avoid dry nares
predisposing to epistaxis.
# Dysphagia: Patient at one point reported a globus sensation
without difficulty swallowing food or changes in cough. Speech
and Swallow Consult (see ___ Note) was called and had no
concerns about her ability to eat/swallow.
# Hematuria: No current symptoms of nephrolithiasis or UTI and
urine culture showed mixed GI flora. Could consider
CT-Abd/Pelvis and cystoscopy as outpatient to evaluate for GU
malignancy as indicated.
# Hypothyroidism: Continued on home levothyroxine.
# Glaucoma: Continued on home eye drops.
TRANSITIONAL ISSUES:
- Patient noted to have leukopenia (not neutropenic) and
thrombocytopenia worse than prior results since ___ without
signs of acute etiology (acute viral infection, destructive
process, liver disease) and may benefit from any outpatient bone
marrow aspiration
- Patient noted to have hematuria on admission without pain or
urinary symptoms suggestive of nephrolithiasis or infection;
patient may benefit form outpatient CT-Abd/Pelvis and cystoscopy
to rule out genitourinary tract malignancy
- Patient was discharged with saline nasal spray to reduce the
risks of further nose bleeding; patient may benefit from
humidified home oxygen if there is a recurrent issue
- There was initial concern that patient might have difficulty
swallowing; Speech & Swallow evaluation did not show any
difficulty with swallowing and she requires no
modifications/limitations regarding consistency
- Consider alterations in antihypertensive regimen given use of
medications requiring multiple doses per day (metoprolol
tartrate, hydralazine); of note patient was severely
hypertensive (SBP>180s) but had no symptoms and blood pressure
improved with administration of home medications
- Code Status: DNR (new from prior admissions, patient felt that
(when its my time its my time), patient was unsure regarding
mechanical ventilation and will discuss with healthcare proxy
and may be further discussed as an outpatient
- Contact: ___ (sister) at ___
- ___: Home without Services
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. HydrALAzine 50 mg PO BID
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Metoprolol Tartrate 50 mg PO BID
6. Travatan Z (travoprost) 0.004 % ophthalmic QHS
7. Vitamin D 50,000 UNIT PO 2X/MONTH
8. Amlodipine 5 mg PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
10. Ibuprofen 400 mg PO DAILY
11. Ipratropium Bromide MDI 2 PUFF IH QID
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 puffs BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. HydrALAzine 50 mg PO BID
6. Ibuprofen 400 mg PO DAILY
7. Ipratropium Bromide MDI 2 PUFF IH QID
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Metoprolol Tartrate 50 mg PO BID
10. Travatan Z (travoprost) 0.004 % ophthalmic QHS
11. Vitamin D 50,000 UNIT PO 2X/MONTH
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 PUFFS BID
13. Sodium Chloride Nasal ___ SPRY NU TID:PRN Dry Nose
RX *sodium chloride 0.65 % ___ SPRY intranasally three times a
day Disp #*1 Spray Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Epistaxis
Concern of Chronic Obstructive Pulmonary Disease Exacerbation
Thrombocytopenia
Leukopenia
Hematuria
Hypertensive Crisis
Concern of Dysphagia
SECONDARY:
COPD on Home Oxygen Gold Stage III
Hypothyroidism
Glaucoma
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because you
had nose bleeding and doctors were concerned about your
breathing. Luckily, you nose bleeding stopped and your
breathing and oxygen numbers were very similar to your previous
numbers. Best of luck to you in your future health.
You were found to have relatively low number of clot-forming
cells and infection-fighting cells as well as a small amount of
blood in your urine. Your primary care doctor has been informed
about these issues and more testing may be done as an
outpatient. We gave you a prescription for a nasal spray to
reduce the likelihood of future nose bleeds. While in the
hospital, you were having thoughts about whether or not you
would want a machine to breath for you if you had severe
difficulty breathing; continue to think about this topic and
talk about it with your healthcare proxy and primary doctor.
Please take all medications as prescribed, attend all doctors
___ as ___ (or call to reschedule), and call a
doctor if you have any questions or concerns.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19809456-DS-21
| 19,809,456 | 28,140,413 |
DS
| 21 |
2176-11-22 00:00:00
|
2176-11-23 13:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Celebrex / Norvasc
Attending: ___.
Chief Complaint:
altered mental status
Reason for MICU transfer: hypercarbia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of COPD (FEV1 43%, 2L home O2), pHTN, HOCM, aortic
aneurysm, HTN, HLD, hypothyroidism, OA, and multiple
hospitalization for hypercarbic respiratory failure who is
presenting with increased confusion for a couple months,
worsening over the last month. Also with generalized weakness.
Today, the patient was noted to be dishelved at home, in bed,
which is atypical for her. Fall while in the bathroom, unsure of
headstrike but head by vanity. No LOC. Forgot to take underwear
down, defecated into underwear. Almost fell again. No changes in
vision.
Per the patient's brother ___, who checked on the patient as
recently as yesterday, she has been confused over at least the
last month. He and other family members have been concerned she
cannot take care of herself at home alone, and they were trying
to get her to go to the hospital for this reason. Finally, when
the patient's sister ___ went over today, she was unable to
get out of bed on her own and fell when they tried to help her
up.
In the ED, initial vitals: 98.0 84 163/59 16 100% 4LNC.
Labs notable for: Na 146, WBC 3.2, Hct 32 (baseline 40), and Plt
83 (at baseline). VBG 7.31/111/39/59. Her recent VBGs showed a
normal pH at pCO2s in the ___ in ___. CT head showed no acute
process. CT neck with no fx or dislocation. CXR showed blunting
of the costophrenic angles vs hyperinflation, otherwise no acute
process.
The patient became somnolent when placed on high dose nasal
cannula. She improved with weaning down to RA/home O2
requirement. Repeat VBG showed ___. UA showed
hematuria but neg leuk and nitrites, few bacteria.
On arrival to the FICU, The patient is confused. She is not
answering questions appropriately. She does not know why she is
at the hospital or what happened today. She denies any shortness
of breath, cough, fever, urinary symptoms, abdominal pain, or
diarrhea.
REVIEW OF SYSTEMS:
(+) Per HPI. 10 point ROS is otherwise negative.
Past Medical History:
- Severe COPD with hypercapnia and hypoxemia, on home O2
(possible asthma)
- Moderate-to-severe pHTN
- HOCM - LVOT 10mmHg cath ___ TTE: LVOT 19mmHg, 1+AR,
1+MR
- S/p endovascular repair of ruptured thoracic aorta and status
post ascending aortic replacement
- Tortuous dilated thoracic aorta.
- L vocal cord dysphagia- ___
- Hypertension.
- Hypercholesterolemia
- Diabetes Mellitus Type II
- Hypothyroidism.
- Glaucoma.
- Osteoarthritis.
- Osteopenia
- Status post total abdominal hysterectomy.
- Status post colonic polypectomy.
- h/o Left Nasolabial abscess, s/p excision. (___)
- Euthyroid multinodular goiter (left-sided dominant ~3cm solid
nodules FNA negative for malignancy).
- Possible TB workup
Social History:
___
Family History:
Father, deceased, possibly due to cancer. Mother, deceased, died
during childbirth when Ms. ___ was approximately ___ years old.
Reports that family members on maternal side have
characteristically "died young." Sister with ___, and another
sister who died in her ___ of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4, 95, 159/62, 21, 86% on RA
GENERAL: Alert, confused, no acute distress
HEENT: Sclera anicteric, MM dry, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: diminished breath sounds throughout, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, ___ RUSB systolic
ejection murmur
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no lesions rashes or bruising
NEURO: CNs grossly intact ___ strength throughout
DISCHARGE PHYSICAL EXAM
VS: 98.0 79 115/52 12 100%2L
GENERAL: AOx3
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: diminished breath sounds throughout, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, ___ RUSB systolic
ejection murmur
ABD: soft non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: no edema
SKIN: no lesions rashes or bruising
NEURO: CNs grossly intact ___ strength throughout
Pertinent Results:
ADMISSION LABS:
================
___ 03:35PM BLOOD WBC-3.2* RBC-3.66* Hgb-10.3* Hct-32.2*
MCV-88# MCH-28.3 MCHC-32.2 RDW-16.4* Plt Ct-83*
___ 04:08AM BLOOD WBC-4.5 RBC-3.48* Hgb-9.8* Hct-30.4*
MCV-87 MCH-28.2 MCHC-32.3 RDW-16.6* Plt Ct-87*
___ 03:35PM BLOOD Neuts-78.4* Lymphs-14.8* Monos-5.5
Eos-0.9 Baso-0.4
___ 04:08AM BLOOD Neuts-73.4* Lymphs-17.1* Monos-8.1
Eos-1.1 Baso-0.3
___ 02:47PM BLOOD ___ PTT-27.7 ___
___ 04:08AM BLOOD ___ PTT-28.7 ___
___ 03:35PM BLOOD Glucose-113* UreaN-20 Creat-0.5 Na-146*
K-4.9 Cl-92* HCO3-45* AnGap-14
___ 04:08AM BLOOD Glucose-119* UreaN-17 Creat-0.6 Na-146*
K-4.1 Cl-92* HCO3-49* AnGap-9
___ 03:35PM BLOOD ALT-12 AST-16 LD(LDH)-283* CK(CPK)-43
AlkPhos-61 TotBili-0.5
___ 03:35PM BLOOD proBNP-484
___ 03:35PM BLOOD cTropnT-<0.01
___ 04:08AM BLOOD Albumin-4.1 Calcium-8.8 Phos-2.7 Mg-1.8
___ 03:35PM BLOOD TSH-0.41
___ 05:36PM BLOOD ___ pO2-39* pCO2-111* pH-7.31*
calTCO2-59* Base XS-22
___ 05:36PM BLOOD K-4.5
___ 03:47PM BLOOD Lactate-2.0
___ 07:10PM BLOOD O2 Sat-60
___ 05:36PM BLOOD O2 Sat-75
___ 07:10PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 07:10PM URINE RBC-12* WBC-1 Bacteri-FEW Yeast-NONE
Epi-0 TransE-<1
___ 07:10PM URINE CastHy-3*
DISCHARGE LABS
=================
___ 04:43AM BLOOD WBC-3.3* RBC-3.84* Hgb-10.8* Hct-32.5*
MCV-84 MCH-28.0 MCHC-33.2 RDW-16.7* Plt Ct-93*
___ 04:43AM BLOOD Glucose-75 UreaN-25* Creat-0.7 Na-140
K-3.9 Cl-88* HCO3-45* AnGap-11
___ 04:08AM BLOOD ALT-13 AST-17 LD(LDH)-221 AlkPhos-59
TotBili-0.7
___ 04:43AM BLOOD Calcium-8.7 Phos-5.2* Mg-2.1
___ 03:35PM BLOOD TSH-0.41
___ 05:31AM BLOOD ___ pO2-37* pCO2-112* pH-7.33*
calTCO2-62* Base XS-25
MICRO
=================
___ 7:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 3:35 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 9:30 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
IMAGING/REPORTS
=================
___-SPINE W/O CONTRAST
There is no acute fracture or traumatic malalignment. There is
no
prevertebral soft tissue swelling. Multilevel, multifactorial
degenerative changes are noted with disc space narrowing,
subchondral sclerosis, and marginal osteophyte formation. There
is also uncovertebral and facet hypertrophy causing mild
bilateral neural foraminal narrowing at C4-C5 and C5-C7.
The thyroid gland is massively enlarged with a dominant
heterogeneous lesion measuring 3.4 x 3.1 cm in the left lobe.
There is no cervical lymphadenopathy. Visualized lung apices
are clear.
IMPRESSION:
1. No acute fracture or traumatic malalignment.
2. Multilevel, multifactorial degenerative changes as described
above.
3. Massively enlarged and heterogeneous thyroid gland for which
clinical
correlation advised.
___ Imaging CT HEAD W/O CONTRAST
There is no evidence of infarction, hemorrhage, edema, or mass.
Slightly
prominent ventricles and sulci suggest mild age related global
atrophy. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation.
No osseous abnormalities seen. There is near complete
opacification of the right maxillary sinus containing
inspissated secretions as well as sclerosis of the maxillary
wall compatible with chronic sinusitis. The remaining
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The orbits are unremarkable. A well-circumscribed
hypodense lesion is seen at the right parietal soft tissues
measuring 2.6 x 1.1 cm compatible with a sebaceous cyst.
IMPRESSION:
1. No acute intracranial process.
2. Near complete opacification of the right maxillary sinus
containing
inspissated secretions with sclerosis of the maxillary wall
compatible with chronic sinusitis.
___ Imaging CHEST (PA & LAT)
FINDINGS:
Cardiac and mediastinal silhouettes are stable. Again, the
aorta is markedly tortuous, dilated with a stent graft, similar
to prior study. Thoracic scoliosis is noted. No new focal
consolidation is seen. No pneumothorax is seen. There is
slight blunting of the costophrenic angles which may be due to
the lungs being hyperinflated, trace pleural effusions not
excluded.
IMPRESSION:
Slight blunting of the posterior costophrenic angles, trace
pleural effusions not excluded. Otherwise, no significant
interval change from the prior study.
Radiology Report CHEST (PORTABLE AP) Study Date of ___
6:11 ___
As compared to the previous image, the patient has made a
stronger inspiratory effort. Unchanged appearance of the
cardiac silhouette. Unchanged appearance of the stent graft.
No pleural effusions. No pneumonia, no pulmonary edema.
Brief Hospital Course:
___ with PMH of COPD (FEV1 43%, 2L home O2), pHTN, HOCM, aortic
aneurysm, HTN, HLD, hypothyroidism, OA, and multiple
hospitalization for hypercarbic respiratory failure who is
presenting with worsening confusion and inability to care for
herself at home.
# Confusion: Per collateral history, the patient may be
gradually declining at home. She has been hospitalized multiple
times in the last ___ years. Her CO2 was noted to be at her
baseline. There was no evidence of infection on CXR or UA. No
acute proess on head imaging in CT and no notable metabolic
derangements. Patientlikely has a baseline dementia. No acute
confusion state in the FICU. Patient was transferred to the
medical floor where she had acute change in her mental status
thought to be from hypercarbia. Confusion resolved with BIPAP
use and patient was back to her baseline mental status for rest
of hospital stay.
# Chronic hypercarbic respiratory failure: Severe COPD FEV1 32
and restriction from cardiomegaly and thoracic aortic graft,
which is also compressing the airways. On 2L O2 by NC at home.
On arrival to the FICU she denied any respiratory symptoms and
esd satting well on home O2 requirement of 2L. Despite shallow,
frequent breaths, she is relatively stable from prior with no
evidence of exacerbation. Neg CXR and no infectious
symptoms.Patient was transferred to the floor.
On ___ the patient was transferred to the floor with clear
mental status and breathing comfortably on intermittent BIPAP.
However, during the afternoon, she was found to acutely
desaturate to 50% with depressed mental status. Her O2 sats
earlier were documented to be 99-100% and she may have
hypoventilated ___ this. She did also receive one dose of IV
lasix which may have led to a metabolic alkalosis further
lessening her respiratory drive. She was placed on BIPAP and
transfrerred back to the ICU on ___. ABG without significant
change in her baseline PC02. Patient was continued on BIPAP in
the ICU and her symptoms improved. She was weaned back to
baseline of 2L NC. The patient ___ BIPAP while sleeping as
well as intermitently throughout the day. The patients O2 goal
should be 89-92%. She was continued on her albuterol,
ipratropium and advair. On discharge the patient will be
discharged on combivent as this may be easier to use.
BiPAP: Settings:Inspiratory pressure (Pressure support) 10
cm/H2O- Expiratory pressure (EPAP Fixed) 5 cm/H2O. IPAP 15
# HTN: Patient was hypertensive to 200s systolic on the floor,
her amlodipine and hydralazine doses were increased, continued
her metoprolol.
# Glaucoma: continued home eye drops.
# Hypothyroidism: contiued home levothyroxine.
# Communication: no signed HCP on file; Sister ___
___ and Brother ___ ___
# Code: DNR/DNI confirmed by patient and family member
TRANSLATIONAL ISSUES
# has been living along, may not be safe will need home
evaluation and physical therapy evaluation
# patient should use bi-pap at night and while sleeping
throughout day. She may intermittently need it throughout the
day for desaturations. Patient uses 2L NC throughout the day.
- Goal O2 sat 89-92%
# Amlodipine and hydralazine doses increased for high blood
pressure
# consider CT trachea to evaluate compression from aortic graft
# oupatient pulmonary rehab
# pulmonary follow-up on discharge
# would benefit from a MOLST
# BiPAP: Settings:Inspiratory pressure (Pressure support) 10
cm/H2O- Expiratory pressure (EPAP Fixed) 5 cm/H2O. IPAP 15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. HydrALAzine 50 mg PO BID
6. Ibuprofen 400 mg PO DAILY
7. Ipratropium Bromide MDI 2 PUFF IH QID
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Metoprolol Tartrate 50 mg PO BID
10. Travatan Z (travoprost) 0.004 % ophthalmic QHS
11. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 PUFFS BID
12. Pilocarpine 1% 1 DROP BOTH EYES Q8H
Discharge Medications:
1. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheezing
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. HydrALAzine 50 mg PO Q8H
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Metoprolol Tartrate 50 mg PO BID
8. Pilocarpine 1% 1 DROP BOTH EYES Q8H
9. Docusate Sodium 100 mg PO BID
10. Senna 8.6 mg PO BID:PRN constipation
11. Ibuprofen 400 mg PO DAILY
12. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 PUFFS BID
13. Travatan Z (travoprost) 0.004 % ophthalmic QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Hypercarbic respiratory failure
SECONDARY:
Hypothyroidism
Glaucoma
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to take care of you at ___
___. You were admitted to the hospital because of
difficulty breathing. You were treated with medications and
your breathing stabilized. You will need to use a breathing
machine at night to help you.
Best of luck to you in your future health.
Please take all medications as prescribed, attend all doctors
___ as ___ (or call to reschedule), and call a
doctor if you have any questions or concerns.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19809503-DS-10
| 19,809,503 | 21,064,073 |
DS
| 10 |
2158-02-18 00:00:00
|
2158-02-18 21:38:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
AVASTIN / Percocet
Attending: ___
Chief Complaint:
right lower back pain
Major Surgical or Invasive Procedure:
___: Epidural catheter placement under fluoroscopy
___: Intrathecal pump placement
History of Present Illness:
___ yo F metastatic RCC s/p R nephrectomy (mets to left kidney,
liver, and chest wall) most recently s/p RT ___, CKD stage
III, h/o uterine cancer, PMR on prednisone taper, s/p colostomy
secondary to ruptured diverticulum in ___, and osteoarthritis
who is referred from heme/onc office to r/o cord compression.
Patient was at heme/onc office today for CT chest w/ contrast to
assess for metastatic disease. Recieved IV hydration and PO
contrast. Prior to heading to CT scan patient attempted to use
commode and was unable to stand up thereafter due to severe
worsening of chronic right lower back pain. She did not have any
weakness, sensory deficit, or other neurologic deficit
associated
with the pain at that time.
She denies any recent illness or infection, fever,
nausea/vomiting, urinary symptoms or bowel (colostomy)
dysfunction, saddle anesthesia, weakness, sensory deficit, or
other neurologic deficit. She has had subacutely worsening
confusion over the past week per her daughter's report. Of note,
typically after prepping for a CT scan, the patient has
significant ostomy output. However, since admission, she has not
had any ostomy output which is concerning.
ED Course:
Vitals 15:11 Pain ___ 81 138/65 18 94% ra
-Multiple doses of morphine 5mg IV and ativan 0.5 mg IV given.
-Exam revealed normal sphincter tone, reflexes, and
sensation/strength bilaterally both upper/lower extremities
-Radiology ordered:
16:28 MR ___ SPINE W/O CONTRAST
16:28 MR THORACIC SPINE W/O CONTRAST
Past Medical History:
Past Oncologic History: Please see oncology notes in OMR for
full
details
--Renal Cell CA diagnosed in ___. s/p nephrectomy; last
cancer-directed therapy (a trial) in ___. recently, she has
undergone RT to a bony met that was causing pain.
--___ CT TORSO shows progression in L sided lytic lesion in
8th rib with growth of the extrapleural soft tissue
--She has been receiving chest cyberknife therapy for chest wall
metastases and was undergoing CT chest on the day of admission
for concern for new R rib cage met.
Chronic medical conditions:
1. Metastatic renal cell cancer as noted above
2. polymyalgia rheumatica on chronic prednisone
3. HTN, stable
4. Heart murmur, stable
5. GERD, stable
6. restless leg syndrome
7. Degenerative joint disease
8. Osteoporosis
9. Hx laparoscopic cholecystectomy
___. Hx motor vehicle accident with submandibular surgery at the
age of ___
11. Hypercholesterolemia
12. Osteoarthritis
13. Depression/anxiety
--h/o uterine cancer
--? asthma/COPD
Social History:
___
Family History:
Stroke. Hypertension. Colon cancer (father).
Stomach, liver, bone, lung cancer (paternal uncle).
Physical Exam:
Admission:
T99.2, 160/80, 83, 16, 95%RA
GEN: NAD, asleep but easily arousable
HEENT: PERRL, EOMI, MMM, oropharynx clear, no cervical LAD
Resp: inspiratory rhonchi diffuse (ausc anteriorly).
CV: RRR with II/VI SEM, nl S1 S2. JVP<7cm
ABD: normal bowel sounds, non-tender, not distended, soft.
Back: significant TTP right para-spinal area. Unable to assess
vertebral tenderness due to patient's drowsiness.
EXTR: Warm, well perfused. No edema. 2+ pulses.
NEURO: drowsy but able to follow commands (too sleepy to answer
questions more than "yes" and "no"), CN ___ grossly intact,
motor grossly intact in all four extremities, 2+ reflexes
symmetric but brisk. Babinski downgoing.
.
.
Discharge:
VS: 97.9 126/45 ___ 16 95/2.5L
GEN: NAD, alert and arousable. A&O to her name, being in the
hospital and the year (thought it was ___. Knows ___ is
the president.
HEENT: Slightly moon-shaped facies, dry mucous membranes
CV: regular rate and rhythm, no murmurs appreciated
PULM: very coarse breath sounds anteriorly, non labored
breathing
ABD: Obese, soft, no TTP elicitied on palpation, LLQ ostomy with
minimal dark brown stool
Extremities: no ___ pitting edema, no rash or excoriations
NEURO: alert and oriented
Pertinent Results:
Admission:
======
___ 06:10PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 06:10PM URINE RBC-2 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 04:09PM GLUCOSE-103* UREA N-22* CREAT-1.3* SODIUM-134
POTASSIUM-5.2* CHLORIDE-100 TOTAL CO2-22 ANION GAP-17
___ 04:09PM WBC-8.7 RBC-4.58 HGB-13.9 HCT-42.2 MCV-92
MCH-30.4 MCHC-33.0 RDW-14.4
___ 04:09PM PLT COUNT-187
.
Discharge:
======
___ 08:00AM BLOOD WBC-5.7 RBC-3.45* Hgb-10.6* Hct-31.3*
MCV-91 MCH-30.8 MCHC-33.9 RDW-16.1* Plt ___
___ 08:00AM BLOOD Glucose-78 UreaN-21* Creat-0.9 Na-134
K-4.4 Cl-97 HCO3-26 AnGap-15
___ 08:00AM BLOOD Calcium-9.9 Phos-3.4 Mg-1.9
.
.
====
Studies:
====
* KUB ___:
There is residual contrast seen throughout the colon. There is
no definite dilated loops of small bowel. There are no signs
for free intra-abdominal gas, however, this is a single supine
view. Air and stool are seen throughout mostly the transverse
colon. There is a paucity of bowel gas within the pelvis.
Degenerative changes of the lumbar spine and of the right hip
are again noted.
* MRI L/T spine ___:
IMPRESSION:
1. Large mass involving the right posterior elements of T12 and
the adjacent right posterior paravertebral muscles, which
extends into the right lateral epidural space, but does not
exert mass effect on the thecal sac. The mass also moderately
narrows the right T11-12 neural foramen and extends minimally
into the superior portion of the right T12-L1 neural foramen.
2. Enlargement of the more medial left eighth rib metastasis
compared to
___ torso CT; the more lateral metastasis is not fully
imaged. Adjacent pleural effusion or thickening is not fully
evaluated.
3. No evidence of additional metastatic disease in the lumbar
spine.
Multilevel lumbar degenerative disease with slight progression
compared to ___ at L2-L3 and L3-4.
4. Markedly distended bladder. Please correlate clinically
whether the
patient may have urinary retention.
* NCHCT ___:
IMPRESSION:
No intracranial hemorrhage or mass effect. Intracranial
metastases are better assessed via MRI.
* CT abd/pelvis ___:
IMPRESSION:
1. Enlarged 5.1 x 3.7 x 2.7 cm heterogeneously enhancing
metastasis along the right costovertebral margin at the
thoracolumbar junction with invasion of the posterior elements
and new compression deformity of T12. Involvement of the
epidural space is better demonstrated on the recent spine MRI.
2. Status post right nephrectomy.
3. Stable 11 mm nodule anterior to the right psoas muscle.
4. Left lower quadrant end colostomy.
5. Stable mild intra and extrahepatic bile duct dilatation.
6. Right inguinal hernia containing nonobstructed small bowel.
* CT chest ___:
IMPRESSION:
1. New right middle lobe pulmonary metastasis, substantial
increase in left lower rib metastasis with local invasion of the
pleura and lower lobe, and substantial growth of T12 metastasis
involving both posterior elements, erector musculature,
vertebral body, and probably vertebral canal.
* MRI brain ___:
IMPRESSION:
1. No evidence for intracranial metastatic disease.
2. Chronic infarction in the left cerebellar hemisphere, new
since ___.
*KUB ___:
FINDINGS: Supine and left lateral decubitus views of the
abdomen demonstrate
a combination of gas and stool within non-distended loops of
colon, which also
contain residual oral contrast. Air-filled non-dilated loops of
small bowel
are also present as well as a moderately distended, gas-filled
stomach. On
the lateral decubitus view, air-fluid levels are present in both
large and
small bowel as well as the stomach. No free intraperitoneal air
is evident.
*CXR ___:
FINDINGS: Left chest wall mass with associated rib destruction,
adjacent
pleural and parenchymal opacification in the left mid and lower
hemithorax is
unchanged since recent CT. Small lung nodules are seen to
better detail on
that study including a dominant right middle lobe nodule
measuring about 8 mm.
No new areas of consolidation are present to suggest the
presence of a
pneumonia. Cardiomediastinal contours are unchanged allowing
for marked
patient rotation and apicolordotic projection.
*CXR ___: FINDINGS: As compared to the previous radiograph,
there is unchanged evidence
of a left chest wall mass, with tips projecting over the left
ventral lateral
chest wall. Moderate cardiomegaly and tortuosity of the
thoracic aorta. No
pleural effusions. No pulmonary edema. No evidence of
pneumonia. No
pneumothorax.
*CXR ___: FINDINGS: Cardiomediastinal contours are stable.
Large left chest wall mass
with rib destruction appears similar compared to the prior
radiograph. No
definite new areas of consolidation to suggest the presence of
pneumonia, but
standard PA and lateral chest radiographs would be helpful to
more fully
evaluate the lung bases which are partially obscured by
overlying breast
tissue and left chest wall mass.
*CT A/P w/o contrast ___:
IMPRESSION: No intra-abdominal findings to explain the
patient's abdominal
pain. Chronic findings include surgically absent right adrenal
gland and
kidney, bony mets/soft tissue mass along the right
costovertebral margins,
compression deformity of the T12 vertebral body and a left lower
quadrant end
colostomy.
*CT Chest w/o contrast ___:
IMPRESSION:
1. New bilateral ground-glass opacity, lower lobe predominant,
with
peribronchial infiltration and also evidence of subpleural
consolidation in
left lower lobes are compatible with miltifocal pneumonia.
2. Middle lobe pulmonary metastasis, and left posterior arch of
VIII rib
metastasis with pleural invasion are unchanged since ___.
*Hip R, 2 view ___:
There is no evidence of fracture, dislocation or osteolytic
osseous lesions.
There are degenerative changes in the joint with decrease in the
joint space
and a small osteophyte. Surgical clips project in the right
pelvis.
*Chest XR ___:
FINDINGS: The patient is intubated. The tip of the
endotracheal tube
projects 4.6 cm above the carina. The known left chest wall
mass with massive
rib destructions has obviously slightly increased in extent and
is causing
relatively large left pleural effusion with both basal, lateral
and apical
component. These changes lead to substantial volume loss in the
left
hemithorax and subsequent shift of the mediastinal structures to
the left.
Mild hyperexpansion of the right lung. Several of the larger
nodules in the
right lung, documented on a CT examination from ___, are seen on
the chest x-ray.
*CXR ___:
AP radiograph of the chest demonstrates interval improvement of
the left lung
aeration with still present left lower lobe atelectasis. The ET
tube tip is
6.5 cm above the carina. Left retrocardiac consolidation is
consistent with
atelectasis. Clips project over the left hemithorax, unchanged.
Right lung
is overall clear. No pneumothorax is seen.
*CXR ___:
FINDINGS: Portable semi-upright frontal view of the chest. The
endotracheal
tube has been removed. The right lung is clear. Left lower lobe
atelectasis
persists. Left lower pleural mass and lower lobe consolidation
appear
unchanged. Clips project over the left hemithorax. Left lower
rib irregularity
is due to known metastatic disease. Normal size heart. No
pleural effusion or
pneumothorax.
IMPRESSION: Unchanged left lower lobe atelectasis and left
pleural
mass/consolidation better characterized on the prior chest CT.
*CXR ___:
FINDINGS: In comparison with the study of ___, there is
continued
opacification involving much of the mid and lower left lung.
Findings are
again consistent with a combination of pleural mass and lower
lung
consolidation as seen on the CT examination of ___. The right
lung is
essentially clear.
___ KUB:
Supine views of the abdomen demonstrate no dilated loops of
bowel or air-fluid
levels to suggest obstruction. There is no evidence of
pneumatosis or
secondary signs of free air on the supine radiograph. Surgical
clips in the
upper abdomen are again noted. Visualized right lung base
appears clear.
Imaged osseous structures are intact. Degenerative joint
changes of the lower
lumbar spine are evident. Multiple surgical clips are in the
pelvis
bilaterally.
IMPRESSION:
No evidence of obstruction.
___ CXR:
FINDINGS: AP portable chest x-ray shows stable left base
opacification due to
a combination of pleural mass and left lower lobe consolidation,
unchanged
since prior chest x-ray. No new consolidation.
Cardiomediastinal silhouette
is unchanged. No pneumothorax.
IMPRESSION: No changes since prior CXR.
The study and the report were reviewed by the staff radiologist.
=======
MICROBIOLOGY
-------------
___ 6:03 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ Urine CX:
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
___ Blood cx x2: NEGATIVE
___ C diff assay - NEGATIVE
___ Urine culture: NEGATIVE
___ Blood cx: NEGATIVE
___ Urine cx: NEGATIVE
___ Urine CX: NEGATIVE
___ Blood CX: NEGATIVE
___ BAL: Commensal respiratory flora
___ SPUTUM: Contaminated
___ Urine cx: NEGATIVE
___ Blood CX x2: ****
___ C diff: NEGATIVE
___ Blood cx x2: ****
Brief Hospital Course:
Ms. ___ is a ___ yo F w/ metastatic RCC s/p R nephrectomy
(mets to left kidney, liver, and chest wall) most recently s/p
RT ___, CKD stage III, PMR on prednisone taper, s/p
colostomy presenting with acutely worsening right lower back
pain, found to have T12 mass compressing epidural space but no
cord compression, treated with XRT and aggressive pain control.
.
# T12 mass/pathologic compression fx: Likely metastatic RCC,
explains her severe acute on chronic right sided back pain. No
e/o cord compression on imaging or exam. She was started on XRT
with radiation oncology, with improvement in her symptoms. She
received trials of gabapentin, baclofen, tizanidine without
marked symptom improvement. The chronic pain service was
involved with her care, directing an epidural catheter placement
___. Infusion of bupivacaine + hydromorphone allowed the
patient to have modestly reduced opiate requirement, allowing
improved mentation. However, she was still unable to move
without severe pain and was not able to sit or stand. Because of
perceived modest improvement, an intrathecal pump was placed on
___ under fluoroscopy. This also seemed to afford a reduced
opiate requirement with somewhat improved mental status.
However, there were again intermittent pain crises. Ultimately,
her lack of pain control was attributed to progressive disease,
especially given newer symptoms involving not just the thoracic
spine but the right hip and leg. She improved with titration of
the ITP and IV dilaudid and was discharged to inpatient hospice.
.
# AMS: Per daughter, pt has been more confused x2 weeks before
admission. Acute confusion/somnolence on admission was likely
medication related from numerous doses of IV morphine and ativan
in the ED, as well as pain. MRI brain w/o CNS disease. She was
initially alert and oriented x3 early in this admission with
some forgetfulness but appeared to tolerate her opioid regimen.
She became more regularly confused and was more reliably
oriented only x2 later in her admission, depending on her
medications that day. Efforts to control her pain with the
intrathecal pump were aimed toward achieving analgesia while
also preventing delirium secondary to narcotics. Her steroid
dose, initially increased given her T12 fracture and lesion in
that area, was tapered later on to avoid any steroid induced
mental status changes. She was discharged to inpatient hospice.
.
# Metastatic renal cell cancer: Has been managed over the last
___ years with palliative XRT - failed VEGF inhibitor systemic
therapy in the past. New mets as above, as well as new R lung
met and worsening left thoracic chest wall/pleural dx. She was
given palliative XRT for T12 spinal met as above. She had
previously been made DNR/DNI given physician recommendations to
the daughter that resuscitation would likely cause more harm
than good and was discharged to inpatient hospice.
.
# Fevers/Diaphoresis: The patient was persistently diaphoretic
and intermittently had fevers during this admission. She was
treated for a hospital acquired pneumonia on ___. However, she
continued to spike fevers every several days, sometimes without
obvious explanation as to the source. Notably, ___ she had a
fever to 102 associated with depressed mental status, and there
was some concern for meningitis given that she had the
intrathecal pump placed 6 days previously. Her mental status
improved to a degree and her WBC was normal. Other infectious
workup was also normal. It was thought that some of her
dysregulated temperature was due to her underlying renal cell
cancer. She did continue to spike fevers, and was started on
treatment with cefepime and vancomycin for presumed HCAP. She
completed the course of antibiotics prior to discharge.
.
# CKD stage III: Cr 1.2-1.3, around baseline. She had no major
nephrologic issues.
.
# Urinary retention: Foley placed on admission, drained 750 ccs.
Likely ___ narcotics. This resolved and the foley was
discontinued. However, it had to be replaced because of ongoing
retention in the setting of high-dose narcotic use as well as
extreme pain associated with getting on the bed pan.
.
# PMR: PO dexamethasone 4mg qd was started per palliative care
recommendations for symptom control. ___ weeks post radiation
therapy this was titrated down to her home prednisone dose so as
to avoid steroid induced mental status changes.
.
.
TRANSITIONAL ISSUES
- Discharged to inpatient hospice
- Intrathecal pump: With 1.5mg/day dilaudid and 11.2mg/day
bupivicaine. Will alarm around ___. Please contact Dr. ___
___ at the ___ Pain ___ regarding titration and
refill of pump. ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 8 mg PO DAILY
2. Lorazepam 0.5 mg PO Q6H:PRN anxiety
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
4. Amlodipine 10 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Hydrocodone-Acetaminophen (5mg-500mg) 2 TAB PO Q6H:PRN pain
7. Morphine SR (MS ___ 30 mg PO Q8H
8. Omeprazole 20 mg PO DAILY
9. Acetylcysteine 600 mg Other BID
10. Vitamin D ___ UNIT PO DAILY
11. Loratadine 10 mg PO DAILY
12. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety
3. PredniSONE 5 mg PO DAILY
4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
5. Baclofen 10 mg PO TID
6. Docusate Sodium 100 mg PO BID
Hold for loose stools
7. Gabapentin 400 mg PO BID
8. Gabapentin 600 mg PO HS
9. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush
10. HYDROmorphone (Dilaudid) ___ mg IV Q1H:PRN breakthrough pain
11. Ipratropium Bromide Neb 1 NEB IH Q6H
12. Methadone 5 mg PO TID
13. Pantoprazole 40 mg PO Q24H
14. Senna 1 TAB PO BID
15. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line
flush
16. TraZODone 25 mg PO HS:PRN insomnia
17. Intrathecal pump
dilaudid 1.5mg/day and bupivicaine 11.2mg/day in the intrathecal
pump
Please contact Dr. ___ at the ___ Pain ___
regarding titration and refill of pump. ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses: Metastatic renal cell cancer
Secondary diagnoses: T12 compression fracture, toxic-metabolic
encephalopathy, urinary retention, health care associated
pneumonia, CKD, PMR
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted
with back pain and found to have a tumor around your spine. This
is likely a new metastasis from your renal cell cancer. You were
treated with pain medication and radiation therapy. Your pain
did not improve much, and seemed to get worse. This required
more pain medications which made you confused at times. We
decided to try directly infusing pain medication into the spinal
area with an epidural catheter (___). Since this seemed to
help a bit, we placed a permanent pump that sits in the right
side of your abdominal wall to deliver pain medications to the
spinal cord. Unfortunately, neither of these interventions
reduced your pain to a point where you were able to sit up or
stand. Because there were no treatments available for your renal
cell cancer, you, your daughter ___, and the medical team
caring for you decided that your goals of care should be focused
on maximizing your comfort. Eventually, you were discharged to
inpatient hospice for continued comfort care.
Again, it was our pleasure participating in your care. We wish
you the best
-- Your ___ Medicine Team
Followup Instructions:
___
|
19810060-DS-12
| 19,810,060 | 25,507,058 |
DS
| 12 |
2158-06-01 00:00:00
|
2158-06-01 12:33:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EUS
ERCP with sphincterotomy
History of Present Illness:
___ year old female w/PMH of cholecystectomy presenting for
RUQ pain radiating to back for several days. She reports she has
been having pain for the past few days that began in RUQ and
moves towards the back. Yesterday, her pain became more acute
after eating chocolate and potato chips. She attempted to vomit
the food and she vomited potato chips. She went to ___ to urgent care and was told to come to the ER.
She currently feels like something is stuck near her abdomen and
is attempting to come up through her lower esophagus. She
reports
she also had right arm numbness yesterday that resolved in the
ER. She denies chest pain or SOB, blurry vision, weakness in
___, difficulty swallowing, dysuria, diarrhea, vaginal
discharge. Last BM this morning.
GYN:
Her LMP was ___, lasts 4 days, irregular, occasional
skips
months. She has never had a pap smear. She was seen by
gynecology
on last hospitalization for concern for lower abdominal pain.
She
has not followed up with gynecology since then. Last sexually
active ___ years prior.
Past Medical History:
___
Cholecystectomy ___
Social History:
___
Family History:
Family History:
Mother: ___, 'enlarged heart', Diabetes
Grandmother(maternal: ___
Father: healthy
Physical ___:
Physical Exam on admission:
VS: T: 97.7, BP: 105/67, HR: 60, RR: 18, O2: 95% RA
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLLA, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: NS1/S2, RRR, no bruits
Gastrointestinal: TTP RUQ/RLQ/LLQ, TTP over epigastrium, NABS,
ND, soft
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. Sensation in ___ intact.
TTP over right lower extremity near ankle (reports prior
injury),
no swelling/erythema appreciated
MSK: ___ strength in ___, +right CVA tenderness
Psychiatric: pleasant, appropriate affect
Discharge physical exam:
Pertinent Results:
Admit: Labs
___ 08:25PM ALT(SGPT)-221* AST(SGOT)-447* ALK PHOS-128*
TOT BILI-0.9
___ 08:25PM LIPASE-38
Procedures:
# EUS (___): Abnormal mucosa in the stomach. CBD max diameter
5.5 mm. No intrinsic stones or sludge were noted. Small stone in
the cystic duct stump with no evidence of obstruction. Otherwise
normal eus to third part of the duodenum
# ERCP (___): The common bile duct, common hepatic duct, right
and left hepatic ducts, biliary radicles and cystic duct were
filled with contrast and well visualized. A small filling
defect was noted at the level of the mid common bile duct.
Sphincterotomy was performed in the 12 o'clock position using a
sphincterotome over an existing guidewire. Balloon sweeps
reveled small amount of sludge and a small stone. Occlusion
cholangiogram showed no evidence of filling defects.
# Pelvic U/S (___): Normal
Brief Hospital Course:
ASSESSMENT & PLAN: ___ h/o CCY ___ admitted with abd pain,
transaminitis. s/p EUS, ERCP w/sphincterotomy ___,
#Abd pain: Ms. ___ was admitted with abd pain, N/V, elevated
LFTs. She had history of chronic cholecystitis in ___ - and
the thought was that her symptoms/signs were c/w
choledocholithiasis. To work this up, EUS was done - showing
small stone in the cystic duct stump - but was otherwise
unremarkable. She has an ERCP with sphincterotomy with removal
of small stone, sludge. Gradually, her LFT's improved and she
had no further abd pain or N/V.
Hep, EBV serologies were negative. She understands that she
should not take aspirin, Plavix, NSAIDS, Coumadin for 5 days.
She should also complete a 5d course of ciprofloxacin post ERCP.
Follow-up with Dr. ___ as previously scheduled.
#Gyn: RLQ/LLQ pain. Hep C, HIV, urine GC/chlamydia, TVUS were
negative. No further pain here. She is recommended to have
follow-up outpatient gynecology to establish care and pap smear
(can be done at PCP as well).
#Bradycardia: TSH wnl, ECG completed
.
#PPX: Heparin subq q12
#Code Status: FULL CODE
# Emergency Contact: Friend: ___: ___
___ on Admission:
Melatonin prn
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
2. Docusate Sodium 100 mg PO BID constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Filling defect note at level of mid common bile
duct/sphincterotomy performed, small stone in the cystic duct
stump
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Please follow-up with hepatology as outpatient
-Please follow-up with primary care appointment next week
-Please follow-up with gynecology for annual exam/pap smear
Followup Instructions:
___
|
19810411-DS-15
| 19,810,411 | 21,922,574 |
DS
| 15 |
2174-09-29 00:00:00
|
2174-09-29 06:56:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
codeine / Demerol
Attending: ___
Chief Complaint:
Fevers post-TURP
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo male with recent TURP and left stent
placement on ___ with Dr. ___ presented yesterday with
one day of fevers. The pt states that he was doing well
post-operatively. He had low-grade fever 5 days ago which
resolved. Yesterday, the pt reports a fever to 105. He
presented
to the ___ Emergency Department with a fever
of 102. He was fluid resuscitated, given ceftriaxone and
ciprofloxacin, and transferred to the ED at ___.
Notably,
UA with leuk est, WBCs, and RBCs, negative nitrites, and CBC
with
WBC 5.4. UCx and BCx's were drawn and he was started on
vanc/zosyn. A CT was done that shows normal post-op changes and
cystitis.
Currently, he is doing well. He complains of mild lower
abdominal crampy pain. No nausea. No fevers overnight. HIs foley
remains in place.
Past Medical History:
HTN
HLD
BPH
Social History:
___
Family History:
No family history of prostate cancer
Physical Exam:
Exam on Admission
Tmax 99.7, Tc 97.5, HR 52, BP 140/68, RR19, 97% on RA
Gen: No acute distress, alert & oriented
HEENT: Extraocular movements intact, face symmetric
CHEST: Warm and well-perfused
BACK: Non-labored breathing, no CVA tenderness bilaterally
ABD: Soft, mild tenderness to palpation of lower abdomen,
non-distended, no guarding or rebound
EXT: Moves all extremities well
PSY: Appropriately interactive
Pertinent Results:
___ 08:07PM LACTATE-1.2
___ 07:53PM GLUCOSE-98 UREA N-17 CREAT-1.2 SODIUM-139
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
___ 07:53PM WBC-5.4 RBC-4.01* HGB-11.5* HCT-35.5* MCV-89
MCH-28.7 MCHC-32.4 RDW-13.9 RDWSD-45.0
___ 07:53PM URINE COLOR-Red APPEAR-Hazy SP ___
___ 07:53PM URINE BLOOD-LG NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
___ 07:53PM URINE RBC->182* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
___ 07:53PM URINE MUCOUS-RARE
Brief Hospital Course:
Pt was admitted to the urology service for management of fevers
after one night of observation in the ED. He was started on
vancomycin and cefepime. He was hydrated and given a regular
diet. He had no fevers while at the hospital. After 24 hours of
being afebrile, he was transitioned to PO antibiotics. His BCx
was NGTD and UCx from outside hospital and ___ with
enterococcus sensitive to ampicillin. He was discharged in
stable condition with instructions to return with further fevers
and a ten day course of amoxicillin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. alfuzosin 10 mg oral Q24H
2. Amlodipine 5 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Simvastatin 10 mg PO QPM
7. Aspirin 325 mg PO DAILY
8. Cyanocobalamin Dose is Unknown PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Simvastatin 10 mg PO QPM
7. Amoxicillin 500 mg PO Q8H urosepsis
RX *amoxicillin 500 mg 1 capsule(s) by mouth every eight hours
Disp #*27 Capsule Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*30 Capsule Refills:*0
9. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 2 tabs by mouth daily Disp #*20
Capsule Refills:*0
10. alfuzosin 10 mg oral Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Urosepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-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.
-If prescribed; complete the full course of antibiotics.
-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.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative
- AVOID STRAINING for bowel movements as this may stir up
bleeding.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks or until
otherwise advised
-Do not lift anything heavier than a phone book (10 pounds) or
participate in high intensity physical activity for a minimum of
four weeks or until you are cleared by your Urologist in
follow-up
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Do not drive or drink alcohol while taking narcotics and do not
operate dangerous machinery. Also, if the Foley catheter and Leg
Bag are in place--Do NOT drive (you may be a passenger).
WHEN YOU ARE DISCHARGED WITH A FOLEY CATHETER:
-Please also reference the nursing handout and instructions on
routine care and hygiene
-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
-IF YOU HAVE A PRESCRIPTION FOR DITROPAN/OXYBUTININ: YOU MUST
STOP at least 24hours before planned foley removal and void
trial.
-DO NOT have anyone else other than your Surgeon or your
surgeon's representative remove your Foley for any reason.
-Wear Large Foley bag for majority of time; the leg bag is only
for short-term periods for when leaving the house.
-Do NOT drive if you have a Foley in place (for your safety)
Followup Instructions:
___
|
19810528-DS-16
| 19,810,528 | 21,167,298 |
DS
| 16 |
2175-07-06 00:00:00
|
2175-07-06 14:29:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
===================================================
MEDICINE NIGHTFLOAT ADMISSION NOTE
Date of admission: ___
====================================================
PCP: ___
CC: ___ pain
HISTORY OF PRESENT ILLNESS:
___ M PMH Crohn's disease (Dx ___ currently on
remicade, ___ s/p ablation ___, with history of multiple prior
small bowel obstructions previously requiring ex lap x3,
presenting with abdominal pain.
Patient had multiple small bowel obstructions and feels the
symptomatology is consistent with prior. On ___ patient noted
worsening abdominal pain and distention, which has improved
somewhat over the past couple days. He noted a subsequent
decrease in the size of his BMs; with eventual cessation of BMs
2
days ago and no passing of gas for the past day. He denies
nausea, vomiting, fevers, dysuria, hematuria. Denies chest pain,
shortness of breath. On a Remicade infusion, last was ___.
Reports he is in the hospital every ___ months with an SBO; last
ex lap was ___ years ago. Denies any cardiac symptoms since his
___ ablation in ___.
In the ED, initial VS were: 96.7 67 129/75 15 99/RA
Exam:
-Mildly distended abdomen, diffusely tender, worse in epigastric
area
-Regular rate and rhythm, no murmurs rubs
Labs:
-Unremarkable chem 7, CBC, LFTs; lactate 1.6; nl coags;
unremarkable UA
Imaging:
-CT A/P: mild/partial SBO.
GI consult: recommended IV methylpred and admission to medicine.
No NGT placed as pt without significant symptoms. CRS made
aware,
they will see the patient on the floor if desired by inpatient
team.
Imaging showed:
Patient received:
___ 06:17 IVF NS ___ Started
___ 06:17 IV Morphine Sulfate 4 mg ___
___ 08:16 IV Ondansetron 4 mg ___
___ 08:16 IVF NS ___ Started
___ 08:17 IVF NS 1000 mL ___ Stopped (2h
___
___ 09:11 IVF NS 1000 mL ___ Stopped
(___)
___ 09:47 IV HYDROmorphone (Dilaudid) .5 mg
___
___ 14:29 IV MethylPREDNISolone Sodium Succ 20 mg
___
___ 14:29 IVF ___ ___ Started
___ 14:42 IV HYDROmorphone (Dilaudid) .5 mg ___
___ 18:34 IV HYDROmorphone (Dilaudid) .5 mg ___
___ 20:34 IVF ___ 1000 mL ___ Stopped
(6h
___
___ 22:01 IV HYDROmorphone (Dilaudid) .5 mg
___
Transfer VS were: 97.8 66 ___
On arrival to the floor, patient reports ongoing abdominal pain
without passing gas, with pain reasonably well controlled at
present.
REVIEW OF SYSTEMS:
10 point ROS reviewed and negative except as per HPI
Past Medical History:
-___ white syndrome with tachycardia had ablation
successfully in ___.
-appendectomy age ___
-episodic small bowel obstructions s/p ex-lap x3, last ___
-Crohn's disease diagnosed in ___ (colonoscopy ___
showing terminal ileitis confirmed on biopsies)
MRI enterography ___ terminal ileitis measuring
approximately
6 cm resulting in upstream partial small bowel obstruction.
At the age of ___ he had an appendectomy and then since then he's
had at least eight admissions for small bowel obstruction. Three
times he's had surgery. The last surgical procedure was done ___
years ago and at that time there was no mention made of
inflammatory bowel disease. He was admitted to ___
with an acute small bowel obstruction on ___ and
released on ___. He underwent tests there which I have
copies of that showed on initial CAT scan on ___ small
bowel obstruction and then subsequent x-rays including an MRI
showed terminal ileitis with 6 cm of inflammation and proximal
to
this there was some dilatation of the small bowel.
-He had negative blood tests for hepatitis B and tuberculosis in
___
Social History:
___
Family History:
father died of heart disease. Mother is alive and well. No one
in
the family has inflammatory bowel disease or other G.I.
conditions.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9 120/80 59 16 99 ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, nl S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Firm but not taut, mildly distended, diffusely tender
to
palpation, faint bowel sounds present.
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
VS: 98.4 132/83 HR66 17 97 Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, JVP not elevated
HEART: RRR, nl S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: Non-distended, soft, non-tender, normal bowel sounds
EXTREMITIES: no cyanosis, clubbing, or edema
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
WBC 9 (up from 5.4 on ___
Hb stable 12.3 (12.1)
BMP wnl
ALT 43 (normal AST 36, Alk phoph 62, TBili 0.2, lipase 26)
Lactate 1.6, nl coags,
U/A bland
PENDING:
INFLIXIMAB CONCENTRATION AND ANTI-INFLIXIMAB ANTIBODY Results
Pending
BMP ___ pending
Urine culture ___ pending
CT scan ___:
LOWER CHEST: There is minimal bibasilar atelectasis. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. 2 subcentimeter hepatic hypodensities are too small
to characterize, however are not significantly changed, likely
representing hepatic cysts or biliary hamartomas. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without
evidence of focal lesions or pancreatic ductal dilatation. There
is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal
nephrogram. Few tiny a cortical hypodensities in the right
kidney are not significantly changed, previously characterized
as
cysts on MRI. There is no hydronephrosis. There is no
perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Again seen is
wall
thickening and mild mucosal hyper enhancement of the
distal/terminal ileum extending to the ileocecal valve (601:32,
2:67). Proximal to this segment of abnormal bowel, there are
mildly dilated loops of small bowel measuring up to 3.6 cm,
the more proximal of which are more prominent in caliber
compared
with prior. The colon and rectum are within normal limits. The
appendix is not visualized, however there are no secondary signs
of acute appendicitis. There is no evidence of free air or free
fluid.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are
normal.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute
fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
Partial or mild small-bowel obstruction secondary to an abnormal
segment of terminal/distal ileum with mild wall thickening and
mild mucosal hyperenhancement, consistent with mild active
Crohn's inflammation.
Brief Hospital Course:
Mr. ___ is a ___ M PMH Crohn's disease (Dx ___
currently on
remicade (last infusion ___, ___ s/p ablation ___, with
history of multiple prior small bowel obstructions previously
requiring ex lap x3, presenting with partial SBO. He was treated
conservatively with bowel rest, IV fluids, and Methylpred for
his Crohn's. His diet was slowly advanced, and he started having
regular bowel movements on ___. At time of discharge, he had
no abdominal pain, he was tolerating a regular diet, vitals were
stable, and his abdominal exam was benign. He was discharged on
Prednisone 60mg daily, and has follow-up with his outpatient
gastroenterologist in ___ week.
TRANSITIONAL ISSUES:
Hb 12.3
Infliximab concentration and anti-infliximab antibody pending
- Patient will take Prednisone 60mg daily until he sees Dr. ___
in clinic. Since he was discharged on a short (2 week maximum)
course of steroids, he was NOT given PPI, Bactrim, Vitamin d, or
Calcium. If prednisone is continued longer term, he will need
these medicines.
- Follow up with Dr. ___ in 1 week
- Contact: ___
___: Brother Phone: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. InFLIXimab 500 mg IV Q4WEEKS
Discharge Medications:
1. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*42 Tablet
Refills:*0
2. HELD- InFLIXimab 500 mg IV Q4WEEKS This medication was held.
Do not restart InFLIXimab until Dr. ___ you to restart it
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- partial small bowel obstruction
SECONDARY DIAGNOSIS
- Crohn's 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 care of you.
Why was I admitted to the hospital?
- You had a partial blockage in your bowels.
What happened while I was here?
- You got steroids and IV fluids.
- Your bowels got better, and you were able to eat food.
What should I do when I go home?
- Take Prednisone 60mg (3 pills) every day until you see Dr.
___
- ___ up with Dr. ___ in 1 week (see below for appointment)
- If you have any abdominal pain, nausea, vomiting, or if you
stop having bowel movements, please call Dr. ___
We wish you all the best in the future!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19810967-DS-5
| 19,810,967 | 20,765,560 |
DS
| 5 |
2169-12-19 00:00:00
|
2169-12-19 18:22:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
worst headache of life
Major Surgical or Invasive Procedure:
___ Angio for AComm aneurysm coiling
History of Present Illness:
___ year old male with history of hypertension (med noncompliant)
who presents today with sudden onset worst headache of life. He
was in class at approximately 10:50am during headache onset; he
waited for class to end then presented to the ___ where he was transferred to ___ ED.
On eval in the ED, the patient reports headache improved. He has
had recent vision changes, difficulty reading. Denies
nausea/vomiting. No weakness/paresthesias.
Past Medical History:
Hernia repair ___
Hypertention (untreated)
Social History:
Single, lives alone. Originally from ___.
Student at ___ - ___ in ___.
Former smoker, ___ yrs, quit ___ yrs ago. Denies ETOH/illicits.
Tobacco Use:
[ ]No
[x]Yes
[ ]Current Smoker
Years: Packs per day:
[x]Previous Smoker
Years: 5 Packs per day:
Recreational Drug use:
[x]No
[ ]Yes
Alcohol Use:
[x]No
[ ]Yes
Family History:
Negative for aneurysm/stroke
Is there a family history of Aneurysms?
[x]No
[ ]Yes
Physical Exam:
=================
ON ADMISSION:
=================
Date and Time of evaluation: ___ 16:45
___ and ___:
[x]Grade I: Asymptomatic, mild headache, slight nuchal rigidity
[ ]Grade II: Moderate to severe headache, nuchal rigidity, no
neurological deficit other than cranial nerve palsy.
[ ]Grade III: Drowsiness/Confusion, mild focal neurological
deficit.
[ ]Grade IV: Stupor, moderate-severe hemiparesis.
[ ]Grade V: Coma, decerebrate posturing.
Fisher Grade:
[ ]1 No hemorrhage evident
[x]2 Subarachnoid hemorrhage less than 1mm thick
[ ]3 Subarachnoid hemorrhage more than 1mm thick
[ ]4 Subarachnoid hemorrhage of any thickness with IVH or
parenchymal extension
___ SAH Grading Scale:
[x]Grade I: GCS 15, no motor deficit
[ ]Grade II: GCS ___, no motor deficit
[ ]Grade III: GCS ___, with motor deficit
[ ]Grade IV: GCS ___, with or without motor deficit
[ ]Grade V: GCS ___, with or without motor deficit
___ Coma Scale:
[ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
_15_ Total
ICH Score:
GCS
[ ]2 GCS ___
[ ]1 GCS ___
[x]0 GCS ___
ICH Volume
[ ]1 30 mL or Greater
[x]0 Less than 30 mL
Intraventricular Hemorrhage
[ ]1 Present
[x]0 Absent
Infratentorial ICH
[ ___ Yes
[x]0 No
Age
[ ]1 ___ years old or greater
[x]0 Less than ___ years old
Total Score: 0
O:
T: 97.8 BP: 181/101 HR: 78 R: 19 O2Sats: 100%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs Full
Neck: Supple.
Lungs: No resp distress
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension. No dysarthria
or
paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
3mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch
Handedness Left
=============
ON DISCHARGE:
=============
Opens eyes: [ ]spontaneous [x]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL 4-3mm bilaterally
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
___
Left5 5555
IPQuadHamATEHLGast
___
Left5 5 5 5 5 5
[x]Sensation intact to light touch
Angio Groin Site:
Right groin: [x]Soft, no hematoma [x]Palpable pulses
Pertinent Results:
Please see OMR for pertinent lab and imaging results.
Brief Hospital Course:
Mr. ___ presented to ___ ED with worst headache of life. A
CTA demonstrated subarachnoid hemorrhage and A-comm aneurysm.
#SAH with A-comm aneurysm
patient went to angio for coiling of an A-comm aneurysm. The
procedure was uncomplicated and he tolerated it well. Please see
separately dicatated operative report for complete details of
the procedure. He was extubated and transferred to PACU for
recovery where he remained neurologically and hemodynamically
stable. He was transferred to the surgical ICU for ongoing close
neurological monitoring. He was started on nimodipine to prevent
vasospasm. He was kept euvolemic with IV fluids running at
100cc/hr. He remained neurologically stable and was called out
to the neuro step-down unit. IV fluids were discontinued but was
given IVF bolus as needed to maintain euvolemia. Repeat CTA was
done on ___ which was negative for vasospasm.
#Back pain
The patient complained of low back pain, which is likely related
to the ___ blood. He was given 6mg IV Dex x1, which helped the
pain. He was subsequently started on a 3 day Dex taper. Given
his ongoing back pain, patient was given oxycodone and was
evaluated by Physical therapy. He was cleared as safe for
discharge to home by physical therapy.
#Hypertension
Patient has baseline hypertension and is prescribed amlodipine
which he was non-compliant with prior to his hospitalization.
His amlodipine was held while he was on the nimodpine as it is
the same class of antihypertensive. He remained normotensive on
this regimen and can start his amlodipine when the nimodipine
course is complete. The patient was sent with nimodipine that
was delivered to his bedside.
Medications on Admission:
amlodipine (non-compliant)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
do not exceed 4g in 24h from all sources
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID
4. Milk of Magnesia 30 mL PO Q6H:PRN constipation
5. NiMODipine 60 mg PO Q4H
Treatment course 21 days (___)
RX *nimodipine 30 mg 2 capsule(s) by mouth every 4 hours Disp
#*200 Capsule Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth every 6 hours
as needed Disp #*28 Tablet Refills:*0
7. Senna 17.2 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid hemorrhage
ACOMM aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Aneurysmal Subarachnoid Hemorrhage
Procedures:
You had a cerebral angiogram to coil the aneurysm. You may
experience some mild tenderness and bruising at the puncture
site (groin).
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
You make take a shower.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you must refrain
from driving.
Medications
Resume your normal medications and begin new medications as
directed.
You may be instructed by your doctor to take one ___ a
day. If so, do not take any other products that have aspirin in
them. If you are unsure of what products contain Aspirin, as
your pharmacist or call our office.
Please do NOT take any ADDITIONAL blood thinning medication
(Aspirin, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on a medication called Nimodipine.
This medication is used to help prevent cerebral vasospasm
(narrowing of blood vessels in the brain).
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
Mild to moderate headaches that last several days to a few
weeks.
Difficulty with short term memory.
Fatigue is very normal
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site or puncture site.
Fever greater than 101.5 degrees Fahrenheit
Constipation
Blood in your stool or urine
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
19811575-DS-21
| 19,811,575 | 22,863,261 |
DS
| 21 |
2138-03-08 00:00:00
|
2138-03-08 15:25:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Right periprosthetic femur fracture
Major Surgical or Invasive Procedure:
Right periprosthetic femur open reduction internal fixation
History of Present Illness:
___ year-old male with history of IDDM with insulin pump, R
THA (___), right acetabular ORIF (___) presents to ___
ED with right hip pain after fall. He reports that he first fell
on his right side after running into someone and tripping last
week while on a cruise in ___. X-rays on the cruise ship
reportedly did not show any evidence of fracture, however he
used
crutches for the remainder of the trip. Upon flying across the
country to return home on ___, he fell again while using the
crutches to go up his driveway. This was immediately followed by
severe pain in the right hip, prompting his presentation to the
___ and subsequent transfer to ___ for management.
He is on ASA 81 daily and took his last dose ___ AM
(___).
No other anticoagulation.
His diabetes is well-controlled with his insulin pump and
glucometer, though he does report a recent burn on the bottom of
his right foot. Denies hx of peripheral neuropathy.
Past Medical History:
-HTN
-HLD
-T2DM complicated by mild retinopathy and peripheral neuropathy
on insulin pump
-Right acetabulum fracture s/p ORIF (___)
Social History:
___
Family History:
Father: ___ at age ___ from prostate cancer
Mother: ___ emphysema
Sister: ___
Physical ___:
On discharge:
Temp: 98.4 PO BP: 110/55 L Lying HR: 109 RR: 18 O2 sat: 97% O2
delivery: Ra
GEN: AOx3 WN, WD in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR
PULM: unlabored breathing
EXT:
Right lower extremity:
Surgical dressing c/d/i
Fires ___
SILT sural, saphenous, superficial peroneal, deep peroneal and
tibial distributions
digits warm and well perfused
Pertinent Results:
See OMR for pertinent lab and imaging results.
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 R periprosthetic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for R periprosthetic femur ORIF, which
the patient tolerated well. For full details of the procedure
please see the separately dictated operative report. The patient
was taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home
with home physical therapy 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
touchdown weightbearing in the right lower extremity extremity,
and will be discharged on Lovenox for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. irbesartan 300 mg oral DAILY
5. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: 80-180
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
4. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 40 mg sc qpm Disp #*30 Syringe
Refills:*0
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*45 Tablet Refills:*0
6. Senna 8.6 mg PO DAILY
7. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: 80-180
8. amLODIPine 5 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Atorvastatin 40 mg PO DAILY
11. Hydrochlorothiazide 12.5 mg PO DAILY
12. irbesartan 300 mg oral DAILY
13. MetFORMIN XR (Glucophage XR) 1500 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Periprosthetic femur 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:
-Touchdown weightbearing right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is an
over the counter medication.
2) Add Dilaudid as needed for increased pain. Aim to wean off
this medication in 1 week or sooner. This is an example on how
to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and continue following
the bowel regimen as stated on your medication prescription
list. These meds (senna, colace, miralax) are over the counter
and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your physicians
at discharge.
8) Continue all home medications unless specifically instructed
to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- If you have a splint in place, splint must be left on until
follow up appointment unless otherwise instructed. Do NOT get
splint wet.
TREATMENT/FREQUENCY:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be left
open to air unless actively draining after POD3. If draining,
you may apply a gauze dressing secured with paper tape. You may
shower and allow water to run over the wound, but please refrain
from bathing for at least 4 weeks postoperatively.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever greater than 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Touchdown weightbearing right lower extremity
Treatments Frequency:
Site: Right hip
Description: Incision dry,healing well.
After POD 2: ___ reapply dry dressing daily then open to air
when no longer draining.
Followup Instructions:
___
|
19811664-DS-9
| 19,811,664 | 27,848,527 |
DS
| 9 |
2136-03-02 00:00:00
|
2136-03-04 23:24:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain, syncope, episodes of apnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old ___ speaking woman presents to the ED after a
syncopal episode during a exercise stress test. the patient was
on the treadmill and after 3 minutes she felt dizzy and her
vision became dark. She does not remember the entire event. The
staff witnessed the event and layed the patient on the floor.
She was in sinus rhythm the entire time and was normotensive.
According to her boyfriend she has had multiple episodes of
syncope when her heart rate is elevated including walking, sex,
climbing stairs. The patient feels light headed prior to passing
out. The episodes last a few minutes and she wakes after with a
normal mental status. Her boyfriend has witness many events the
last ___ months in which she appears limp and becomes apneic
lasting between 30 seconds to a few minutes. No tonic-clonic
activity.
She also has had chest pain for the past few months. The pain is
substernal and does not radiate. It is usually is associated
with walking or climbing stairs. The pain is relieved with rest.
Associated with shorntess of breath.
She is also complaining of left temporal headache today. She
denies any visual changes.
In the ED the patient was hemodynamically stable. She describes
chest pain. She was given aspirin, 3 doses of sub-lingual nitro,
a GI cocktail, and 4mg IV morphine with some relief. While in
the ED the patient was witnessed to have one episode of
unresponsiveness with associated apnea on the monitor lasting a
few seconds. No tonic-clonic activity. Normal sinus on the
monitor with a normal blood pressure. An EEG was performed
without any noted abnormality. She had one of her unresponsive
episodes while on the EEG and did not demonstrate and pathology.
In the ED, initial VS were: 61, 100% on RA, 113/71, 14,
afebrile
.
On arrival to the MICU, the patient is alert and oriented. She
describes having substernal chest pain without radiation. She
feels tired and a little dizzy.
.
Review of systems:
-Denies any fever or chills, no abd pain, no N/V/D, no rash, no
focal neurological symptoms
Past Medical History:
GERD
Social History:
___
Family History:
Denies
Physical Exam:
Vitals: T:98.6 BP:128/75 P:64 R:18 O2: 98% 2L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL; no
temporal tenderness
Neck: supple, JVP not elevated,
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops; no chest tenderness with palpation
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
On discharge stable with no episodes of apnea. Was able to
ambulate without difficulty.
Pertinent Results:
___ 10:50AM BLOOD WBC-5.8 RBC-4.56 Hgb-11.4* Hct-35.2*
MCV-77* MCH-25.0* MCHC-32.4 RDW-14.7 Plt ___
___ 04:46AM BLOOD WBC-4.8 RBC-4.51 Hgb-11.3* Hct-35.4*
MCV-79* MCH-25.1* MCHC-31.9 RDW-15.0 Plt ___
___ 06:32AM BLOOD WBC-5.4 RBC-4.20 Hgb-10.4* Hct-32.8*
MCV-78* MCH-24.7* MCHC-31.6 RDW-14.7 Plt ___
___ 06:32AM BLOOD ___
___ 10:50AM BLOOD ESR-13
___ 06:32AM BLOOD Glucose-94 UreaN-13 Creat-0.8 Na-138
K-4.4 Cl-103 HCO3-28 AnGap-11
___ 10:50AM BLOOD cTropnT-<0.01
___ 10:04PM BLOOD cTropnT-<0.01
___ 04:46AM BLOOD Calcium-9.1 Phos-4.0 Mg-2.3
___ 10:04PM BLOOD D-Dimer-341
___ 10:50AM BLOOD TSH-1.7
___ 10:50AM BLOOD CRP-1.4
.
Stress ECHO at rest:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). The estimated cardiac index is normal
(>=2.5L/min/m2). There is no left ventricular outflow
obstruction at rest or with Valsalva. Right ventricular chamber
size and free wall motion are normal. There is no aortic valve
stenosis. No aortic regurgitation is seen. Physiologic mitral
regurgitation is seen (within normal limits). The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Post exercise images not possible pt collapsed on treadmill at
the termination of exercise. Rhythm was sinus tachycardia prior
to and post collapse.
.
CT HEAD:
Final Report
INDICATION: ___ woman with syncope event, question
intracranial
process.
COMPARISON: None.
TECHNIQUE: Contiguous axial imaging was obtained through the
brain. No
contrast was administered. Coronal and sagittal reformats were
completed.
FINDINGS: There is no acute intracranial hemorrhage, edema, mass
effect, or
territorial infarction. The ventricles and sulci are normal in
size and
configuration. The visualized paranasal sinuses, mastoid air
cells and middle
ear cavities are clear. Osseous structures are intact.
IMPRESSION: No acute intracranial process.
The study and the report were reviewed by the staff radiologist.
.
CXR:
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: ___ female with history of chest
pain.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the chest were obtained.
Lungs are
clear without focal consolidation. No pleural effusion or
pneumothorax is
seen. Cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
#Chest Pain: Patient has had multiple months of exertional SOB
that seem to be more frequent. Was in stress testing today with
syncopal episode. She received aspirin in the ED. Has had one
negative troponin this morning. She was ruled out for an MI with
serial enzymes and had no evidence of disease on an
echocardiogram. Her EKG did not demonstrate any changes.
#Syncope: Pt had episode of syncope during a stress test. per
the history she has been experiencing similar symptoms over the
last few months. Does not have associated seizure like activity
or post-ictal activity. She had a normal short term EEG while in
the ED including one of her episodes. Had a normal resting TTE
today prior to stress testing. Normal CT head. She was
evaluated by cardiology and neurology, neither of whom could
determine a physiologic source for her syncope. She was
discharged with neurology followup.
- Telemetry
#Apnea episodes: Patient seems to have short episodes of
unresponsiveness with apnea. Was witnessed today while in the
ED. unclear etiology. Does not have any hypoxia during episode.
She may benefit from sleep testing as an outpatient.
#Temporal headache: No evidence of temporal arteritis at this
time. Likely tension headache. No vision changes. Normal CRP and
ESR, improved with tylenol.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
syncope
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 falls and blacking out.
You were evaluated thoroughly and no clear reason for your
symptoms was identified. You do not seem to have seizures or
any problems with your heart. We discussed the plan with your
primary care physician.
Please follow up with your physicians as below. If you have
worsening symptoms or fall please contact a physician or come to
an emergency room.
We have not made any changes to your medications.
Followup Instructions:
___
|
19811688-DS-16
| 19,811,688 | 28,400,288 |
DS
| 16 |
2190-05-31 00:00:00
|
2190-06-01 10:44:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with neurofibromatosis 1 with metastatic nerve sheath
tumor who presented to the ED with acute onset chest pain.
Patient reports that since discharge last ___ he began
having hiccups and heart burn sensation. Reports his oncologist
discontinue many of his nausea meds and then started
Chlorpromazine, without relief. Subsequently he began
experiencing worsening "heart burn" sensation in his mid chest
with occasional episodes of sharp, tight, burning sensation in
his mid chest which lasts seconds and resolves but recurrs
frequently. He reports this is ___ in severity and nothing
has bene improving his symptoms. Also reports nausea without
emesis. The pain occurs at rest, worst with laying down. Also
reports ongoing SOB for the past week.
Of note the patient was just discharged from Oncology service
last ___ fo an elective chemotherapy admission. Denies leg
pain/leg swelling.
In ED labs were notable for neutropenia and acute renal failure,
vitals notable for tachycardia to 125. He was given 500cc bolus,
aspirin, zofran, vanc/cefepime and started on a heparin drip for
presumed PE. Unable to obtain CTA due to ___.
Patient arrived without an EKG in the chart
Past Medical History:
Hypothyroidism
hypercholesterolemia
neurofibromatosis 1
metastatic nerve sheath tumor with pancreatic and lung mets
Social History:
___
Family History:
Mother - NF, breast ca age ___
Father - unknown
___ GM - kidney failure
Maternal Aunt- kidney failure on HD
Maternal uncle- kidney cancer
Physical Exam:
Admission Exam:
Vitals: 98.1 116/64 113 20 96%RA
Pain Scale: ___ currently
General: Patient appears overall well, he is pleasant,
appropriate interactive and in NAD. During exam he has constant
hiccups and once experienced similar symptoms to previous which
occurred after multiple hiccups, this resolved spontaneously.
HEENT: Sclera anicteric, MMM
Neck: Port-a-cath site left chest appears c/d/i, non-tender
Lungs: Clear to auscultation bilaterally, moving air well and
symmetrically, no wheezes, rales or rhonchi appreciated
CV: Tachycardic rate, regular rhythm, S1 and S2 clear and of
good quality, no murmurs, rubs or gallops appreciated
Abdomen: soft, non-tender, non-distended, normoactive bowel
sounds throughout, no rebound or guarding
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema
Neuro: AOx3
Discharge Exam:
98.5 99.2 110/60 100 18 97%RA
Appears well overall, walking around the floors in NAD,
hiccuping during exam but improved.
NF subcutaneous nodules evidence on face, trunk and extremities
Slightly odd affect but appropriate and interactive
Lungs clear
CV Tachy but regular. Per patient always has tachycardia around
100
Pertinent Results:
Admission Labs:
___ 02:00PM BLOOD WBC-1.8*# RBC-4.22* Hgb-11.4* Hct-33.1*
MCV-79* MCH-27.1 MCHC-34.6 RDW-15.1 Plt ___
___ 12:44AM BLOOD WBC-2.3* RBC-3.88* Hgb-10.6* Hct-31.2*
MCV-80* MCH-27.2 MCHC-33.9 RDW-15.8* Plt ___
___ 02:00PM BLOOD Neuts-38.0* Lymphs-46.7* Monos-12.7*
Eos-1.6 Baso-0.9
___ 12:44AM BLOOD Neuts-20* Bands-2 Lymphs-49* Monos-25*
Eos-0 Baso-0 Atyps-4* ___ Myelos-0
___ 02:00PM BLOOD UreaN-26* Creat-1.6* Na-132* K-3.3 Cl-92*
HCO3-26 AnGap-17
___ 12:44AM BLOOD Glucose-133* UreaN-30* Creat-1.7* Na-129*
K-3.4 Cl-92* HCO3-24 AnGap-16
___ 12:44AM BLOOD ___ PTT-26.8 ___
___ 02:00PM BLOOD ALT-127* AST-55* AlkPhos-111 TotBili-0.3
___ 12:44AM BLOOD ALT-123* AST-61* AlkPhos-110 TotBili-0.2
Discharge Labs:
___ 06:00AM BLOOD WBC-5.4# RBC-3.28* Hgb-9.1* Hct-26.7*
MCV-81* MCH-27.6 MCHC-34.0 RDW-16.4* Plt ___
___ 06:00AM BLOOD Glucose-89 UreaN-14 Creat-0.9 Na-138
K-3.2* Cl-103 HCO3-24 AnGap-14
___ 06:00AM BLOOD ALT-69* AST-29 AlkPhos-84 TotBili-0.1
___ 06:00AM BLOOD Calcium-7.9* Phos-2.9 Mg-2.3
Reports:
___: No evidence of deep venous thrombosis in the bilateral
lower extremity veins.
CXR PA/LAT (my read): Port in place left chest, pulm vascular
congestion but otherwise clear lung fields
V/Q scan: No evidence for PE, normal examination
Brief Hospital Course:
___ with neurofibromatosis 1 with malignant peripheral nerve
sheath tumor of L lower leg in ___ s/p radiation and surgical
resection, recently diagnosed new
pancreatic mass and lung nodules in ___ s/p biopsy
consistent with MPNST now s/p C1 AIM admitted now with chest
pain most likely GERD and hiccup related, ruled out PE.
# Chest pain: His symptoms were most consistent with a primary
GI process such as GERD and esophageal spasm especially since
this occurred after significant hiccups. While suspicion was low
for a PE the patient was tachcyardic to the 120s with dyspnea
and has active malignancy and a recent hospitalization for
chemotherapy so V/Q performed (ARF on admission) which ruled out
PE. Started on PPI and Maalox with improvement in symptoms.
# Hiccups: New onset after chemo administration, continuous and
refractory. Attempted Reglan, Lorazepam, Zofran and Thorazine in
the outpatient setting without improvement. Started on standing
Baclofen inpatient and Thorazine PRN with improvement in
symptoms though also with continuing hiccups. Would recommend
uptitrating dose of Baclofen if hiccups continue.
# Acute Renal Failure: Pre-renal given poor PO intake and
ongoing lasix use in a patient who previously did not require
diuretics (was started for edema after massive IVF
administration with chemo). Treated with IVFs with resolution.
Discontinued Furosemide, no indication for ongoing lasix use.
# Hyponatremia: Hypovolumic and resolved with IVFs
# Neutropenia: Chemo related s/p Neulasta ___ prior to
admission, counts recovered as expected.
# Malignant peripheral neural sheath tumor: Metastatic s/p
resection in ___ currently C1 adriamycin/ifosfamide. Dr
___ was involved during patients admissions
Transitional issues:
# CONTACT: Mother ___ ___ or ___
# Recommend uptitrating Baclofen if hiccups continue
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Lorazepam 0.5-1 mg PO Q6H:PRN Anxiety
5. Acetaminophen 325-650 mg PO Q6H:PRN pain
6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
7. Docusate Sodium 100 mg PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Prochlorperazine 10 mg PO Q6H:PRN nausea and vomiting
10. Senna 8.6 mg PO BID:PRN constipation
11. Ondansetron ___ mg PO Q8H:PRN nausea
12. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Atorvastatin 40 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. ChlorproMAZINE 25 mg PO TID:PRN Hiccups
5. Docusate Sodium 100 mg PO BID
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Senna 8.6 mg PO BID:PRN constipation
9. Baclofen 10 mg PO TID
RX *baclofen 10 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
10. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
11. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Active:
- GERD
- Hiccups
Chronic:
- Malignant peripheral neural sheath tumor s/p resection ___
and C1 adriamycin/ifosfamide
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a pleasure treating you during this hosptialization. You
were admitted with chest pain however this seems most consistent
with esophageal reflux and heartburn exacerbated by hiccups.
Your medications were adjusted to include an acid suppressing
agent and medications to reduce your hiccups. You also had some
mild renal failure which improved with IV fluids, this occurred
because you were dehydrated. It is important you eat and drink
plenty of fluids to prevent this from happening, also stop
taking Lasix.
Followup Instructions:
___
|
19811704-DS-6
| 19,811,704 | 26,196,091 |
DS
| 6 |
2187-01-14 00:00:00
|
2187-01-14 16:53:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
(history derived from OSH notes as pt unable to provide)
___ with h/o dementia, CAD s/p CABG in ___, CHF 35-40%,
presents with 2 days of intermittent L anterior CP. Pain started
last night, recurred when he awoke today. Recieved sublingual
nitro at nursing home. He presented initially to ___,
where ther was initial concern for 0.5mm STE's in III, avF,
which resolved. Troponin was 0.06 at 2:45pm. He received 3 SLN
with good effect, and was started on ASA 325mg, morphine 2mg IV
and started on heparin gtt. He was then transferred to ___ ED.
In the ED, initial VS were:98.4 78 150/64 16 97% RA. Labs not
performed. EKG showed SR 74, RBBB, Inferior Q waves c/w prior.
No ST changes. CXR not performed. Pt was seen by cardiology, who
recommended admission to ___ for medical mgmt of NSTEMI and
possible cath. Pt was given no new medications.
On the floor pt's VS were notable for BP of 176/81. He denied CP
or SOB. He denied any other kinds of pain.
Past Medical History:
# CAD s/p MI ___ & CABG (5 vessel)- anatomy unknown
# History of GIB ___ erosive gastritis
# Depression
# Inclusion Body Myositis
- presented previously in ___ with weakness and elevated CK
- followed by Neuro (Dr. ___
# OSA
# BPH
Social History:
___
Family History:
father died at ___, mother died at ___ of ICH, son has GERD ___
hiatal hernia
Physical Exam:
Initial Physical Exam:
VS: 98.9, 176/81, 77, 18, 97% on RA
General- Alert, orientedx2ish (knows month and year and the
president, not the date), no acute distress, resting
comfortably.
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Mild bibasilar crackles, no wheezes or ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 1+ pulses in the LEs, no clubbing,
cyanosis or edema
Neuro- CNs2-12 grossly intact, motor function grossly normal
Discharge PHysical:
VS: 98.6 101-150/51-59 ___ 18 95-98% RA
UOP: ___ yesterday
Telemetry- No overnight events; Avg HR 50-60s
GENERAL: alert, awake, responsive to questions, breathing
comfortably completely recumbent on CPAP
HEENT: NCAT. PERRLA, EOMI, MMM. Sclera anicteric, no
conjunctival pallor. OP clear, trachea midline, no thyromegaly
or cervical LAD.
NECK: Supple, with JVP of 5 cm without evidence of HJR. Carotids
benign bilaterally.
CARDIAC: S1/S2 soft ___ early systolic murmur RUSB. PMI
non-enlarged, non-displaced. No parasternal or subxiphoid
heaves, precordial thrills, or palpable pulsations in the 3LICS.
LUNGS: coarse crackles at bilateral bases, clear in upper lung
fields
ABDOMEN: Soft, NT, ND. BS + X4, No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominal bruits.
EXTREMITIES: No CCE or edema. No femoral bruits. L femoral
access site unremarkable.
SKIN: No concerning lesions.
Pertinent Results:
ADMISSION LABS:
___ 07:50AM BLOOD WBC-9.7# RBC-4.34* Hgb-13.7*# Hct-39.3*#
MCV-91# MCH-31.5# MCHC-34.8 RDW-14.1 Plt ___
___ 01:50AM BLOOD Glucose-85 UreaN-28* Creat-0.7 Na-146*
K-3.7 Cl-107 HCO3-28 AnGap-15
___ 01:50AM BLOOD Calcium-8.2* Phos-2.3* Mg-1.9
PERTINENT LABS:
___ 03:30PM BLOOD cTropnT-0.07*
___ 01:50AM BLOOD cTropnT-0.07*
DISCHARGE LABS:
___ 09:30AM BLOOD WBC-10.1 RBC-3.74* Hgb-12.1* Hct-34.2*
MCV-91 MCH-32.2* MCHC-35.3* RDW-14.1 Plt ___
___ 09:30AM BLOOD Plt ___
___ 09:30AM BLOOD Glucose-89 UreaN-42* Creat-0.8 Na-144
K-3.8 Cl-109* HCO3-21* AnGap-18
___ 09:30AM BLOOD ALT-14 AST-22 LD(LDH)-216 AlkPhos-63
TotBili-0.4
___ 09:30AM BLOOD Lipase-27
___ 09:30AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.8
Brief Hospital Course:
This is a ___ year old man with h/o CAD s/p CABG ___, dementia,
inclusion body myositis, remote UGIB who presents with NSTEMI,
hospital course c/b likely aspiration pneumonitis.
#NSTEMI: patient was poor interventional candidate and so was
treated with medical management that included aspirin,
metoprolol, no statin due to his myositis. He was given
amlodipine for anti-anginal activity. On hospital day 2 he
developed recurrent chest pain that was unresponsive to
nitroglycerin; this subsequently resolved with morphine and did
not recur. He was started on isosorbide mononitrate with good
effect. On discharge, he does not complain of chest pain.
#aspiration pneumonitis: patient had an aspiration episode in
which he had a witnessed regurgitation during sleep ___. The
next morning, he was newly hypoxemic, lethargic but arousable. A
chest x-ray showed opacities at bilateral bases consistent with
aspiration pneumonitis. He was started on empiric
vanc/cefepime/flagyl and given IV hydration. Over the next two
days he markedly improved and reduced his oxygen requirement. He
was transitioned to PO clindamycin for a further 5 days of
therapy.
#anorexia: patient was noted to have markedly decreased appetite
in-house. His home PPI dose was increased and stool softeners
given, with some improvement in his symptoms. Recommend
continued observation and symptomatic treatment.
Transitional issues:
-follow-up appetite loss
-clindamycin finishes ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyanocobalamin 100 mcg PO DAILY
2. Nitroglycerin SL 0.3 mg SL PRN chest pain
3. Vitamin D 50,000 UNIT PO Frequency is Unknown
4. Senna 1 TAB PO HS
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. Calcium Carbonate 1250 mg PO HS
8. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
9. Omeprazole 20 mg PO DAILY
10. Venlafaxine XR 225 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Calcium Carbonate 1250 mg PO HS
4. Cyanocobalamin 100 mcg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Senna 1 TAB PO HS
7. Venlafaxine XR 225 mg PO DAILY
8. Amlodipine 5 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Clindamycin 300 mg PO Q6H
Last day ___. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
12. Lisinopril 5 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. Vitamin D 50,000 UNIT PO Frequency is Unknown
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
16. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Non-ST elevation myocardial infarction
Aspiration pneumonitis
Angina
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 ___ because of chest pain. After doing
some tests, we determined that you were having a small heart
attack. We gave you medicines to treat this heart attack and
your chest pain improved.
You had an episode where you regurgitated and got stomach
contents in your lungs. This caused you to be short of breath.
We gave you extra oxygen and antibiotics and this improved your
breathing markedly. Finish taking the antibiotic, called
Clindamycin, on ___.
Please call your doctor or visit the emergency room if you feel
further chest pain, shortness of breath, dizziness, or swelling
in your legs.
Followup Instructions:
___
|
19811865-DS-13
| 19,811,865 | 23,872,234 |
DS
| 13 |
2142-12-16 00:00:00
|
2142-12-17 12:51:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
dacarbazine / metformin
Attending: ___.
Chief Complaint:
fever, hemoptysis, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F with Hodgkin's Lymphoma Stage IIIB
(EBV+)
on ABVD chemotherapy, s/p bronchoscopy here ___ with
transbronchial biopsy complicated by intraalveolar hemorrhage,
who presents with fevers, hemoptysis, and left upper back pain.
She had an admission ___ ___BUS and fluoroscopic
guided transbronchial biopsies in LLL and tracheal biopsies with
IP. Biopsies were performed for pulmonary nodules noted on
imaging. She had hemorrhage with biopsy, resulting in hypoxia
which had resolved by the time of discharge. She was still
having
hemoptysis at time of discharge.
On ___ she received 2 U PRBCs as an outpatient for Hgb 7.5
(which
she was discharged from the hospital with).
She reports that in the last days she has been experiencing DOE
with ADL. She has had a cough since the bronchoscopy, but is
bringing up less brown matter than before (seen at bedside,
appears to be old blood). No pleuritic chest pain. + pain and
she
points to the left posterior costal margin; she thinks this
started some time after bronchoscopy. + fatigue. Fever to 100.7
today. She has otherwise been eating well. She has intermittent
nausea, no vomiting, no diarrhea. No headache, no focal
neurologic symptoms. No urinary symptoms. Notes two weeks of
calf
pain L>R. Went to her PCP and was directed to ED for fever.
In the ED, initial VS were: 8 99.6 127 124/74 18 97% RA
Labs were notable for: H/H 9.5/28.0 (appropriate bump from
recent
transfusion), lactate 2.5.
Imaging included: CTA Chest which showed no PE, focal
consolidation in LLL c/w prior hemorrhage, but unable to r/o
infection, and post-surgical seroma.
Treatments received: 2L NS, 2g cefepime, 1g vanco, 500mg
azithro,
10mg oxy. She was seen by IP who did not feel there was any
indication for repeat bronchoscopy and agreed with empiric
therapy for HCAP.
On arrival to the floor, T 100.6, BP 134/60, HR 119, RR 18, SpO2
97% RA.
REVIEW OF SYSTEMS: as above
Past Medical History:
PAST ONCOLOGIC HISTORY
Presented in ___ to her PCP complaining of not
feeling well for a couple of months. + fatigue and weight loss
In ___, she developed a rash. 2 weeks prior to
presenting to her PCP she had had flu-like symptoms. Off and on
abdominal pain.
Chest CT without contrast showed right axillary and mediastinal
adenopathy. The largest mediastinal node measured 1.5 cm in the
AP window. There was retroperitoneal and epigastric adenopathy
with the largest lymph node in the prepancreatic area measuring
10 mm and she also had multiple lung nodules, all subcentimeter.
She underwent a mammogram and ultrasound of the right axilla.
The right axillary lymph node was biopsied and was negative for
malignant cells.
The patient then underwent on ___, an abdomen and
pelvis
CT with contrast, which demonstrated an enlarged spleen at 14.7
cm. There was moderate upper abdominal retroperitoneal
adenopathy, retrogastric, peripancreatic, and paraaortic
lymphadenopathy. The largest lymph node was in the left
paraaortic area just below the origin of the SMA measuring 1.6
cm in short axis diameter.
The patient then underwent a PET CT on ___, which
demonstrated multiple enlarged FDG-avid lymph nodes including
the right level 5 nodes measuring up to 9 mm with an SUVmax of
5.1, right level 4 lymph node measuring 1.4 cm with an SUVmax of
10.4, and a right supraclavicular lymph node measuring up to 1
cm with an SUVmax of 2.1. Scattered small left cervical lymph
nodes were not FDG-avid. There were multiple enlarged FDG-avid
axillary nodes including the largest being a 1.8 x 1.2 cm right
axillary node with SUVmax 9.4. There were multiple FDG-avid
mediastinal, bilateral hilar, and epicardial lymph nodes. There
was a right upper paratracheal node measuring 1 cm with an
SUVmax
of 10.2, a right lower paratracheal node measuring 8 mm, SUVmax
of 4.6. There were bilateral hilar nodes with SUVmax of 4.7 on
the right and 3.3 on the left, a 1.7 x 0.5 cm right epicardial
node with an SUVmax of 4.5. Spleen was enlarged at 15 cm,
intensely avid with an SUVmax of 8.8. There was extensive
FDG-avid upper abdominal retroperitoneal lymphadenopathy
including celiac nodes measuring up to 1.4 cm with an SUVmax of
8.4 and multiple periportal and portacaval lymph nodes up to 4.5
x 2.2 cm with an SUVmax of 6.9. There were multiple
retroperitoneal nodes seen such as retrocaval node measuring 1
cm
with an SUVmax of 8.7. There were enlarged FDG-avid right common
iliac node measured 1 cm with SUVmax 13 and a right external
iliac node measuring up to 9 mm with SUVmax 5.2.
She underwent a right axillary lymph node biopsy, which was
unfortunately also an FNA at ___ on ___.
The cytology showed atypical lymphoid proliferation. The
pathology revealed focal effacement of the lymph node
architecture by a polymorphous infiltrate associated with
fibrosis. The morphologic and immunophenotypic findings were
suspicious for Hodgkin lymphoma.
Bone marrow biopsy done ___ was unremarkable. Excisional
biopsy was recommended.
Underwent excisional biopsy of right axilla lymph node on ___.
Biopsy confirmed diagnosis of Hodgkin's lymphoma, classical
nodular sclerosing type. In situ hybridization studies for
___ virus encoded RNA (___) is positive in neoplastic
cells ___ cells and their variants).
___- echocardiogram showed EF 55%
___ underwent left sided port placement at ___ which
was complicated by left subclavian artery puncture.
Procedure was aborted and pt was transported to ___ for
vascular repair on evening of ___, admitted to vascular surgery
service.
___- underwent successful port placement through ___ ___
the unaffected side
___- spiked fever on ___ and infectious work up was
unremarkable. She was transferred to the oncology service. No
evidence of infection.
___- PFTs- FEV1 77% (mildly reduced), FVC 80% (borderline
normal), ratio normal, diffusing capacity normal adjusted for
Hgb
___- given C1 D1 ABVD on ___ afternoon at the following
doses:
Bleomycin 19 units IV (10 units/m2)
Bleomycin - TEST DOSE 1 unit IV
DOXOrubicin 48 mg IV (25 mg/m2)
VinBLAStine (Velban) 11.5 mg IV (6 mg/m2)
Dacarbazine 720 mg IV (375 mg/m2) - had infusion reaction
(rigors) x 2 despite infusion reaction treatment with
(solumedral, benadryl, tylenol and demerol) so received 60% of
the total 720 mg dose. She received on demerol 12.5 mg IV x 2,
may benefit from higher dose in future
Reaction noted in allergy section of epic.
___- She received 1 unit of blood on ___ prior to
discharge.
___- hospitalized for orbital cellulitis- PRESEPTAL
CELLULITIS - severe swelling but limited to preseptal space on
imaging, no intra-ocular abnormalities on opthal exam in setting
of neutropenia will cover broadly, since Staph/Strep most common
- was treated with vancomycin and Zosyn for 5 days while in
house. Culture data from purulent fluid expressed from infection
yielded MSSA. Zosyn was discontinued for just vancomycin while
awaiting sensitivities. Antibiotic therapy was narrowed to
complete 14 days of dicloxicillin as an outpatient. While
inpatient, she developed antibiotic-associated diarrhea, which
resolved with stopping Zosyn. She also developed vaginal
candidiasis, which was treated with fluconazole 150 mg x1.
Ophthalmology followed the patient while in house with daily
assessment of IOP & visual acuity. She briefly received
latanoprost for elevated IOP in the right eye, which was
attributed to artifact/infection, and not glaucoma. This
resolved
after day 1 of infection/use of latanoprost. Warm compresses and
hygiene were use and emphasized. Analgesia with oxycodone.
___- diagnosed with shingles
___- repeat PFTs- unchanged compared to baseline
___- PET after 2 cycles with marked improvement (initial PET
done at ___, CD being sent to ___ for comparison)
PAST MEDICAL HISTORY:
-Herpes Zoster
-COPD, not on home O2
-HEADACHE - CLASSICAL MIGRAINE, INTRACTABLE
-H/O TOBACCO DEPENDENCE
-ADJUSTMENT DISORDER W DEPRESSED MOOD
-MENOPAUSE
-DM (diabetes mellitus), type 2, uncontrolled
-GERD
-Vitamin D deficiency
-Hyperlipidemia
-Nonproliferative diabetic retinopathy of both eyes
-Major depression
-Anxiety
-s/p Left subclavian artery puncture from attempted port
placement and repair on ___
Social History:
___
Family History:
Father ___ Grandmother dementia, cancer-colon
Paternal Aunt ___ Inflammatory Bowel Disease
Paternal Uncle Cancer - ___
Sister ___ Disease
Physical Exam:
ADMISSION EXAM:
T 100.6, BP 134/60, HR 119, RR 18, SpO2
97% RA.
GENERAL: chronically ill-appearing woman in NAD
HEENT: Alopecia, NC/AT, EOMI, PERRL, MMM, poor dentition,
CARDIAC: RRR, nl S1 and S2, no murmurs
LUNG: decreased breath sounds throughout, very slight rales at
the left base
ABD: +BS, soft, NT/ND, no r/g
EXT: No lower extremity pitting edema, ttp of the left calf
PULSES: 2+DP pulses bilaterally
NEURO: A&OX3, strength ___ in proximal and distal extremities,
sensation grossly intact
SKIN: Warm and dry
DISCHARGE EXAM:
VS T 98 102 18 120/68 97RA
GENERAL: chronically ill-appearing woman in NAD
HEENT: Alopecia, NC/AT, EOMI, PERRL, MMM, poor dentition,
CARDIAC: RRR, nl S1 and S2, no murmurs
LUNG: decreased breath sounds throughout, very slight rales at
the left base
ABD: +BS, soft, NT/ND, no r/g
EXT: No lower extremity pitting edema, ttp of the left calf
PULSES: 2+DP pulses bilaterally
NEURO: A&OX3, strength ___ in proximal and distal extremities,
sensation grossly intact
SKIN: Warm and dry
Pertinent Results:
ADMISSION LABS:
___ 12:12PM BLOOD WBC-4.4# RBC-3.25* Hgb-9.5*# Hct-28.0*
MCV-86 MCH-29.3 MCHC-34.0 RDW-17.8* Plt ___
___ 12:12PM BLOOD Neuts-89.3* Lymphs-7.8* Monos-2.0 Eos-0.8
Baso-0.2
___ 12:12PM BLOOD ___ PTT-26.4 ___
___ 12:12PM BLOOD Glucose-296* UreaN-7 Creat-0.6 Na-133
K-3.6 Cl-98 HCO3-22 AnGap-17
___ 01:00PM BLOOD Lactate-2.5*
___ 05:33AM BLOOD ALT-12 AST-15 AlkPhos-113* TotBili-0.7
___ 02:00PM URINE Color-Straw Appear-Clear Sp ___
___ 02:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 02:00PM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
DISCHARGE LABS:
___ 06:00AM BLOOD WBC-1.8* RBC-3.34* Hgb-9.7* Hct-28.2*
MCV-84 MCH-29.0 MCHC-34.4 RDW-17.4* Plt ___
___ 06:00AM BLOOD Glucose-201* UreaN-8 Creat-0.6 Na-139
K-4.3 Cl-105 HCO3-28 AnGap-10
___ 06:00AM BLOOD Calcium-9.4 Phos-3.2 Mg-2.1
MICROBIOLOGY:
___ BLOOD CULTURE: NO GROWTH ON DISCHARGE
___ URINE CULTURE (Final ___: <10,000 organisms/ml.
___ SPUTUM CULTURE: GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field - cancelled
STUDIES:
___ CXR: IMPRESSION:
Interval improvement of left lung base opacity, possibly
representing
resolving hemorrhage. Interval improvement and now new opacity
due to
underlying infection or new hemorrhage, is not excluded.
___ CTA: Final Report
EXAMINATION: CTA CHEST
IMPRESSION:
1. No pulmonary embolism or acute aortic pathology.
2. Focal consolidation in the left lower lobe may represent
resolving
post-operative hemorrhage, but superimposed infection should
certainly be
considered in the appropriate clinical setting. Several other
subtle areas of
ground-glass opacity as described above may be due to the
expiratory phase of
the scan versus mild pulmonary edema.
3. Overall stable appearance of right axillary simple fluid
collection, which
most likely represents a postsurgical seroma.
___ BILATERAL LOWER EXTREMITY DOPPLER ULTRASOUNDS:
IMPRESSION:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
Brief Hospital Course:
___ with COPD (no home O2), hx of major depression and anxiety
and stage IIIB Hodgkin's lymphoma (EBV+) on C4D8 ABVD (her
treatment history has been complicated by multiple problems
including subclavian injury with initial port placement,
preseptal cellulitis, zoster) who presents with fever and left
sided back pain after undergoing bronchoscopy and biopsies on
___ which were complicated by bleeding. Imaging with
consolidation in LLL which may represent resolving hemorrahge
and/or pneumonia. Patient was started on Vancomycin and Cefepime
for
empiric coverage but narrowed eventually to levofloxacin on
discharge for PNA.
# Hodgkin's Lymphoma, Stage IVB. On cycle 4 of ABVD. She
continued Neupogen 300 mcg SC qod and received last dose on
___, day of discharge.
# Community acquired pneumonia: Likely source of her fevers,
chest pain. BAL grew S. viridans. Briefly on
vanc/cefepime/azithro, but changed to ceftriaxone/azithro on
___ and then to PO levofloxacin to include atypical coverage.
Discharged home with total 7 days antibiotics. Blood, urine
cultures with no growth. Sputum culture inadequate.
# Hemoptysis: Complication of recent bronchoscopy. This improved
throughout admission, although she still had scant brown
hemoptysis on discharge.
# Back Pain: Possibly acute from PNA. She continued home
oxycodone and bowel regimen with colace and senna.
# Left leg pain: Due to complaints of left leg pain, bilateral
___ dopplers were performed, which revealed no DVT. Pain may be
due to neupogen.
# DMII: She continued home lantus and ISS.
# COPD: She continued atrovent and albuterol nebs PRN dyspnea,
cough, wheezing
# Post-herpetic neuralgia: She continued gabapentin. Acyclovir
was given instead of home prophylactic
Valacyclovir, as this is non-formulary.
# Migraines: Contined Topamax
# HLD: Cont statin.
# Hypothyrodisim: Cont Levothyroxine.
# Depression: Cont Cymbalta.
TRANSITIONAL ISSUES:
===============
- Discharged with 3 remaining days of PO levoquin (last day =
___
- Still having left calf pain, however doppler showed no DVT.
- Hemoptysis resolving, still with some dime-sized, brown
sputum.
- Code: Full
- Name of health care proxy: ___
Relationship: Son
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Duloxetine 60 mg PO DAILY
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Loratadine 10 mg PO DAILY
5. Lorazepam 1 mg PO Q6H:PRN anxiety, nausea
6. Omeprazole 20 mg PO BID
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
8. Pravastatin 40 mg PO QHS
9. Senna 8.6 mg PO BID:PRN constipation
10. Topiramate (Topamax) 25 mg PO QHS
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Prochlorperazine 10 mg PO Q8H:PRN nausea
15. Gabapentin 300 mg PO TID
16. ValACYclovir 1000 mg PO Q8H
17. Glargine 10 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
18. Filgrastim 300 mcg SC QOD
Discharge Medications:
1. Duloxetine 60 mg PO DAILY
2. Filgrastim 300 mcg SC QOD
3. Gabapentin 300 mg PO TID
4. Glargine 10 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Levothyroxine Sodium 25 mcg PO DAILY
6. Loratadine 10 mg PO DAILY
7. Lorazepam 1 mg PO Q6H:PRN anxiety, nausea
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Omeprazole 20 mg PO BID
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Pravastatin 40 mg PO QHS
14. Prochlorperazine 10 mg PO Q8H:PRN nausea
15. Senna 8.6 mg PO BID:PRN constipation
16. Topiramate (Topamax) 25 mg PO QHS
17. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
18. ValACYclovir 1000 mg PO Q8H
19. Levofloxacin 750 mg PO DAILY Duration: 3 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth dailyd Disp #*3
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: healthcare-associated pneumonia
Secondary diagnoses: hodgkin's lymphoma, type II diabetes
mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at the ___
___. You were admitted for fevers,
shortness of breath and pain in your back. Imaging of your chest
showed that you may have a pneumonia that was causing those
symptoms. We initially gave you antibiotics through your IV, but
then transitioned you to oral antibiotics. We also performed
ultrasounds of your legs, which showed no clot.
We are discharging you with 3 more doses of antibiotics. Start
taking one pill of levofloxacin daily tomorrow. Your last pill
will be on ___.
Please continue to take all your medications as prescribed and
follow-up at the appointments below.
On behalf of your ___ team,
We wish you all the best
Followup Instructions:
___
|
19812073-DS-15
| 19,812,073 | 22,683,833 |
DS
| 15 |
2141-01-06 00:00:00
|
2141-01-05 15:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
ALL antibiotics except penicillin
Attending: ___.
Chief Complaint:
headaches, interhemispheric SDH s/p fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old ___ speaking female with a history of
Afib on coumadin, CAD s/p PCI (cordis) to RCA in ___, CHF with
EF 30%, presenting s/p mechanical fall (missed a stair). No LOC.
Complaning of upper back pain only. No nausea, vomiting, HA,
blurred vision
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, ?Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: PCI (Cordis) to RCA in
___ at ___
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
rapid Atrial fibrillation
Systolic heart failure with an EF of 30% and global hypokinesis
h/o lower GI bleed (hemorrhoidal) while on pradaxa in the past
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On Admission:
awake, alert, oriented x 3
follows commands throughout
PERRL, EOMI, FSTM
no drift
MAE x ___
sensation intact to light touch
At discharge: she is a awake, alert and oriented, PERRLA, EOMi,
face symmetrical, no pronator drift, MAE well.
Pertinent Results:
___ 10:40PM ___ PTT-37.6* ___
___ 10:40PM PLT COUNT-242
___ 10:40PM WBC-16.0*# RBC-4.91 HGB-12.3 HCT-37.6 MCV-77*
MCH-25.0* MCHC-32.7 RDW-17.3*
___ 10:40PM GLUCOSE-171* UREA N-16 CREAT-0.9 SODIUM-131*
POTASSIUM-4.3 CHLORIDE-93* TOTAL CO2-27 ANION GAP-15
CT head ___ :
IMPRESSION:
1. Moderate left parietal subgaleal hematoma.
2. Small 3.5 mm wide and 35 mm long left parafalcine acute
subdural hematoma.
CT C-spine ___ height of the vertebral bodies of the C-spine
is preserved. There is no acute fracture or acute malalignment.
There is no prevertebral soft tissue swelling. There is are
bridging anterior osteophyte from C3-C6 anteriorly as well as a
mild posterior osteophyte formation at C4 and C5, but no
significant spinal canal or neural foraminal narrowing.
CT T-Spine ___: The height of the vertebral bodies of the
thoracic spine is preserved. There is no acute fracture or
malalignment. Anterior and lateral (right greater than left)
bridging osteophytes are seen throughout the thoracic spine,
likely representing DISH. There is no evidence of posterior rib
fracture and the partially seen posterior lungs are clear.
Visualized soft tissues are unremarkable.
CT head ___:
1. Mild interval improvement of the parasagittal subdural
hematoma along the anterior falx as well as the left parietal
subgaleal
hematoma.
2. No new acute hemorrhage, mass effect, or infarction.
CXR ___:
As compared to the previous radiograph, there is no relevant
change. Moderate cardiomegaly without pulmonary edema. No
acute findings
such as edema or pneumonia. No pleural effusions, no
pneumothorax.
Brief Hospital Course:
Mrs. ___ was admitted to the Neurosurgery service for
frequent neuro checks and systolic blood pressure control less
than 140. Her Coumadin and Aspirin were held and she was placed
on Vitamin K daily x3 days. Her INR of 2.6 was not actively
reversed because her hemorrhage was small.
On ___ she complained of a feeling in her chest that she
described as being short of breath. EKG was stable, Chest Xray
was negative for cardiopulmonary process. Repeat Head CT was
stable. Initial troponin was mildly elevated at 0.06 and thus
medicine consult was initiated. Cardiac enzymes were trended
and serial EKGs were obtained. Potassium and Magnesium were
repleated. She refused the third set of cardiac enzymes. The
medicine service and Dr. ___ that there was no acute
cardiac issue. They patient had no other complaints of chest
pain on this date, ___.
She was seen and evaluated by ___ and OT. They felt that she
needed rehab or 24 hour supervision at home. Her son told
nursing and case management that he could provide this service
and she was discharged home with ___.
Medications on Admission:
Glipizide 5mg BID
Metformin 500mg QAM and 100mg QPM
CHLORTHALIDONE - chlorthalidone 25 mg tablet
1 Tablet(s) by mouth once a day
DILTIAZEM HCL [DILTIA XT] - (Dose adjustment - no new Rx) -
Diltia XT 120 mg capsule, extended release
1 capsule(s) by mouth once a day
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - Nexium 40 mg capsule,delayed
release
1 Capsule(s) by mouth daily ()
ISOSORBIDE MONONITRATE - (Prescribed by Other Provider) -
isosorbide mononitrate ER 120 mg tablet,extended release 24 hr
1 Tablet(s) by mouth once a day
LISINOPRIL - lisinopril 20 mg tablet
1 tablet(s) by mouth once a day
METOPROLOL SUCCINATE - metoprolol succinate ER 100 mg
tablet,extended release 24 hr
2 Tablet(s) by mouth once a day
NITROGLYCERIN [NITROSTAT] - (Prescribed by Other Provider) -
Dosage uncertain
ROSUVASTATIN [CRESTOR] - Crestor 20 mg tablet
1 Tablet(s) by mouth DAILY (Daily)
WARFARIN - warfarin 1 mg tablet
2 Tablet(s) by mouth as directed
ASPIRIN [ASPIRIN LOW DOSE] - (Prescribed by Other Provider) -
Aspirin Low Dose 81 mg tablet,delayed release
1 tablet po once a day
Discharge Medications:
1. Diltiazem Extended-Release 120 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Metoprolol Succinate XL 200 mg PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN headaches
6. Chlorthalidone 25 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
8. Rosuvastatin Calcium 20 mg PO DAILY
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN headache
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
Q6hr Disp #*60 Tablet Refills:*0
10. GlipiZIDE 5 mg PO BID
11. MetFORMIN (Glucophage) 500 mg PO BID
12. Nitroglycerin SL 0.3 mg SL PRN chest pain
Please give one now
Discharge Disposition:
Home with Service
Discharge Diagnosis:
acute parafalcine SDH
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:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
Do not restart your Aspirin or Coumadin until you have seen
Dr. ___ in Follow up clinic in onem week.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
19812073-DS-18
| 19,812,073 | 24,222,082 |
DS
| 18 |
2144-03-16 00:00:00
|
2144-03-28 00:15:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ALL antibiotics except amoxicillin / lidocaine
Attending: ___
Chief Complaint:
Chest pain and weight gain
Major Surgical or Invasive Procedure:
___ - TTE
History of Present Illness:
Ms. ___ is a ___ female with history CAD s/p MI
and 3 stents, paroxysmal atrial fibrillation on coumadin,
chronic
venous stasis, previous pericardial effusion, and diastolic
dysfunction (last echo ___ 60%EF) who presents with chest pain
since 5pm last night. Chest pain initially ___ and persisted
until now, currently ___. Additionally when she took her blood
pressure last night while having chest pain SBP was in the 200
mmHg. Pain is not obviously positional or pleuritic, however
she feels SOB and that she cannot take a deep breath. She noted
___ pound weight gain recently and took an extra torsemide and
metolazone yesterday accordingly. Also has minor nonproductive
cough, HA and nausea. Denies fever or chills, changes in BM
(last yesterday).
In the ED initial vitals were: 99.7 70 175/69 20 100% RA. Labs
notable for WBC 9.4, H/H 10.3/33.1 (at baseline), Plt 158, INR
3.2, Na 135, K 3.3, BUN/Cr ___ (at baseline), trop 0.01, BNP
3160, lactate 1.4. CXR showed minimal pulmonary vascular
congestion and trace pleural effusions. Bedside ultrasound
without pericardial effusion. Patient was given Aspirin 324mg PO
plus Omeprazole 40 mg, Amiodarone 100 mg, Torsemide 40 mg,
Potassium Chloride 40 mEq, and Tylenol ___. Patient refused
further potassium and IV lasix. ECG with SR and 1st degree block
with rate 70 bpm. Vitals on transfer were 98.3 59 131/62 24 100%
NC.
On the floor patient states she is not currently having chest
pain ___ chest pain and back pain worse when she moves.
Past Medical History:
- Diabetes
- Dyslipidemia
- Hypertension
- CAD with PCI (Cordis) to RCA in ___ at ___
- Atrial fibrillation on coumadin
- Transient systolic heart failure (Tachycardia induced
cardiomyopathy) with an EF of 30% which has resolved with noraml
EF on most recent TTE.
- h/o lower GI bleed (hemorrhoidal) while on pradaxa in the past
- ___ in ___ resolution on CT on ___ (EF 30% --> 55%)
- CAD, s/p IMI ___ and DES to RCA.
- Hx LGIB on dabigatran
- Venous stasis
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ON ADMISSION:
================================
PHYSICAL EXAM:
VS: T=98.4F BP=132/69 HR=65 RR=22 O2 sat=100% 3L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 10 cm.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: Mild crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ pitting edema through thighs bilaterally w/
venostatic changes; skin sloughing on left skin.
PULSES: Distal pulses palpable and symmetric
ON DISCHARGE:
===========================================
PHYSICAL EXAM:
VS: T98.2 BP 140/54, HR 61, RR 20, O2 95% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 10 cm.
CARDIAC: RR, normal S1, S2. No murmurs/rubs/gallops.
LUNGS: Mild crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ pitting edema through thighs bilaterally w/
venostatic changes; skin sloughing on left shin.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ON ADMISSION:
===============================
___ 04:00PM GLUCOSE-129* UREA N-21* CREAT-1.3* SODIUM-135
POTASSIUM-3.7 CHLORIDE-92* TOTAL CO2-27 ANION GAP-20
___ 04:00PM CK-MB-2 cTropnT-0.03*
___ 11:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
___ 11:25AM URINE RBC-<1 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-1 TRANS EPI-<1
___ 11:25AM URINE HYALINE-4*
___ 08:02AM LACTATE-1.4
___ 07:50AM GLUCOSE-162* UREA N-18 CREAT-1.3* SODIUM-135
POTASSIUM-3.3 CHLORIDE-93* TOTAL CO2-31 ANION GAP-14
___ 07:50AM proBNP-3160*
___ 07:50AM CALCIUM-9.6 PHOSPHATE-3.7 MAGNESIUM-1.7
___ 07:50AM WBC-9.4# RBC-3.83* HGB-10.3* HCT-33.1* MCV-86
MCH-26.9 MCHC-31.1* RDW-16.8* RDWSD-52.2*
___ 07:50AM NEUTS-89.1* LYMPHS-4.3* MONOS-5.4 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-8.39*# AbsLymp-0.41* AbsMono-0.51
AbsEos-0.03* AbsBaso-0.03
___ 07:50AM PLT COUNT-158
___ 07:50AM ___ PTT-38.5* ___
ON DISCHARGE:
====================================
___ 06:40AM BLOOD WBC-5.3 RBC-3.33* Hgb-8.8* Hct-28.4*
MCV-85 MCH-26.4 MCHC-31.0* RDW-16.7* RDWSD-52.9* Plt ___
___ 07:50AM BLOOD Neuts-89.1* Lymphs-4.3* Monos-5.4
Eos-0.3* Baso-0.3 Im ___ AbsNeut-8.39*# AbsLymp-0.41*
AbsMono-0.51 AbsEos-0.03* AbsBaso-0.03
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-104* UreaN-51* Creat-1.7* Na-133
K-4.1 Cl-94* HCO3-29 AnGap-14
___ 06:30AM BLOOD CK-MB-2 cTropnT-0.03*
___ 06:40AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.1
IMAGING/STUDIES:
=====================================
___ TTE
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is ___ mmHg.
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is mild regional left ventricular systolic
dysfunction with akinesis of the basal inferior wall. The
remaining segments contract normally (LVEF = 55-60 %). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is an anterior space which most likely represents a
prominent fat pad.
Compared with the prior study (images reviewed) of ___
heart rate is slower. Pulmonary pressures are higher. Other
findings are similar.
___
No focal consolidation is seen. There may be very trace pleural
effusions. No pneumothorax is seen. The cardiac silhouette is
moderately enlarged. There may be minimal pulmonary vascular
congestion. Mediastinal contours are unremarkable. Moderate
cardiomegaly and possible minimal pulmonary vascular congestion.
Possible trace pleural effusions.
Brief Hospital Course:
Ms. ___ is a ___ female with history CAD s/p
Cordis to LAD, paroxysmal atrial fibrillation on Coumadin,
chronic venous stasis, previous pericardial effusion, and
diastolic dysfunction (last echo ___ 60%EF) with normal ECG,
elevated trops with volume overload on exam and pulmonary
congestion on CXR.
# Chest pain: Patient presented to the ED with chest pain.
Cardiac enzymes were negative and EKGs were unchanged. Her chest
pain improved with diursesis and she was started on Imdur for
relief of chest pain. On discharge she was chest pain free. She
was continued on her aspirin and crestor as well as omeprazole.
# Decompensated Diastolic Heart Failure: She was disuresed with
60 mg IV Lasix and responded with good urine output net negative
2L and Cr of 1.3-1.4. TTE on ___ demonstrated LVEF 55-60%
with mildly elevated left ventricular filling pressures but was
otherwise unremarkable. One day prior to discharge, she was
started on home dose toresmide 40 mg and Indur 30 mg daily was
started to help relieve chest pain. She stated her shortness of
breath and chest pain were both improved. She was discharged on
amiodarone 100 mg daily, isorbide mononitrate 30 mg daily,
labetaolol 100 mg BID and toresmide 40 mg. Her lisinopril wad
held at time of discharge as her creatinine increased from 1.4
to 1.7.
# Paroxysmal Atrial Fibrillation: Patient was on warfarin for
history of paroxysmal atrial fibrillation, 3 mg daily. On
admission, her INR was supratherapeutic to 3.9. Her dose was
held on ___ INR in AM was 1.9 and she was restarted on 3 mg
warfarin daily with INR 2.0 for remainder of the
hospitalization.
===========================
Transitional Issues:
===========================
- Patient had an increased Cr 1.7 on discharge. Held lisinopril
5mg on discharge. Please check electrolytes and renal function
on ___ and assess for restarting lisinopril.
- Patient had a constant ___ somewhat responsive to SLN.
Started 30 mg isosorbide mononitrate 30 mg daily with
improvement in chest pain.
- Patient in sinus brady to ___ with frequent PACs with SBPs
100-110's. Continued amidarone 100 mg daily/labetalol 100 mg
BID.
- Discharge weight: 80.1 kg
- Code: Full Code
- Contact: ___ (son) ___, ___
___ home care (___): ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 100 mg PO DAILY
2. Warfarin 3 mg PO DAILY16
3. Lisinopril 5 mg PO DAILY
4. Labetalol 100 mg PO BID
5. Rosuvastatin Calcium 10 mg PO QPM
6. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
7. Torsemide 40-60 mg PO DAILY
8. Metolazone 2.5 mg PO DAILY:PRN weight gain
9. Aspirin 81 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Acetaminophen 975 mg PO Q8H
12. Omeprazole 40 mg PO BID
13. Senna 17.2 mg PO BID
14. TraMADOL (Ultram) 50 mg PO BID:PRN pain
Discharge Medications:
1. Acetaminophen 975 mg PO Q8H
2. Amiodarone 100 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Labetalol 100 mg PO BID
5. Omeprazole 40 mg PO BID
6. Rosuvastatin Calcium 10 mg PO QPM
7. Senna 17.2 mg PO BID
8. Torsemide 40-60 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO BID:PRN pain
10. Vitamin D 1000 UNIT PO DAILY
11. Warfarin 3 mg PO DAILY16
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
13. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
14. Metolazone 2.5 mg PO DAILY:PRN weight gain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ACUTE:
- HFpEF (LEVF 55-60% on ___
- CAD s/p IMI with PCI (Cordis) to RCA in ___ at ___
- Paroxysmal atrial fibrillation on Coumadin
- Pulmonary hypertension
CHRONIC:
- Dyslipidemia
- Hypertension
- Diabetes
- Arthritis s/p hip replacement
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with chest pain and
increased weight. We treated you with a high dose of water pill
(Lasix) to remove the extra fluid weight. We were concerned
about your chest pain. We examined the functioning of your heart
by electrocardiogram which showed your heart rate was slow, but
there was no evidence of heart attack. We also examined the
functioning of your heart with an electrocardiogram, it showed
your heart muscle was working the same as before and functioning
relatively normally.
While in the hospital, we started you on a new medication to
help with your chest pain called Imdur (isorbide mononitrate).
It is important to go to your appointment on ___ to see
if you should continue this medication.
Please take your medications as prescribed. Weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
Thank you for allowing us to participate in your care
- ___ care team
Followup Instructions:
___
|
19812073-DS-19
| 19,812,073 | 20,555,520 |
DS
| 19 |
2147-05-13 00:00:00
|
2147-05-13 13:23:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ALL antibiotics except amoxicillin / lidocaine / ACE Inhibitors
/ lisinopril
Attending: ___.
Chief Complaint:
Cough and Dyspnea
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ ___ speaker w/ HFpEF, CAD s/p stents, afib (on
apixaban), HTN, HLD, DM, CKD, who presented to the ED for cough
and shortness of breath.
Patient was referred in by her ___ after ___ days of worsening
cough, dyspnea, myalgia and general malaise. Cough may be worse
when supine, she is unsure. It has been non-productive, and she
denies hemoptysis. It has limited her mobility, so that her
average level of activity around the house has caused her more
dyspnea than usual. She denies any sick contacts. She denies
fever, rhinorrhea, sore throat. She hasn't been hungry and has
been eating less.
She is compliant with her medications with the help of her home
aide.
In the ED:
- Initial vital signs were notable for: Temp 98.2, HR 61, BP
190/83, RR 22, SPO2 100% on 4L nasal cannula
- Labs were notable for: Cr 1.9, Flu negative, lactate 0.6,
proBNP 8196, INR 1.7
- Portable CXR: pulmonary edema, peribronchial cuffing, and no
overt pneumonia
- Patient was given: IV methylpred 80, duonebs, lasix IV 40,
home
meds
Admitted to medicine for CHF and presumed viral respiratory
infection.
Past Medical History:
- Atrial fibrillation on coumadin
- HFpEF
- Transient systolic heart failure (Tachycardia induced
cardiomyopathy) with an EF of 30% which has resolved with noraml
EF on most recent TTE.
- CAD (s/p IMI with stent to RCA in ___ at ___)
- Diabetes
- Dyslipidemia
- Hypertension
- h/o lower GI bleed (hemorrhoidal) while on pradaxa in the past
- Hx LGIB (while on Pradaxa)
- Venous stasis
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM:
=========================
VITALS: ___ 1706 Temp: 97.6 PO BP: 156/76 R Lying HR: 51
RR:
18 O2 sat: 96% O2 delivery: 2 L FSBG: 241
GENERAL: Elderly woman, alert and interactive, well-nourished
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Bilateral rhonci, more prominent at the bases. No
wheezing.
ABDOMEN: Slightly distended but non-tender
EXTREMITIES: bilateral pedal edema, pitting, 1+. Brawny
discoloration consistent with venous stasis of legs.
NEUROLOGIC: CN2-12 grossly intact. ___ strength throughout.
Sensation grossly intact.
========================
Discharge Physical Exam:
========================
PHYSICAL EXAM:
___ 0715 Temp: 98.4 PO BP: 164/84 HR: 75 RR: 18 O2 sat: 94%
O2 delivery: Ra FSBG: 111
Wt: 175.71 lb
General: Elderly woman in no acute respiratory distress on RA
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
Neck: Supple, no palpable lymphadenopathy.
Lungs: Decreased aeration, clear to auscultation bilaterally
CV: Audible S1 and S2 with no appreciable m/r/g. Normal rate and
rhythm.
GI: Soft, non-tender.
Ext: 1+lower extremity edema. Brawny discoloration.
Neuro: CN ___ intact. Alert, interactive. Moving all 4
extremities with purpose.
Pertinent Results:
Pertinent Results:
ADMISSION LABS
==============
___ 09:25PM PLT COUNT-149*
___ 09:25PM ___ PTT-30.6 ___
___ 09:25PM NEUTS-77.5* LYMPHS-13.1* MONOS-6.6 EOS-1.8
BASOS-0.5 IM ___ AbsNeut-3.43 AbsLymp-0.58* AbsMono-0.29
AbsEos-0.08 AbsBaso-0.02
___ 09:25PM WBC-4.4 RBC-3.49* HGB-9.2* HCT-29.4* MCV-84
MCH-26.4 MCHC-31.3* RDW-15.7* RDWSD-47.8*
___ 09:25PM proBNP-8196*
___ 09:25PM cTropnT-<0.01
___ 09:25PM estGFR-Using this
___ 09:25PM GLUCOSE-136* UREA N-32* CREAT-1.9*
SODIUM-132* POTASSIUM-3.5 CHLORIDE-92* TOTAL CO2-26 ANION GAP-14
___ 09:28PM LACTATE-0.6
___ 10:24PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:24PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:24PM URINE UHOLD-HOLD
___ 10:24PM URINE HOURS-RANDOM
___ 11:00PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 07:52AM cTropnT-<0.01
___ 07:52AM GLUCOSE-187* UREA N-29* CREAT-1.9* SODIUM-140
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14
Discharge Labs
===============
___ 06:53AM BLOOD WBC-6.4 RBC-3.90 Hgb-9.9* Hct-33.0*
MCV-85 MCH-25.4* MCHC-30.0* RDW-16.1* RDWSD-50.2* Plt ___
___ 06:53AM BLOOD Plt ___
___ 06:53AM BLOOD Glucose-96 UreaN-23* Creat-1.4* Na-139
K-4.1 Cl-96 HCO3-29 AnGap-14
___ 06:53AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.1
Relevant Studies
=================
CHEST (AP AND LAT) ___
Moderate to severe cardiac enlargement is unchanged.
Mediastinal and hilar
contours are similar. Pulmonary vasculature does not appear
engorged. Lungs remain hyperinflated. Minimal blunting of the
right costophrenic angle appears similar to prior exams, likely
chronic pleural thickening. No definite pleural effusion or
pneumothorax. Patchy atelectasis is seen in the lung bases
without focal consolidation. No acute osseous abnormality.
Remote left third rib fracture is present.
IMPRESSION: Mild atelectasis in the lung bases. No definite
focal consolidation to suggest pneumonia.
Brief Hospital Course:
___ ___ speaker w/ HFpEF, CAD, afib (on apixaban), HTN,
HLD, DM, CKD, admitted with acute hypoxic respiratory failure
secondary to bronchitis (likely viral, but treated with
antibiotics out of an abundance of caution), and a CHF
exacerbation.
# Acute on chronic diastolic heart failure
BNP was 8K, compared to baseline of about ___. Patient also
appeared volume overloaded with elevated JVP and peripheral
edema. She was diuresed with 80mg IV Lasix BID with improvement
in her clinical exam, pulmonary symptoms, and her creatinine.
Prior to discharge, patient was advised to increase her dose of
home Torsemide from 40mg daily to 40mg BID; however, given
patient resistance to this dose, a compromise was reached at
60mg daily for torsemide.
# Acute Bronchitis/bronchopneumonia, possibly bacterial
Lung exam clinically consistent with bronchitis or
bronchopneumonia. CXR was nonspecific, but given her hypoxia and
cough, we treated empirically for possibility of bacterial
bronchitis or CAP. Completed 5-day course of CTX/azithro on
___.
# Acute hypoxemic respiratory failure
She initially required ___ O2 in the setting of her infection
and CHF, but was weaned to room air by time of discharge.
# ___ on CKD, likely cardiorenal syndrome
Creatinine has been slowly rising over the last few years. At
time of admission creatinine was 1.9. Cr improved with diuresis
- down to 1.4 on day of discharge, suggestive that 40mg
torsemide was likely an inadequate dose for her (see above for
torsemide adjustment). Losartan was increased to 100mg for
greater BP control without a discernible effect on her
creatinine.
# Asymptomatic Bradycardia
Patient experienced heart rates intermittently in the ___ on
___ - likely a junctional escape rhythm - though she remained
asymptomatic. Cardiology was consulted and recommended holding
labetalol and diltiazem while continuing the amiodarone to
maintain sinus rhythm given her history of Afib.
# HTN
Home losartan was initially held during early diuresis. However,
was restarted once renal function was found to be stable.
Patient's diltiazem and labetolol were discontinued (per cards
recs) due to junctional bradycardia (40s-50s) noted on first few
days of admission. Patient's losartan was increased to 100mg and
amlodipine 10mg was added for further BP control.
# Anemia
Hb has dropped two points since last checked in ___ (11 to
9). Ferritin, Transferrin and TIBC labs were consistent with an
anemia of chronic disease.
#Insomnia
Difficulties with sleep. Started on Ramelteon on ___.
Recommended melatonin at time of discharge.
CHRONIC ISSUES:
===============
# CAD
Patient relays that she is s/p multiple cardiac stents. She
occasionally has chest pain with exertion. Aspirin and statin
were continued.
# Atrial fibrillation
Was in sinus rhythm at last cardiology visit in ___. Home
Amiodarone and Apixaban (reduced dose due to age and Cr) were
continued throughout admission. Diltiazem was stopped, as above.
Transitional Issues
[] DIURETIC DOSE: Increased torsemide from 40mg daily to 60mg
daily. This is a lower maintenance dose than we felt was needed
(based on her IV Lasix requirements), but it was the highest
dose she would consent to try. Please reassess volume exam,
weight, creatinine.
[] ADHERENCE: If she is back in CHF at the time of her follow up
appointment, please probe her on whether she took the higher
dose or not. Barriers to diuretic adherence include her concern
for possible ___ if she were to be over-diuresed, and a general
distrust of most healthcare providers (although she seems to
like her PCP and cardiologist).
[] HYPERTENSION: Labetalol and Diltiazem discontinued due to
bradycardia (HR in ___, Losartan increased to 100mg and
Amlodipine started (10mg) - will likely need further titration
of antihypertensive regimen as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Torsemide 20 mg PO BID
2. Rosuvastatin Calcium 10 mg PO QPM
3. Amiodarone 100 mg PO DAILY
4. Labetalol 100 mg PO BID
5. Losartan Potassium 50 mg PO DAILY
6. Diltiazem Extended-Release 120 mg PO DAILY
7. Apixaban 2.5 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Omeprazole 20 mg PO DAILY
11. TraMADol 50 mg PO TID:PRN Pain - Moderate
12. Meclizine 25 mg PO Q12H:PRN nausea
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
2. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth Once a day Disp #*90
Tablet Refills:*0
3. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Amiodarone 100 mg PO DAILY
5. Apixaban 2.5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Meclizine 25 mg PO Q12H:PRN nausea
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. Omeprazole 20 mg PO DAILY
10. Rosuvastatin Calcium 10 mg PO QPM
11. TraMADol 50 mg PO TID:PRN Pain - Moderate
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Heart Failure Exacerbation
Viral Upper Respiratory Infection
Bacterial Bronchitis
Diabetes
Hypertension
Bradycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You had a bad cough and low oxygen levels - this was likely
because you had bronchitis and worsening of your heart failure.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given a medicine called Furosemide ("Lasix") in order
to remove some of the excess fluid that had accumulated in your
body.
- You were started on antibiotics to help treat the bacterial
infection in your lungs that we believe has contributed to your
low oxygen level and cough.
- You were seen by our physical therapists, who recommended that
you get physical therapy at home when you leave the hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments. Weigh yourself every morning, call Dr ___
weight goes up more than 3 lbs.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19812212-DS-19
| 19,812,212 | 28,972,811 |
DS
| 19 |
2145-07-30 00:00:00
|
2145-07-31 13:08:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
vertigo and nausea
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
The patient is a ___ woman with a past medical history
significant for AFib on coumadin, PPM, HTN, HLD, uterine CA s/p
resection, NIDDM, hypothyroidism presents with sudden onset
vertigo, nausea, vomiting. Patient reports that yesterday she
was in her usual state of health, other than feeling a slight
cold with sniffles she was going to the bathroom around 9 ___,
and while she was sitting on the toilet room started spinning
around her. She tried to get up, but she was unable to she
called her daughter who she lives with. Her daughter called
EMS, and EMS brought her to ___. Patient believes that
the spinning will be stopped when she got to the hospital. At
___, they performed a head CT which showed an old
cerebellar infarct. Patient speech was initially slurred, but
reportedly was back to baseline according to the family. She
was noted to be mildly hypertensive to 177 systolic. Her ___
stroke scale was 0. She was noted to have very beating
nystagmus and mild left-sided ataxia. Her family requested
transfer to ___. ___ arriving to the
emergency department here, the patient does
not endorse room spinning vertigo. Reports overall "unwell" and
not like her usual self.
On neurologic review of systems, the patient denies headache,
or confusion. Denies difficulty with producing or comprehending
speech. Denies loss of vision, blurred vision, diplopia,
vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies focal muscle weakness, numbness, parasthesia. Denies loss
of sensation. Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt endorses 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 diarrhea, constipation or abdominal pain.
No recent change in bowel or bladder habits. No dysuria.
Denies arthralgias or myalgias. Denies rash.
Past Medical History:
AFib on coumadin
PPM
HTN
HLD
Uterine cancer s/p resection
NIDDM
Hypothyroidism
PPM info (___, ___:
The patient had a single chamber pacemaker VVI placed by Dr.
___. The patient tolerated the procedure well. She underwent
a ___ placement of a generator with a model #
___, serial # ___. The right ventricular lead is Guidant
Model # ___, ___ # ___.
Social History:
___
Family History:
Unknown
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
Vitals: T: afebrile P: 65 R: 18 BP: 145/58 SaO2: 95% on 2L NC
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, slightly sleepy. Oriented x 3. Able to
relay recent events, but cannot give specific details. Requires
repeated stimulation to attend to examiner. Intact repetition
andcomprehension. Normal prosody. There were no paraphasic
errors. Pt was able to name both high and low frequency objects.
Patient is unable to read, but can accurately describe stroke
card and name objects. Speech was slightly 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. Fine vertical
nystagmus on primary gaze that does not extinguish. Persistent
horizontal nystagmus bilaterally that does not extinguish,
although patient has a hard time sustaining end gaze. Does not
fully bury sclera bilaterally.
V: Facial sensation intact to light touch.
VII: Slight left NLFF with symmetric activation.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
Was unable to complete head impulse test due to patient
cooperation, she couldn't follow command to move her head. No
skew. ___ did not reproduce symptoms, although it did
not make her feel "good" and patient did have fine nystagmus as
she did on primary gaze.
-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 5
5 5
R 5 5 5 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
in the upper extremities. Persistently extinguishes to DSS on
the right in the lower extremities.
-DTRs:
Bi Tri ___ Pat Ach
L 1 1 1 0 0
R 1 1 1 0 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally. When patient sits up, she leans
to the left and can momentarily sit up straight but then slumps
back to the left.
-Gait: Patient extremely fatigued with sitting, and did not feel
comfortable attempting to walk.
========================
DISCHARGE PHYSICAL EXAM:
========================
General: Awake, cooperative, NAD
HEENT: No scleral icterus noted, MMM
Pulmonary: CTAB, no crackles
Cardiac: Skin warm, well-perfused
Extremities: No peripheral lower extremity edema
Neurologic:
-Mental Status: Alert and cooperative. Language is fluent with
intact comprehension.
-Cranial Nerves: EOMI with prominent right-beating nystagmus on
right end gaze that extinguishes, subtle left-beating nystagmus
on left gaze, and subtle torsional nystagmus on upgaze. Face
symmetric at rest.
-Motor: No pronator drift bilaterally. Full motor exam deferred.
-Coordination: No dysmetria on FNF bilaterally. Mild dysmetria
on
finger tapping bilaterally.
Pertinent Results:
___ 05:32PM LACTATE-3.1*
___ 04:30PM GLUCOSE-107* UREA N-32* CREAT-1.3* SODIUM-139
POTASSIUM-5.1 CHLORIDE-95* TOTAL CO2-23 ANION GAP-21*
___ 04:30PM CALCIUM-9.3 MAGNESIUM-1.6
___ 06:30AM LACTATE-2.3* K+-5.4*
___ 06:25AM GLUCOSE-137* UREA N-34* CREAT-1.2* SODIUM-136
POTASSIUM-5.7* CHLORIDE-98 TOTAL CO2-21* ANION GAP-17
___ 06:25AM estGFR-Using this
___ 06:25AM ALT(SGPT)-23 AST(SGOT)-31 ALK PHOS-50 TOT
BILI-0.5
___:25AM LIPASE-39
___ 06:25AM ALBUMIN-4.2 CALCIUM-8.9 PHOSPHATE-3.7
MAGNESIUM-1.7 CHOLEST-113
___ 06:25AM TRIGLYCER-110 HDL CHOL-33* CHOL/HDL-3.4
LDL(CALC)-58
___ 06:25AM TSH-2.5
___ 06:25AM DIGOXIN-0.5*
___ 06:25AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 04:55AM URINE HOURS-RANDOM
___ 04:55AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 04:55AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:55AM URINE BLOOD-NEG NITRITE-POS* PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:55AM URINE RBC-1 WBC-<1 BACTERIA-MANY* YEAST-NONE
EPI-0
___ 04:55AM URINE HYALINE-1*
___ 04:55AM URINE MUCOUS-RARE*
___ 04:22AM %HbA1c-6.2* eAG-131*
___ 04:00AM cTropnT-<0.01
___ 04:00AM VoidSpec-HEMOLYSIS
___ 04:00AM WBC-10.9* RBC-3.94 HGB-12.0 HCT-38.4 MCV-98
MCH-30.5 MCHC-31.3* RDW-17.3* RDWSD-61.6*
___ 04:00AM NEUTS-78.4* LYMPHS-12.5* MONOS-8.2 EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-8.58* AbsLymp-1.37 AbsMono-0.90*
AbsEos-0.01* AbsBaso-0.03
___ 04:00AM PLT COUNT-203
___ 04:00AM ___ PTT-34.4 ___
___ 02:44AM LACTATE-2.6*
___ 04:00AM BLOOD Neuts-78.4* Lymphs-12.5* Monos-8.2
Eos-0.1* Baso-0.3 Im ___ AbsNeut-8.58* AbsLymp-1.37
AbsMono-0.90* AbsEos-0.01* AbsBaso-0.03
___ 04:45AM BLOOD Plt ___
___ 04:45AM BLOOD ___ PTT-40.9* ___
___ 04:45AM BLOOD Glucose-96 UreaN-20 Creat-1.1 Na-140
K-4.3 Cl-98 HCO3-27 AnGap-15
___ 04:45AM BLOOD Calcium-9.1 Phos-3.1 Mg-1.9
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Brief Hospital Course:
The patient is a ___ year old woman with history of AFib on
Coumadin, permanent pacemaker, diastolic heart failure,
diabetes, hypertension, hyperlipidemia, prior cerebellar
infarct, endometrial cancer, hypothyroidism, who presents with
acute onset of vertigo and nausea on ___.
# Neurologic
History and examination were somewhat challenging in localizing
her symptoms to peripheral or central location. Possibilities
included a peripheral vestibulopathy, given the severity of
symptoms and rapid resolution, vs. central, such as
recrudescence of a chronic cerebellar infarct visualized on head
CT, or an acute posterior fossa infarct, although this was felt
less likely given that she had presented with a therapeutic INR.
Unfortunately, MRI to confirm absence of acute infarct was not
possible due to her MRI-incompatible pacemaker. CTA head/neck
was negative for vertebrobasilar atherosclerotic disease. She
does have several risk factors including DM (A1c of 6.2),
hyperlipidemia (LDL 58), and hypertension (initial SBPs in
130-150s range, which then improved to 110-140s). No changes
were made to her medication regimen while inpatient; she should
continue to follow with PCP and physician at her ___ clinic
to optimize her regimen for her cardiovascular risk factors.
# CV/Pulm
The patient on presentation was slightly dyspneic and had
pitting edema in her lower extremities, with evidence of
pulmonary edema on CXR and bilateral crackles on pulmonary exam.
She was given Lasix 40mg IV x1 with dramatic improvement in her
symptoms, and did not have any further desaturations or edema.
She reportedly had a history of diastolic heart failure. She did
not require any further dosages but will require further follow
up and consideration of need for small standing diuretic dose.
She was also placed on her home digoxin.
In terms of her history of hypertension, patient was placed on
her home atorvastatin. She was initially placed on her half dose
of metoprolol (25 mg BID) but was transitioned to full dose day
of discharge.
# Heme
The patient's INR upon presentation was within therapeutic range
of 2.6, however on HOD 3, it had increased to 3.6, so dose was
held x2 days. Her INR on therapeutic on day of discharge at 2.4.
# Endo
Patient has a history of diabetes. She was placed on an insulin
sliding scale throughout admission. Patient also has a history
of hypothyroidism. She was continued and discharged on her home
levothyroxine dose.
# ID
Ms. ___ was found to have >100K E. coli on urine culture.
However, she did not endorse any symptoms of a UTI (urgency,
frequency, pain). Because this is consistent with asymptomatic
bacteriuria, she was not placed on antibiotics.
Transitional issues:
[ ] Obtain INR ___, consider decreasing pt's daily warfarin
dosage regimen.
[ ] Monitor patient's weight, I/Os, vital signs; start on
diuretic as needed for mild diastolic heart failure.
[ ] If febrile or complaining of urinary symptoms, considering
treating for UTI. E. coli sensitivity data below.
[ ] Patient will be scheduled Stroke clinic follow up in ___
months.
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 20 mg PO QPM
2. Digoxin 0.125 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Metoprolol Tartrate 50 mg PO BID
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Allopurinol ___ mg PO DAILY
7. Warfarin 5 mg PO 6X/WEEK (___)
8. Warfarin 2.5 mg PO 1X/WEEK (SA)
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Levothyroxine Sodium 100 mcg PO DAILY
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Metoprolol Tartrate 50 mg PO BID
6. Pravastatin 20 mg PO QPM
7. Warfarin 5 mg PO 6X/WEEK (___)
8. Warfarin 2.5 mg PO 1X/WEEK (SA)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute onset vertigo
Possible acute infarct vs. recrudescence of chronic cerebellar
infarct
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital due to symptoms of vertigo,
nausea, and vomiting. Fortunately, your symptoms improved
rapidly.
The cause of your symptoms is not clear. There are a number of
possibilities, including a possible problem with your vestibular
system (such as in BPPV), or worsening of your previous stroke.
Finally, while unlikely because your INR level was on the high
side, it is always possible that you had a new small stroke.
Unfortunately, because of your pacemaker, we are unable to
obtain an MRI to confirm this definitively.
You have many risk factors for stroke, including:
- Atrial fibrillation
- Hypertension
- Hypercholesterolemia
- Diabetes
Your INR level was good on presentation but later became high
during the admission at 3.6, so we held your Coumadin dose for a
few days, then resumed it when it came back to therapeutic
range. This will need to be closely monitored and titrated. In
addition, you had evidence of edema (excess water) in your lungs
and other tissues, possibly due to heart failure, so we gave you
a dose of Lasix (a diuretic medication) to help remove some of
the fluid. You ___ need to be on a dose chronically to prevent
fluid buildup, so you should follow up with your PCP to continue
care for your heart. You should continue all of your other
medications as prescribed, and continue following with your PCP
to ensure that your diabetes and blood pressure are well
managed.
It was a pleasure taking care of you. We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19812383-DS-17
| 19,812,383 | 29,497,775 |
DS
| 17 |
2180-07-25 00:00:00
|
2180-07-25 16:28:00
|
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / Pollen Extracts
Attending: ___.
Chief Complaint:
constipation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: Pt is an ___ y/o F with PMHx of pancreatic neuroendocrine
tumor not currently undergoing treatment, who presented to the
ED
with constipation. The patient reports chronic problems with
constipation, which has been particularly bad for the past 2
days, with no BM during that time. She also endorses anorexia as
well as intermittently episodes of dysphagia (recently both to
solids and liquids). She also reports chronic RUQ abdominal pain
that radiates to the shoulder. Prior to presentation, she
attempted to manually disempact herself however was unable to do
so successfully.
ED Course:
Initial VS: 99.0 116 128/72 18 100% Pain ___
Labs significant for WBC 14.0. Lactate 2.3. Mild transaminitis.
Imaging: CT with hepatic lesion; no SBO.
Meds given: none
VS prior to transfer: 98.2 100 119/69 20 97% RA Pain ___
On arrival to the floor, the patient reports feeling better. Per
her report, she had a large loose BM after drinking the CT
contrast, which helped with her symptoms. She reports a 10 pound
weight loss over the past ___s some
lightheadedness with walking.
ROS: As above. Denies fever, headache, lightheadedness,
dizziness, sore throat, sinus congestion, chest pain, heart
palpitations, shortness of breath, cough, nausea, vomiting,
diarrhea, urinary symptoms, muscle or joint pains, focal
numbness
or tingling, skin rash. The remainder of the ROS was negative.
Past Medical History:
ONCOLOGIC HISTORY:
- Ms. ___ presented with chronic constipation in ___. CT
imaging revealed two suspicious lesions in her liver concerning
for metastatic disease which was corroborated by both MRI and
PET/CT findings showing similar findings. She underwent an
ultrasound-guided biopsy of a liver lesion which showed tumor
cells positive for CK-20, negative for CK-7, HePar1, ER, PR,
mammoglobin, and GCDFP; immuonphenotypically not characteristic
of metastatic breast cancer.
- On ___, she underwent surgical resection of segment 8, 6
and 4a, performed by Dr. ___, with pathology revealing
metastatic neuroendocrine carcinoma, 4a = 0.5 cm, 6 = 0.6 cm, 8
=
1.6 cm. Staining positive for chromogranin, synaptophysin and CK
20 (focal), negative for ER, mammoglobin, CK 7, GCDFP.
- A subsequent CT scan showed a distal pancreatic tumor nodule
and she then underwent distal pancreatectomy and splenectomy on
___, performed by Dr. ___.
- She had a CT scan performed on ___ that showed two more
metastatic sites in her liver.
- An image-guided biopsy confirm that these were metastasis, and
she had radiofrequency ablation to these on ___. She had
a follow up scan on ___ that showed these to be well
ablated.
- Last seen in ___ clinic in ___.
OTHER MEDICAL HISTORY:
1. History of ovarian cyst.
2. Status post appendectomy.
3. Status post cholecystectomy.
4. Breast cancer diagnosed in ___ when she was ___ years old
for
which she underwent a modified mastectomy and radiation.
5. Metastatic neuroendocrine tumor as above.
6. Carpel tunnel
7. Hemorrhoids
Social History:
___
Family History:
Her mother had ___ disease at age ___ and died at age ___.
Her materal grandmother died of breast cancer. Maternal
granfather was a smoker and died of lung cancer. Paternal
grandmother died of melanoma. No other family history of
malignancy.
Physical Exam:
Physical Examination:
VS: 97.6 137/70 92 14 98%RA
GEN: Alert, oriented to name, place and situation. no acute
signs of distress. cachectic
HEENT: NCAT, Pupils equal and reactive, sclerae non-icteric,
MMM.
Neck: Supple
Lymph nodes: No cervical, supraclavicular or axillary 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
EXTR: No lower leg edema
DERM: No active rash
Neuro: muscle strength grossly full and symmetric in all major
muscle groups
PSYCH: Appropriate and calm.
Pertinent Results:
==================================
Labs
==================================
___ 10:15PM BLOOD WBC-14.0*# RBC-4.39 Hgb-13.8 Hct-43.1
MCV-98 MCH-31.5 MCHC-32.1 RDW-12.9 Plt ___
___ 06:30AM BLOOD WBC-10.6 RBC-3.76* Hgb-11.7* Hct-37.1
MCV-99* MCH-31.1 MCHC-31.6 RDW-13.0 Plt ___
___ 10:15PM BLOOD Glucose-95 UreaN-19 Creat-1.0 Na-140
K-5.7* Cl-103 HCO3-19* AnGap-24*
___ 06:30AM BLOOD Glucose-80 UreaN-18 Creat-0.8 Na-140
K-3.8 Cl-105 HCO3-20* AnGap-19
___ 10:15PM BLOOD ALT-41* AST-83* AlkPhos-152* TotBili-1.0
___ 06:30AM BLOOD Calcium-9.9 Phos-3.7 Mg-1.9
___ 10:15PM BLOOD Albumin-4.4
___ 10:15PM BLOOD Lactate-2.3* K-4.0
==================================
Radiology
==================================
CT a/p
FINDINGS:
Imaged lung bases demonstrate sub-5-mm pulmonary nodules, which
are stable
since prior (2:5, 9). No pleural effusion is seen. Visualized
distal
esophagus is unremarkable. Heart is normal in size without
pericardial
effusion.
There is a large heterogeneous hypoenhancing mass centered in
the right
hepatic lobe measuring 16.3 x 11 x 12 cm (2:14, 601B:21), which
is new since
prior exam. There is intrahepatic biliary ductal dilatation in
the right
hepatic lobe distal to this mass and slight mass effect on the
right kidney.
The visualized left hepatic lobe demonstrates homogeneous
enhancement. The
patient is status post partial liver resection and
radiofrequency ablation of
segments VIII and VI. The portal vein appears patent.
Perihepatic fluid
collection measures 2.8 x 1.8 cm and is unchanged (2:29). The
patient is
status post splenectomy and distal pancreatectomy. A 2.3 x 1.1
cm fluid
collection, likely lymphocele, within the resection bed is also
stable (2:27).
Residual pancreas enhances homogeneously without ductal
dilatation or
peripancreatic fluid collection. The adrenal glands are
prominent, unchanged.
The kidneys enhance and excrete contrast symmetrically without
evidence of
hydronephrosis or renal masses.
Small and large bowel loops are normal in caliber without
evidence of bowel
wall thickening or obstruction. There is no free air or free
fluid within the
abdomen. Intra-abdominal aorta and its branches demonstrate
calcified
atherosclerotic disease without associated aneurysmal changes.
There are
multiple mesenteric and retroperitoneal lymph nodes, unchanged.
CT OF THE PELVIS: The bladder, distal ureters, and uterus are
unremarkable.
The rectum is distended with moderate amount of fecal matter,
with
hyperenhancing mucosa. There is no free air or free fluid
within the pelvis.
No inguinal or pelvic wall lymphadenopathy is detected.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony
lesion is seen.
IMPRESSION:
1. Large hypoenhancing heterogeneous mass centered in the right
hepatic lobe
is new since prior exam and most likely represents metastatic
disease in this
patient with known history of prior metastatic lesions to the
liver. There is
intrahepatic biliary ductal dilatation distal to this lesion and
slight mass
effect on the right kidney.
2. Post-surgical changes related to splenectomy, distal
pancreatectomy with
stable fluid collection, likely lymphocele within the resection
bed.
3. Stable pulmonary nodules in the visualized lung bases.
Brief Hospital Course:
___ y/o F with PMHx of pancreatic neuroendocrine tumor not
currently undergoing treatment, who presented to the ED with
constipation. She had a bowel movement after drinking contrast
for CT scan. She felt much better afterward. She will begin
taking colace and senna twice a day at home. If there is no BM
after two days, she will take miralax and then dulcolax.
On the CT scan there was a new large 16cm liver lesion which is
presumably a new metastasis from her pancreatic neuroendocrine
cancer. We discussed possible treatments and she again confirmed
that she does not want any cancer directed treatment such as
ablation or chemotherapy. She would like to focus on symptomatic
care, with the understanding that her cancer will progress and
eventually may lead to her death. we discussed that her current
symptoms of weight loss and fatigue may be cancer related. She
is very interested in establishing care with our palliative care
service to help manage these symptoms as well as others as they
come up, and eventually being set up with home hospice when
needed. She has an appointment in clinic in the coming weeks.
She has been having some intermittent trouble with dysphagia,
with a feeling that things are getting stuck in her midchest.
She has no trouble with food going down the wrong way or cough
after eating. I suggested a barium swallow to further evaluate
this, which she will set up as an outpatient with her PCP.
# Dispo:
[x] Discharge documentation reviewed, pt is stable for
discharge.
[x] Time spent on discharge activity was greater than 30min.
[ ] Time spent on discharge activity was less than 30min.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
unknown unknown oral unknown
3. Docusate Sodium 100 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 1 TAB PO DAILY:PRN constipation
6. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Senna 1 TAB PO BID
3. Aspirin 81 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 0
unknown ORAL Frequency is Unknown
7. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
constipation
neuroendocrine pancreatic cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure taking care of you during your stay at ___
___. You were admitted for constipation
and weakness. Your constipation resolved after drinking contrast
for a CT scan. You have had weakness and weight loss for the
past few months. We suspect this may be related to the onset of
symptoms from your cancer, which was found on CT scan to have
grown in the liver over the past year. You confirmed that you do
not want any treatment directed at this cancer, but would like
to focus on treatment to alleviate any symptoms that may come.
We have scheduled an appointment with the palliative care clinic
to help you in this regard.
Followup Instructions:
___
|
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